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+{"text":" \nNATIVE AMERICAN FAMILY LIFE\n\n_**Colleen Madonna Flood Williams**_\n\n**NATIVE AMERICAN LIFE**\n\n**E UROPEANS AND NATIVE AMERICANS**\n\n**H OMES OF THE NATIVE AMERICANS**\n\n**H UNTING WITH THE NATIVE AMERICANS**\n\n**N ATIVE AMERICAN CONFEDERACIES**\n\n**N ATIVE AMERICAN COOKING**\n\n**N ATIVE AMERICAN FAMILY LIFE**\n\n**N ATIVE AMERICAN FESTIVALS AND CEREMONIES**\n\n**N ATIVE AMERICAN HORSEMANSHIP**\n\n**N ATIVE AMERICAN LANGUAGES**\n\n**N ATIVE AMERICAN MEDICINE**\n\n**N ATIVE AMERICAN RELIGIONS**\n\n**N ATIVE AMERICAN RIVALRIES**\n\n**N ATIVE AMERICAN SPORTS AND GAMES**\n\n**N ATIVE AMERICAN TOOLS AND WEAPONS**\n\n**W HAT THE NATIVE AMERICANS WORE**\nNATIVE AMERICAN FAMILY LIFE\n\n_**Colleen Madonna Flood Williams**_\n\n**Miniconjou men, women, and children pose between two teepees, circa 1890**.\n\n**SENIOR CONSULTING EDITOR DR. TROY JOHNSON PROFESSOR OF HISTORY AND AMERICAN INDIAN STUDIES CALIFORNIA STATE UNIVERSITY**\n\nAs always, to Paul R.Williams and Dillon J. Meehan with all my love. Especially for Kayleigh and Michael Baker and for Mathew and Maureen.\n\n  |\n\nMason Crest  \n450 Parkway Drive, Suite D  \nBroomall, PA 19008  \nwww.masoncrest.com\n\n---|---\n\n\u00a9 2014 by Mason Crest, an imprint of National Highlights, Inc.\n\nAll rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, taping, or any information storage and retrieval system, without permission from the publisher.\n\nPrinted and bound in the United States of America.\n\nCPSIA Compliance Information: Batch #NAR2013. For further information,  \ncontact Mason Crest at 1-866-MCP-Book\n\nFirst printing  \n1 3 5 7 9 8 6 4 2\n\nLibrary of Congress Cataloging-in-Publication Data\n\nWilliams, Colleen Madonna Flood.\n\nNative American family life \/ Colleen Madonna Flood Williams.\n\npages cm. \u2014 (Native American life)\n\nIncludes bibliographical references and index.  \nISBN 978-1-4222-2969-9 (hc)  \nISBN 978-1-4222-8856-6 (ebook)\n\n1. Indians of North America\u2014Kinship\u2014Juvenile literature.\n\n2. Families\u2014United States\u2014Juvenile literature. I. Title.\n\nE98.K48W55 2013  \n649'.108997\u2014dc23\n\n2013007470\n\nNative American Life series ISBN: 978-1-4222-2963-7\nTABLE OF CONTENTS\n\nIntroduction: Dr. Troy Johnson\n\n1 Native American Families\n\n2 The Iroquois Family of Nations\n\n3 Parrots for Pets and Postball as a Pastime\n\n4 Buffalo Hunters, Sheep Herders, and Desert Farmers\n\n5 Families of Abundance and Subsistence\n\n6 Family Ties in Central and South America\n\nChronology\n\nGlossary\n\nFurther Reading\/Internet Resources\n\nIndex\nINTRODUCTION\n\nFor hundreds of years the dominant image of the Native American has been that of a stoic warrior, often wearing a full-length eagle feather headdress, riding a horse in pursuit of the buffalo, or perhaps surrounding some unfortunate wagon train filled with innocent west-bound American settlers. Unfortunately there has been little written or made available to the general public to dispel this erroneous generalization. This misrepresentation has resulted in an image of native people that has been translated into books, movies, and television programs that have done little to look deeply into the native worldview, cosmology, and daily life. Not until the 1990 movie _Dances with Wolves_ were native people portrayed as having a human persona. For the first time, native people could express humor, sorrow, love, hate, peace, and warfare. For the first time native people could express themselves in words other than \"ugh\" or \"Yes, Kemo Sabe.\" This series has been written to provide a more accurate and encompassing journey into the world of the Native Americans.\n\nWhen studying the native world of the Americas, it is extremely important to understand that there are few \"universals\" that apply across tribal boundaries. With over 500 nations and 300 language groups the worlds of the Native Americans were diverse. The traditions of one group may or may not have been shared by neighboring groups. Sports, games, dance, subsistence patterns, clothing, and religion differed\u2014greatly in some instances. And although nearly all native groups observed festivals and ceremonies necessary to insure the renewal of their worlds, these too varied greatly.\n\nOf equal importance to the breaking down of old myopic and stereotypic images is that the authors in this series credit Native Americans with a sense of agency. Contrary to the views held by the Europeans who came to North and South America and established the United States, Canada, Mexico, and other nations, some Native American tribes had sophisticated political and governing structures\u2014that of the member nations of the Iroquois League, for example. Europeans at first denied that native people had religions but rather \"worshiped the devil,\" and demanded that Native Americans abandon their religions for the Christian worldview. The readers of this series will learn that native people had well-established religions, led by both men and women, long before the European invasion began in the 16th and 17th centuries.\n\nGender roles also come under scrutiny in this series. European settlers in the northeastern area of the present-day United States found it appalling that native women were \"treated as drudges\" and forced to do the men's work in the agricultural fields. They failed to understand, as the reader will see, that among this group the women owned the fields and scheduled the harvests. Europeans also failed to understand that Iroquois men were diplomats and controlled over one million square miles of fur-trapping area. While Iroquois men sat at the governing council, Iroquois clan matrons caucused with tribal members and told the men how to vote.\n\nThese are small examples of the material contained in this important series. The reader is encouraged to use the extended bibliographies provided with each book to expand his or her area of specific interest.\n\nDr. Troy Johnson  \nProfessor of History and American Indian Studies  \nCalifornia State University\n\n**This Native American family is dressed in traditional clothing, called regalia, which is worn for special occasions or tribal ceremonies. Family relationships are very important to Native Americans, and social life often revolves around the family.**\n**1** **Native American Families**\n\nFamilies are the building blocks of society. Thus, it is no wonder that Native American societies of the past and present revolve around the family. Traditionally, Native American family ties are traced through blood relationships, clans, bands, and tribes. Sometimes, adoptions establish family ties.\n\nThe varying family structures of Native Americans are quite complex. There are nuclear and extended Native American families. A nuclear family, or one generational family, is composed of a mother, father, and their children. An extended family is composed of two or more generations of a family living together.\n\nClans are another form of Native American families. A totem or a common ancestor generally links a clan. Clan traditions, customs, and organizational patterns vary greatly from region to region and people to people.\n\n**This photograph from the 19th century shows a Native American family of the Plains outside of their home.**\n\nObviously, Native American family life is a broad and complicated subject. The following chapters of this book will look at some of the different aspects of the family lifestyles of select groups of pre-Columbian and early-contact Native American cultures. These groups have been chosen to provide a representation of the differing lifestyles of pre-Columbian and early-contact Native American families throughout the Americas.\n\nIn this book, the past tense is used not to suggest that Native American families are a thing of the past. It is used solely to signify that these family descriptions are referring to Native American families from pre-European contact to early-European contact periods.\n\nTo learn more about Native American families, the author recommends that you study in greater depth the family structures, traditions, and customs of individual tribes. Keep in mind that no two families are exactly alike. This applies to Native American families, just as it does to all other families. It is important to note that while the families of the cultural regions depicted in this book shared many things in common, they were also vastly different in many ways. \u00a7\n\n**A shaman wearing a mask peers through the doorway of an Iroquois longhouse. When the first French and English settlers arrived in northeastern North America during the early 17th century the Iroquois Nation\u2014actually a group of tribes that included the Onondaga, Mohawk, Seneca, Oneida, Cayuga, and Tuscarora tribes\u2014controlled much of the region.**\n**2 The Iroquois Family of Nations**\n\nThe Haudenosaunee (Iroquois) people envisioned themselves as being one giant family. In fact, they formed a family of nations. The name, Haudenosaunee, which is used to refer to this Iroquoian nation, means, \"People of the Longhouse.\" The symbolic longhouse they shared was the northeast woodlands. The Mohawk were the Guardians of the Eastern Door of the Haudenosaunee's great figurative longhouse. The Seneca were the Guardians of the Western Door. Lineage was traced through the maternal, or mother's side, of the longhouse family.\n\nIn descriptions of their large, extended family, the Haudenosaunee referred to the tribes within their nation as brothers. The Elder Brothers of the Haudenosaunee are the Onundagaono (Onondaga), Kanienkahagen (Mohawk), and Onondowahgah (Seneca). The Younger Brothers are the Onayotekaono (Oneida), Guyohkohnyoh (Cayuga), and Ska-Ruh-Reh (Tuscarora).\n\nThe Haudenosaunee taught their children to respect and honor both their younger and elder brother tribes. They also taught their children to be thankful for their \"Three Sisters\"\u2014corn, squash, and beans. These three important food staples supported, sustained, and nurtured the growth of the Haudenosaunee nation.\n\nIroquois children inherited the clan symbol and ties of their mother. When a man and a woman married, the man moved from his mother's longhouse to the longhouse of his wife. He owned only personal items, clothing, and weapons.\n\nThe true center of longhouse family relationships revolved around the fireside family. A fireside family, like a nuclear family, was made up of a mother, a father, and their children. The Iroquois family then branched out to include extended family or clan members. Tribal nationality was comprised of clans. Finally, the intertribal family of the nation was made up of the members of all of its smaller tribes, bands, or \"brother\" nations.\n\nAnother group of Native Americans that lived on the Atlantic Coast of North America was the Algonquians. The members of the Algonquian-language family formed alliances similar to the Iroquois Confederacy. However, these alliances were never as structured as that of the Haudenosaunees. They tended to be looser groupings of small bands of Algonquian peoples that joined together only during battle or to trade with one another.\n\nGrand sachems, or chiefs, led Algonquian bands joined together as confederacies. The lesser chiefs of the individual tribal bands were known as sagamores. The grand sachems often served as negotiators for the sagamores. Algonquian tribes were often matrilineal **;** however, some, like the Mi'kmaq, were patrilineal.\n\nDaily work was divided between the two moieties of a clan. When a member of one moiety died, the members of the other moiety would take care of the chores associated with the death of a family member. This allowed the deceased person's immediate moiety members to attend solely to their mourning.\n\n**A group of Native American boys practice with bows and arrows. In Iroquois tribes, boys learned archery and other hunting skills at a young age. This training would serve them well when they became adults, and therefore responsible for providing food for their family.**\n\nThroughout the Northeast, women did the cooking, raised the children, and cared for the elderly members of their tribes. They did the weaving, tanning, pottery, and basket making. Women also made footwear and clothing for their families.\n\nWomen made cradleboards to make carrying their babies as they worked easier. The cradleboards were often decorated with ornate designs. Relatives and friends gave the woman special totems to hang from her child's cradleboard. This was done in order to help keep the baby healthy and safe.\n\n**These small figures depict a Native American storyteller entertaining a group of young listeners. Storytelling was a popular pastime among the Native Americans of the northeast. Both the adult figure and the young girl to the right are holding infant children in cradleboards.**\n\nNortheastern mothers often bathed their children in cold lakes and streams. This was believed to be necessary to help ensure a young child's survival through his or her first winter. The woodlands could be a cold and harsh place to live during the winter. Young children needed to be acclimated to the cold. Being bathed in cold water helped to acclimate the young.\n\n**The Mi'kmaq decorated their clothing with their clan symbol. They also painted it on their canoes, snowshoes, and other possessions.**\n\nThe Haudenosaunee women owned all property, and a respected elder matron led each family clan. Female clan leaders chose the sachems, or clan chiefs, for their tribes. If the woman who chose a sachem became displeased with the way he was representing their people, she could have him removed from his leadership position.\n\nHaudenosaunee women were the keepers of the \"Three Sisters.\" Mothers, daughters, and grandmothers sowed, tended, prayed over, and harvested the beans, squash, and corn that helped to feed their families. It was their responsibility to weed the fields and to store supplies of food for the family in underground caches.\n\nThe men of the Haudenosaunee nation hunted and trapped animals. They were brave warriors who protected their families and their nation. Haudenosaunee men were also responsible for making weapons and canoes. The clan sachems were men of the Haudenosaunee who represented their tribes at meetings of the Iroquois Confederacy. (If the men were from Algonquian tribes, then their sachems represented them at meetings of their own confederacies.)\n\n**The majority of the Haudenosaunee were divided into three main clans: the turtle, bear, and wolf clans. Animals played an important role in Haudenosaunee spiritual life. A clan's totem animal was considered to be its kindred spirit. Animals were also often the main characters of religious and teaching stories told by the elders to the young.**\n\nMaternal uncles played an especially big role in the life of young male Haudenosaunees. Clans were linked through the mother's bloodlines, so a young man learned his family history from his mother's brothers. Maternal uncles were responsible for preparing their young nephews for clan life, important rituals, marriage, and the responsibilities of adult life.\n\nAround the age of seven or eight, Haudenosaunee children were expected to begin performing chores. The chores that they were given helped ease the day-to-day workload of their fireside family. More importantly, the chores helped to prepare the children for their roles later on in life.\n\nYoung girls would help haul water and tend to the crops. They would also assist their mothers, aunts, and grandmothers with sewing and cooking. They learned to make clothing and footwear. They also learned to make cornhusk dolls and other toys for their younger siblings. Their aunts, grandmothers, and mothers shared stories and bits of wisdom with them as they worked. In this way, young girls gradually learned the skills necessary to be a responsible, productive wife and clan mother.\n\nHaudenosaunee men were often away from home for long periods of time. Because of this, young boys were encouraged to \"play\" at fighting, hunting, and camping. This type of \"play\" helped them to learn important life skills.\n\nTheir mothers often made toy war clubs for them out of corn silk. The boys would use these soft clubs to participate in mock battles against their friends. This allowed them to learn important hand-to-hand combat skills.\n\nTo be capable providers and effective warriors, the young boys needed to perfect their use of snares, bow and arrows, blowguns, and other weapons. When their grandfathers, fathers, and uncles were home from hunting or war parties, the young boys learned how to make canoes, weapons, and tools. The elder men gave the younger men advice on how to become respected hunters, warriors, husbands, and fathers.\n\nAfter a young boy killed his first deer, he was allowed to join the adult hunting parties. When he reached puberty, he was sent into the woods on a vision quest. A respected elder would often accompany the adolescent on this sacred journey.\n\nAt this time, the young man would demonstrate his physical strength, intelligence, and manliness. These were important assets, as life in the woodlands could be quite demanding. A young man would strive to demonstrate that he was capable of withstanding great challenges in order to protect and provide for his family and nation.\n\n**Around the year 1570, two influential men, Hiawatha and Deganawida, first encouraged the Cayuga, Mohawk, Oneida, Onondaga, and Seneca to unite. The Huron prophet Deganawida spoke of a vision of the tribes united beneath a \"Great Tree of Peace.\" Hiawatha, a Mohawk medicine man, traveled by canoe throughout the Haudenosaunee territories speaking about the importance of unity.**\n\n**Hiawatha and Deganawida's efforts were rewarded with the formation of the Iroquois Confederacy. This confederacy of tribes, or Iroquois nations, started out as a union of five nations. In the early 1700s, the Tuscarora joined the Haudenosaunee family of nations, bringing the number to six. Many historians now believe that the United States of America owes a debt of gratitude, not only to the Roman ideals of democracy and the republic, but also to the political models of the Haudenosaunee's Pine Tree Sachems, Grand Council, and Grand Council Fire.**\n\nThe young man might also reveal his dreams to his elder companion. The elder would consider the young man's dreams carefully and identify the guardian spirit that was trying to show itself to the young man. The young man would then find or carve a symbol of that spirit to keep as a personal totem.\n\nA young girl generally came of age around the same time that she became capable of bearing children. At this time, the girl's mother would build a small wigwam outside the main village. The girl would retreat into the wigwam for several days. She would pray for the blessings of healthy children, a good husband, and a long life. She would fast during this time, drinking only water.\n\nDelaware boys participated in a coming-of-age initiation rite called the Youth's Vigil. A boy would enter the woods and fast for a number of days. Hopefully, he would have a vision during this time that revealed the spirit guides and forces that would protect and direct him from young manhood to old age.\n\nFor the Delaware tribe of the Algonquian people, marriage and divorce were simple matters. A man and woman who moved in together were considered to be husband and wife. If either one wanted a divorce, the man would leave the family dwelling. It was the wife's right to retain custody of the home and children.\n\nFamily life in the woodlands culture area was not all work. Although the children owned few possessions, their parents did make toys for them. Young girls and boys used sticks to roll hoops made out of birch bark along the ground. Animal skin balls were stuffed with feathers or fur. Men and boys played a demanding game, much like modern-day lacrosse, called baggataway.\n\nStory telling was a favorite family activity that included young and old alike. The stories shared might be exciting, funny, scary, or sad. They were most certainly always entertaining, as the Haudenosaunee were known for their oratorical skills. Family elders used these stories to teach young people the secrets of successful living and the art of story telling, so that they might pass these things on to their own children. \u00a7\n\n**A child watches from his position tied into a cradleboard. Native American women used the device to carry their children while they worked at their daily chores: planting and cultivating crops, preparing meals, and making household items.**\n**3 Parrots for Pets and Postball as a Pastime**\n\nIn the region of the American South and the Caribbean Sea, clans were the most common family system. Among Native American tribes of the southeast, clans were mainly matrilineal. This was also the case with the Tainos, who lived in the Caribbean before arrival of Europeans in the late 15th century and early 16th century.\n\nIn the Caribbean, male rulers of Taino villages were known as caciques. If a female was the ruler of the village, she was called a cacias. The eldest son of the ruler's eldest sister traditionally succeeded a Taino leader. This practice made the Taino society primarily patriarchal, but also matrilineal.\n\nDuring labor, a Southeastern woman often retreated to the privacy of a birthing hut. After the child was born, a ritual cleansing took place. Animal grease was rubbed all over the child's body and then the infant was placed in a cradleboard. Much of a child's first year of life would be spent in this cradleboard.\n\nSoutheastern women nursed their babies until they were about two years old. They were gentle mothers who did not often resort to physical punishments. More often than not, these wise mothers disciplined their children verbally. Good behavior was promoted through the use of high expectations, wit, and wisdom. through the use of high expectations, wit, and wisdom.\n\nMothers tried to instill the traits of humility, industriousness, common sense, and cool-headedness in the young women of their families, clans, or tribes. They did this through story telling, by being good role models, and by having their young girls assist them with the family chores.\n\nWomen did the planting, tended the gardens, and harvested the crops. Women made clothing for themselves, their husbands, and their children. They also made pottery, tanned animal skins, and wove fine baskets and mats. These skills were all patiently taught to their granddaughters, nieces, and daughters.\n\nWomen prepared the meals. Corn chowders, cornbreads, or some other corn dish was a part of almost every family meal. Family meals often featured wild game, such as bear, deer, fish, or turkey. Pumpkins, beans, peas, potatoes, and squash might also accompany such meats.\n\nTaino women wove, made hammocks, cooked, and prepared the cassava. They also attended to their husbands' hair and painted their bodies according to ceremonial rules. If single, a women went without clothes; if married, she would wear a kind of apron that covered her from her waist to the middle of her legs.\n\n**A French explorer and artist named Jacques le Moyne was assigned the task of documenting the lifestyles and homes of the natives of Florida, as well as mapping the terrain. His journals and drawings have become an important historical resource on the Timucua people.**\n\n**The Timucua and other Indians native to the Florida region lived in houses such as this one made of grass and reeds over a wooden framework. When the first Spanish explorers arrived in the region during the 16th century, they found many Timucua settlements. Some were walled, as in this drawing, to keep out enemy tribes or wild animals.**\n\nMen were the family guardians and bravely protected their families and homes. They stood up for the rights of their family, both within their communities and within the world at large. They held the members of their family accountable for poor behavior, but also celebrated the achievements of their wives and children.\n\n**This 16th-century illustration by Jacques LeMoyne shows Taino natives paddling a dugout canoe. To make these canoes, the Taino cut down a large tree and hollowed it by using stone tools as well as careful applications of fire. Men used the canoes to hunt and fish.**\n\nThe men of the Southeast did the arduous work of clearing the fields so that the women could farm. Creek boys helped women in the gardens until they reached puberty. More often than not, however, men were usually off hunting, fighting, or fishing.\n\nMany Southeastern men were permitted to have more than one wife. A good provider or a wealthy man might have as many wives as he could support. However, his first wife always retained her social status as being the first. Frequently, it was the right of a first wife to approve of or disapprove of her husband's choice of subsequent wives.\n\nTimucua and other men of the Southeast often tattooed their bodies. A man's family status and skill as a warrior was often indicated through such tattoos. The Timucua would severely punish a man who tattooed himself with tattoos that reflected a higher status than he had truly earned. The offender was forced to remove the tattoos from his body.\n\nFurther south, in the Caribbean, the Taino men wore a breechcloth of cotton or palm fibers cut to a specific length to show rank. This made it easy for other members of his home and village to see his status among them.\n\n**The name the Cherokee use for their people is Ani-Yun'Wiya. This means the \"main people.\" The name \"Cherokee\" is thought to have come from a word used by the Choctaw to label the Ani-Yun'Wiya as \"the people of the land of many caves.\"**\n\nLarge groups of Taino men lived in houses called bohios. One bohio might house from 10 to 15 Taino men, as well as their entire families. It was not uncommon for a Taino bohio to serve as home to up to 100 people.\n\nTaino men cleared the land so that their women could farm it. They hunted, fished, and made wooden dugout canoes. They used their canoes to hunt ducks and sea turtles.\n\nTaino men trained dogs to assist them in their hunts. Taino men were peaceful and engaged in battle primarily only for self defense from the warrior Caribs that raided their villages.\n\nThe Carib men were known as fierce warriors. They traveled about the Caribbean, raiding the villages of neighboring communities. They often took prisoners, and it is said that they were cannibals. Male prisoners would be eaten. Female prisoners became the wives or slaves of their captors. Carib men were also expert sailors and fishermen whose dugout canoes were sometimes fitted with sails.\n\nCarib communities traced their relationships through matrilineal kin groups. They did not have chiefs. Carib wives were often women who had been taken from other island communities, like the Tainos, that the Carib had raided.\n\nChildren played together for the first few years of their lives. It was not unusual for children under four or five years of age to go without clothing during the warm months of spring and summer. Around five or six, children were expected to begin learning their respective life skills.\n\nBoys learned from their uncles, fathers, and grandfathers. They had close relationships with their maternal uncles, who oversaw their growth from boys to men. Boys were taught how to fish, hunt, and trap. They learned how to make bows and arrows. They carved spears and clubs to be used in battle. They were taught how to clear the land for farming and how to build palisades to protect their villages.\n\nIn their spare time, when they weren't helping their families or their villages, boys learned to do fine carvings and make tobacco pipes and ceremonial drums. A top-quality drum, ornately carved war club, or a first-rate tobacco pipe was a treasured item. Skillful craftsmen who could make these types of items were held in high regard.\n\nWomen of the village trained young girls in the arts of weaving, sewing, cooking, courting, marriage, and motherhood. Grandmothers, aunts, and mothers all spoke to the girls about the qualities of a good wife and mother. They talked to the girls about traditional family values, religious beliefs, and acceptable social behavior.\n\nThe little girls watched, learned, and helped as their mothers and other women of the tribe made clothing and blankets. They learned to make pottery, sleeping mats and floor mats out of cane, and finely woven grass baskets. The girls were also taught to cook, dry, and store corn and other food staples.\n\n**The Caribs were a fierce people that lived in the Caribbean region. They often attacked the villages of other tribes, as this Theodore DeBry illustration of 1570 shows.**\n\nFor many young women of the Southeast, coming of age meant starting their menstrual cycles. This great milestone in a young girl's life was marked by a special ceremony. At this time, young girls began to practice a ritual that they would observe monthly, until late in life when they reached menopause. The day their period began, they were separated from the rest of their family and village.\n\nA hut was set aside to house a menstruating woman. She used this time to rest, pray, and meditate. When her period ended, she took a ritual cleansing bath. Afterwards, she would put on clean clothing and return to her family home.\n\nThere were many things that a young boy needed to know and do to become a man. His uncles, father, and grandfathers tried to help him understand his place in the family, community, and world at large. Young men in the Southeast were expected, in some tribes, to participate in a battle and prove their skill as warriors before they would be declared men. Other tribes dictated that a young man who wished to marry must build a home and kill a bear or a deer, proving to all that he could be a good provider. The transition from boyhood to manhood was always cause for great family celebration.\n\nMarriage for the Seminoles was a fairly casual relationship. If a man wanted to divorce his wife, he merely left their home. Other Southeastern tribes planned arranged marriages for their children.\n\nA series of talks would take place between the women of the two clans. They would let the fathers of both children know what was going on, but the men had no real influence in the matter. If the women decided it was a good match, the young girl would be asked if she would consent to the marriage.\n\nNext, the girl would place a bowl of food outside her home. The young man who wished to marry her would ask if he might have a taste of the food. If the young girl said yes, then the marriage was arranged. If she said no, the young man knew that he had been turned down.\n\nSoutheastern families made time to have fun together. Men, women, and children alike would gather around a post in the village center to play a game called postball. The women were given the advantage of being able to use their hands. The men had to use sticks, similar to those used in lacrosse. The object of the game was to hit the post with a ball. After the game was over, everyone would share a festive meal and dance.\n\nTaino families enjoyed having fun, too. Taino parents allowed their children to have parrots as pets. Together, families watched and participated in recreational wrestling matches, foot races, and archery contests. Singing, swimming, and dancing were other ways that Taino families entertained themselves in their tropical homeland. \u00a7\n\n**The interior of a Mandan home is shown in this drawing from the 1840s. The Mandan were a tribe of Native Americans that lived on the prairies when the first European settlers arrived in the West.**\n**4** **Buffalo Hunters, Sheep Herders, and Desert Farmers**\n\nThe tribes of the American West are a diverse lot, ranging from the Native Americans of the Great Plains like the Sioux and Pawnee to the pueblo-dwelling Hopi and Zu\u00f1i of the southwest. There were some similarities in family relationships among these many tribal groups, however.\n\nThe Hopi were bound by the family ties of 12 clan groups. Called _phratries_ , these 12 main clans have many smaller clans within them. Men have always been Hopi religious leaders, but children inherit the clan of their mother. Hopi mothers, daughters, and granddaughters lived together with their children and husbands in one-room homes that were built side by side or atop the one-room dwellings of other Hopi families. The Spanish called these adobe apartment-style complexes \"pueblos.\"\n\nHopi women made clay pottery for their families, wove baskets from various plants, harvested edible wild plants, and did the cooking. They also maintained the family home, continually smoothing the adobe walls to keep them from weakening due to erosion. Hopi men farmed and hunted. They wove cotton for use in blankets and clothing. A Hopi man even made his wife's wedding outfit for her.\n\nThe men of Hopi communities belonged to special religious groups that met in kivas. They dressed as spirits called kachinas for religious ceremonies. Hopi men, dressed as kachinas, rewarded or disciplined Hopi children based on each child's behavior. Uncles were also the family disciplinarians.\n\nAlthough they did not do the farming, Hopi women owned the crops farmed by their men. Hopi women also owned their houses, but were only allowed in kivas when invited by the men. Hopi mothers raised both their sons and daughters until the age of six, when the boys were taken into the company of the village men.\n\nHopi girls had a special squash-blossom hairstyle that announced to the world that they were young women, eligible to marry. A young Hopi maiden had to earn the right to wear this special hairstyle. In order to do so, she participated in a coming-of-age ritual. During part of this ceremony, the young girl had to demonstrate her skill at grinding corn. If she successfully completed her coming-of-age ceremony, she was no longer regarded as a child.\n\nAnother tribe of the southwest was the Apache. They were more likely to wander than were the Hopi. Apache men were responsible for hunting and for protecting the family. In some tribal groups, Apache men also were responsible for providing farm labor for their in-laws. The men sometimes dressed up like gans, or mountain spirits, in order to ward off evil spirits, cure illness, or to ask these special spirits to watch over their crops and game.\n\nMost Apache men had only one wife. However, if a man decided to have a second wife, she would usually be one of his first wife's sisters or cousins. He could bring this second wife into the wickiup where his first wife lived, or build a second wickiup for his new wife.\n\nApache women gathered wood for their extended families, worked together to prepare feasts, gathered acorns, picked mulberries, and collected pine nuts. They made tools, clothing, and baskets for their families. After contact with Europeans, they started sheep herding and passed this skill onto their daughters. They taught their children respect for their elders, the land, and the sacred religious traditions of the Apache nation.\n\n**A Hidatsa woman grinds grain inside of a building made of wooden beams.**\n\nApache boys had to learn all of the many skills necessary for participation in their band's gathering, hunting, and raiding parties. They usually began war training around the age of 10. Over the course of their pre-teen and early teenage years, Apache boys were taught the qualities and skills of a wise and honorable Apache father, husband, and warrior.\n\n**This photograph shows the famous Sioux medicine man Sitting Bull with his family in front of their home. Sitting Bull was an influential Sioux leader during the 19th century. He opposed the invasion of white settlers into tribal lands, especially the Black Hills of South Dakota, which the Sioux considered a sacred place. Sitting Bull took part in many battles, including the battle of the Little Bighorn where the Sioux and Cheyenne won a great victory over the U.S. 7th Cavalry. After the Sioux were forced to stop fighting and move to a reservation, Sitting Bull traveled throughout the country, asking the government to respect the rights of his people. He was killed in December 1890.**\n\nLike the Apache, the tribes living on the Great Plains were nomadic. Until the late 19th century, most Plains tribes traveled through their territories following the buffalo herds. Men of the Plains spent much of their lives in pursuit of buffalo. The buffalo was the source of food, shelter, and clothing for their people, and these men had to be brave, skillful hunters to bring down such large game animals. When they were not hunting, Plains men were kept busy making tools and weapons to help them hunt and protect their families. Although they spent much time away from home, when they were home, Plains fathers were often playful and loving.\n\nWomen of the Plains tribes were responsible for child rearing, tepee construction, and transportation. They did the cooking and processed buffalo into dried and fresh meat, storage containers, blankets, tools, clothing, tepee covers, and other essential items. They were also responsible for repairing and maintaining both summer and winter camps. Tepees generally belonged to women.\n\nBeautifully decorated clothing given to Lakota Sioux family members was and still is a sign of affection and respect from wives, mothers, sisters, and grandmothers. Lakota women were quite accomplished in quillwork. The women converted porcupine quills into elaborate decorations for clothing and personal items.\n\n**Blackfoot fathers taught their daughters how to be proper ladies. They would spend a great deal of time telling their daughters jokes and silly stories over and over again. When their daughters could listen to their teasing and joking without giggling like silly little girls, their fathers praised them generously.**\n\n**In Hupa villages, women were the healers. They were paid for their services, but only retained their fees if their treatments were successful. Hupa healers were highly regarded within their village social structures. They were often wealthy, and Hupa social standing was based upon wealth.**\n\nIn many of the families throughout the Plains area, mothers and daughters were quite close. Because mothers had so much work to do processing buffalo meat and hides, grandmothers often oversaw the education of young girls. These honored elder women taught their young granddaughters all the skills necessary to become a respected wife, mother, and adult family member. Grandmothers also taught their granddaughters the tribe's moral values, history, and traditions.\n\nThe organization of families differed from tribe to tribe. For example, the Omahas were organized into 10 paternal clans, while the Blackfoot were bilateral. This meant a Blackfoot could trace his or her lineage through both sides of the family. A Blackfoot woman generally joined her husband's band upon marriage. Like other tribes, chiefs led the extended Skidi Pawnee families. The chief's sons usually followed in his footsteps and became family leaders after their fathers' deaths. Unlike the Blackfoot tribe, however, once a young Pawnee man married he lived in the earth lodge of his wife's family.\n\nThe tribes of the Great Plains also had different traditions of courting\u2014what we would call dating today. Courting with blankets was part of the Cheyenne lifestyle. A single girl who was of age might stand in front of her family tepee wrapped in a blanket. Young men who were attracted to her would stand in line for a chance to enter the blanket with her. The young girl would invite the man of her choice to stand with her inside the folds of the blanket. There, they would stand face to face, sharing a few innocent moments together.\n\n**On the Great Plains, the men of the tribe were responsible for hunting buffalo. This animal provided the tribe with meat for food. The buffalo's hide could be used to make clothing, blankets, or tepee coverings and its bones could be made into tools. Women of the tribe dried the meat and prepared the skins, as this 19th-century photograph shows. The women in the center and on the right have staked out the hides and are beating them with sticks as they dry in the sun.**\n\n**Hopi women check on a meal they are baking in an adobe oven.**\n\nA young Sioux man who was interested in a young woman might attempt to win her favor by playing love songs for her on a flute. He could also use the flute to send her special, secret messages that were in a code only he and his beloved understood. If she indicated that she was interested in him, the young man might begin to pursue her more openly.\n\nThe parents of a Cora groom would make a number of ritual requests to the bride's parents. The bride's parents could then accept or decline the marriage proposal. The Cora people also gave their young adults a form of premarital counseling. Elders from the family relayed marital advice of the ancestors to the couple in a ceremonial meeting.\n\nChildren living in the southwest played a variety of games. One shared by several tribes was a game of skill that involved a hoop and some darts. A player would roll a hoop across the ground as fast as he or she could. Other players would try to throw darts through the moving hoop. Each player had different-colored darts to make keeping score easier.\n\nSouthwest girls and boys often played running games. Kick-ball was played, and contests in relay racing were often held between villages, tribes, or bands. Sometimes, different villages staged races during which gambling and feasting took place. The racers often ran distances of up to 25 miles.\n\nPlains families sometimes played shinny. This was a game that used special sticks and a small ball. It was played much like modern-day field hockey. Young boys were also expected to practice with their bows, lances, and other weapons so that they would become good hunters and help provide food for the tribe one day. \u00a7\n\n**These Athabaskan parents stand proudly behind their children, who hold up the otters they have trapped. Family life was especially important to the Native Americans of the far north.**\n**5 Families of Abundance and Subsistence**\n\nThe Native Americans who lived in what today are the northwestern United States and Canada had very diverse lifestyles. The Northwest was a land of abundance. The people living here did not have to work as hard as the natives living in the far north. The Arctic and subarctic regions, on the other hand, were areas in which farming was impossible and survival was difficult.\n\nTraditionally, bilateral extended families formed the basis of most Arctic Inuit societies. Although Inuit society was primarily arranged around the nuclear family, the Inuits also maintained close relationships with their extended family members.\n\nNuclear and extended families often lived together. If they did not share the same winter sod home or summer caribou-skin tent, they often lived close to one another in small communities. Individual survival in the Arctic regions was dependent upon the cooperative contributions of all family members, especially during whaling season.\n\nAbove all else, Inuit men needed to be hunters and fishermen of the highest quality. Life in the Arctic depended upon stockpiling foods such as whale, seal, caribou, and arctic char. In coastal whaling villages, whaling captains were highly respected and admired. In villages that did not whale, the best hunters were held in high regard. Respected and admired above all Inuit men, however, was the family shaman.\n\n**Women of the northwestern tribes were well known for the watertight baskets they wove from grasses and plants, as well as their for beautifully decorated wooden boxes. The boxes were so finely fitted together that they could be used to cook food. Very hot rocks were put into the box around or under the food. The box was then closed and the food was left to cook in this small wooden oven. The tighter the box was fit together, the more heat it would hold in and the better it would cook food.**\n\nThe Inuit shaman possessed a gift for contacting spirits. He was also a wise man, able to instruct his people in times of trouble. The Inuit shaman was a healer and teacher who had great knowledge of humans, animals, and the spirits. A good shaman knew many herbal remedies and other types of treatments for illnesses.\n\n**Members of an Inuit family sit down together for a meal. Traditionally, the Inuit maintained close relationships with both immediate and extended family members.**\n\nInuit women of the Arctic were mothers, wives, homemakers, and gatherers. They kept track of the family food supplies. They sewed fine fur parkas to keep their husbands and children warm. They sewed seal-and walrus-gut raincoats to keep their husbands and sons dry during whale and seal hunting season. They collected salmonberries and other edible tundra plants in the late spring, summer, and early fall.\n\n**This painting of Inuit snow cottages, also called igloos, was made around 1834 by a man who had sailed with Captain James Ross's polar expedition. Ross was a 19th century English explorer who traveled to both the Arctic and Antarctic regions. After returning from the Arctic in 1833, he described how the Inuit people he met lived.**\n\nInuit children were often adopted out of large families and into smaller ones. This was done so that they would receive the amount of food, shelter, attention, and clothing necessary for survival in the harsh environment of their homeland. Children who were adopted into another family often grew up knowing both sets of parents. As this was an accepted and understood practice, they did not feel ashamed or unwanted because of their adopted status.\n\nAn Inuit girl who was fully grown exchanged the clothes of her childhood for those of an adult woman. In some Inuit groups, she was also tattooed to mark her status as an adult. Inuit boys also changed their style of dress when they became recognized as grown men.\n\nWhen an Inuit boy was deemed ready for marriage, two slits were cut in his cheeks or near the corners of his mouth. Ivory or bone cheek or lip plugs were placed in the openings. These cheek plugs visually announced to all that the boy was now a man, eligible for marriage.\n\nAnother people of the Arctic were the Aleut, who lived in the far northwest. The Aleut traced their family relatives through their mother's family bloodlines. Aleut society had hereditary classes of high nobles, commoners, and slaves. The leaders were recruited from the high nobles' class. They lived in communal homes called _barabaras_.\n\n**GAMES OF THE NORTH**\n\n**Native American children who lived in the Far North and Northwest played a variety of games. In some areas of the Arctic children played a game called \"polar bear.\" One child pretended to be a sleeping old lady. Another pretended to be her sleeping child. The \"polar bear\" snuck up to them and took away the sleeping child. The \"child\" had to hide wherever the \"polar bear\" put him or her. The \"old lady\" was then awakened and had to search for her child.**\n\n**Inuit kick-ball was played with a stuffed ball made from caribou or other animal skin. Two teams opposed each other and tried to maintain control of the ball. There were no goals like in soccer, but the game resembled modern-day soccer in many other ways.**\n\n**Story telling was another form of Inuit entertainment. At night, when the family was safe inside their home, a father would entertain his children and wife with tales from his life or the lives of his ancestors. During this special family time, he would share stories that taught his children the history of their people, the values of their culture, and the teachings of their religion.**\n\n**Northwest boys competed against each other in foot races, archery contests, and wrestling matches. The girls played with carved wooden dolls. Both girls and boys swam and played on the beaches.**\n\nIn comparison to the subsistence families of these other regions, the people of the Northwest lived in relative splendor.\n\nThe Northwest Haida were divided into two phratries: the Raven and the Eagle. Each of these was divided into a large number of clans. One or more clans formed a village. Haida clans were matrilineal.\n\n**Boys and girls alike played a game much like modern-day horseshoes. Stakes were driven into the ground at opposite ends of a playing field. The players tossed roots at these stakes and tried to see who could land their root closest to the stake.**\n\n**Families in the subarctic culture region played a game that was similar to the shell game. Players would each be given an equal number of tokens or markers of some sort. A player would take one token and then with both hands out of his or her opponent's view, place it in one hand. Now, he or she would display two clenched fists. The opponent would guess in which hand the token was being held. If he or she guessed correctly, the prize was the marker. When one player ran out of markers, the other player was declared the winner.**\n\n**Young Sanpoil girls of the plateau area played with dolls. They made these dolls by sticking clay balls atop sticks and wrapping them in bits of animal skin. The boys played with tops that were made from available local hardwoods. Sanpoil girls and boys turned somersaults, practiced walking on their hands, and did handstands. Their parents liked to play gambling games. Entire families enjoyed playing several games of skill that used hoops and poles.**\n\nHaida men's titles and wealth were inherited through the mother's side of the family. Men, however, owned the houses in Haida society. The fathers' clans built these wooden-plank longhouses. When a man died, his sister's eldest son inherited his house.\n\nHaida clan chiefs were men. All of the clan chiefs of a village would be members of a council. The wealthiest clan chief was recognized as the village chief.\n\nHaida marriages were often arranged. The two parties who were to be married had to be from different clans. They also were expected to be from the same social class. Sometimes, marriages were arranged when the husband- and wife-to-be were still small children. Unless one of the two children disgraced themselves or their families, they would usually be married to their arranged spouse when they came of age.\n\nIf a Haida man neglected or abused his wife, her parents had the right to take her and their grandchildren away from him. If he left his wife for another woman, then he was forced to pay reparations to his first wife. If he refused, he was punished severely, sometimes by death. However, if there was no other woman involved, a Haida man could leave his wife and family without fear of retribution.\n\nAnother tribe of the Northwest was the Cayuse. In this tribe men and boys hunted for food and to provide hides for clothing. They also provided their people with animal bones and antlers for making tools and utensils. Elk, deer, bear, antelope, and mountain sheep were hunted across their north-central North American homeland. The Cayuse men were accomplished hunters who learned to be comfortable hunting with bows, spears, knives, nets, and traps. Cayuse men also fished for salmon. This was often done from shore, using long-handled dip nets. The nets were used to reach out into the rushing streams and capture salmon that were swimming upstream to spawn.\n\nCayuse women cleaned salmon and hung them on long racks to dry in the sun. They dug for roots using wooden or bone digging tools. They mashed roots together and shaped them into little balls to make small sun-dried biscuits. When there was time, the Cayuse women took their children into the mountains to go berry picking. There they would pick huckleberries for drying. They also picked chokecherries to mix with dried meat or fish to make pemmican.\n\nChildren of the Salish tribe, which lived on the coast of North America, spent a lot of time with their grandparents while their parents were hunting, fishing, or gathering food. In fact, grandparents were the primary teachers. They taught family history, as well as the qualities and skills the young Salish children would need to be a good member of their society. \u00a7\n\n**The members of this family are Maya Indians of Central America. Around 1,600 years ago, their ancestors established a highly evolved society in Mexico and Central America. Today Mayan families still follow some of the same practices of the ancient Maya.**\n**6 Family Ties in Central and South America**\n\nBefore the arrival of Europeans during the 16th century in the region today called Latin America, two of the major native groups were the Maya of Mexico and Central America and the Inca of South America.\n\nThe Inca of South America had a hierarchical, patriarchal class structure. Men were the heads of their families and of the Incan society. Families were divided into classes. The ruling class was composed of the ruler and his family members. Temple priests, architects, and regional army commanders were lower in class only to the elite members of the ruling-class family. The two lowest classes were made of artisans, soldiers, and peasant farmers. These farmers grew all of the crops necessary to feed their own families, as well as the families of the upper classes.\n\nRuling-class women sometimes had power, but it was more usual for rulers to be men. The sapa (high priest or ruler) and the army commander were the most important men in any Incan village.\n\nInca women used llama wool and cotton to weave cloth. Dyes were made from indigo and other plants. The finest dyed and woven cloths were given to the ruling class. A particularly fine weaving might be given to the gods during an important religious ceremony. Cloth was also used as a material for bartering. Fine cloth might be traded for cocoa, turkey, or even gold.\n\n**Both the Inca and Maya enjoyed a special ball game. Most cities had ball courts close to their centers, and ball games were a big event. To play, two teams faced off on the ball court. The players could not touch the ball with their hands\u2014they could only use elbows, knees, or hips. The players scored by touching special markers or passing the ball through their team's ring.**\n\nInca children did not always live long lives. Sometimes, they were chosen to serve as sacrifices to the Sun God. These children were taken high into the mountains and buried alive with food, corn beer, and coca leaves during annual ceremonies that were held to ensure a good harvest and a happy Sun God. To be chosen to serve as a sacrifice was considered to be a great honor.\n\nInca men were expected to marry by the age of 20. Brides and grooms would exchange sandals at their wedding ceremonies. Inca leaders married their sisters to keep the blood of their families pure. Their sisters became their first, or principal, wives. The Inca tradition was for the son of the ruler and his principal wife, or sister, to be the heir to the throne.\n\nLike the Inca, the Maya of Central America also had a family-based caste system. Caste membership was hereditary. The elite noble class was made up of the ruler, his family, nobles, and priests. Upon the death of a ruler, his son or brother took his place. Mayans who were not born into the elite noble class were divided into a class of warriors, a middle class of tradesmen and craftsmen, or a lower-class peasantry.\n\n**Inca men loosen the soil with a taccla (foot-plow), while women behind them sow seeds in this drawing from an Inca codex. The book, which dates to 1565, is the only codex in existence that shows drawings of 16th-century Peruvian life.**\n\nMayan working-class men were skilled tradesmen. The peasant men were farmers. They spent most of their days in the fields. They grew maize (corn), cotton, beans, squash, and cacao. Mayan peasant women were often skilled weavers as well. They used cotton to weave cloth. The dyes used by Mayan women included indigo, brazil wood, logwood, annatto, and iron oxide. They also made baskets.\n\nSoon after birth, a Mayan infant's head was pressed between two boards. It was secured and left this way for several days. The pressure reshaped the child's skull. It is believed that this was done to make the shape of the head resemble that of an ear of corn.\n\nUpper-class Mayan children were taught to read and write using pictograms and hieroglyphics. They studied religion, math, and astronomy. They also studied the Mayan calendar and learned to count and write out the Mayan numeral system.\n\n**If an Inca child went to school, the child was taught to make and read the Inca _quipu_. A _quipu_ was made of many colored knots tied together. The way that the knots were spaced and the colors of the cotton rope used to make them all had special meanings. Religion, law, and math were also studied.**\n\nWhen Mayan boys and girls became teenagers, they participated in a celebration called the \"Descent of the Gods.\" After this, a matchmaker could negotiate their marriages. The bride's father expected to receive a good price for his young daughter's hand in marriage. The bridegroom's father would try to negotiate a fair amount of time for his son to work for his father-in-law. After the marriage, the husband would have to work for his wife's parents for five to six years. \u00a7\nCHRONOLOGY\n\nBefore 10,000 B.C. | **Paleo-Indians migrate from parts of Asia and begin settling throughout the Americas.**  \n---|---  \n10,000\u20135000 B.C. | **Medicine-wheel spiritual sites are built in the Great Basin region.**  \n6000\u20135000 B.C. | **The subarctic regions are settled as the climate begins to warm with the waning of the last Ice Age.**  \n5000\u20133000 B.C. | **Earliest-known organized Native American settlements are built in the Southeast.**  \n1400 B.C.\u2013A.D. 1500 | **Northeastern woodland cultures rise and prosper.**  \nA.D. 300\u2013900 | **Maya civilization reaches its highest point.**  \n300 | **Native Americans begin settling in the Plains region and migrating with the buffalo herds and the seasons of the year.**  \n1400\u20131521 | **The Aztecs dominate Mesoamerica.**  \n1492\u20131502 | **Columbus explores the West Indies and Central America.**  \n1740\u20131780 | **European wars in the Northeast severely affect lifestyles of Native Americans in this region.**  \n1760\u20131848 | **Growing Spanish influence around California begins to have impact on the lives of Native Americans in this region; missionaries begin attempts to \"civilize\" and \"Christianize\" Native Americans of this area.**  \n1830 | **Congress passes the Indian Removal Act, calling for Native Americans living east of the Mississippi River to be moved to a government-established Indian Territory located in what is present-day Oklahoma.**  \n1838 | **Cherokee are forced to move from the Southeast to Oklahoma on the \"Trail of Tears.\"**  \n1887 | **The Dawes\/General Allotment Act divides reservations into 80- and 160-acre tracts; these land parcels are to be owned by individual Indians.**  \n1952 | **Federal Relocation Policy is passed; this policy seeks to terminate all government services for Native Americans, negate treaty agreements, and relocate Native Americans from reservations to inner cities.**  \n1971 | **Congress passes Alaska Native Claims Settlement Act.**  \n1972 | **\"Trail of Broken Treaties\" organized by AIM results in a weeklong occupation of the Bureau of Indian Affairs headquarters in Washington, D.C.**  \n1992 | **This year marks the 500th anniversary of Columbus' entry to the West Indies, prompting many Native American artists to create artwork expressing their feelings about Columbus and subsequent Europeans and their effects upon the Native American culture.**  \n2013 | **Recent census figures indicate that there are more than 5.2 million Native Americans living in the United States and Canada.**\nGLOSSARY\n\n**acclimate** to adapt to a new temperature, altitude, climate, environment, or situation.\n\n**bilateral** having two sides.\n\n**breechcloth** a cloth worn about the loins or hip area.\n\n**cassava** a type of melon.\n\n**caste** a division of society based on differences of wealth, inherited rank or privilege, profession, or occupation.\n\n**char** a small-scaled trout with light-colored spots.\n\n**clan** a group of people tracing descent from a common ancestor.\n\n**erosion** the wearing away of soil, usually by wind or water.\n\n**fast** to go without food for a period of time.\n\n**kiva** a ceremonial structure that is usually round and partly underground.\n\n**lineage** descent in a line from a common progenitor.\n\n**longhouse** a long communal dwelling.\n\n**matrilineal** relating to, based on, or tracing descent through the maternal line.\n\n**moiety** one of two basic complementary tribal subdivisions.\n\n**oratorical** relating to speaking in public eloquently or effectively.\n\n**palisade** a fence of stakes designed for defense.\n\n**paternal** of or relating to the father.\n\n**patriarchal** characteristic of a social organization marked by the supremacy of the father in the clan or family.\n\n**patrilineal** relating to, based on, or tracing descent through the paternal line.\n\n**pemmican** a concentrated food consisting of lean meat dried, pounded fine, and mixed with melted fat.\n\n**sagamore** a subordinate chief of the Algonquian Indians of the North Atlantic coast.\n\n**totem** an object serving as the emblem of a family or clan and often as a reminder of its ancestry.\n\n**vision quest** a personal spiritual search undertaken by an adolescent Native American boy in order to learn the identity of his guardian spirit.\n\n**wickiup** a hut with a usually oval base and a rough frame covered with reed mats, grass, or brushwood.\n\n**wigwam** a hut having typically an arched framework of poles overlaid with bark, rush mats, or hides.\nFURTHER READING\n\nBrasser, Theodore. _Native American Clothing: An Illustrated History_. Buffalo, N.Y.: Firefly Books, 2009.\n\nCarew-Miller, Anna. _Native American Confederacies_. Philadelphia: Mason Crest Publishers, 2014.\n\nHoffman, Elizabeth DeLaney. _American Indians and Popular Culture_. 2 vols. Santa Barbara, Calif.: ABC-CLIO, 2012.\n\nOberg, Michael Leroy. _Native America: A History_. Malden, U.K.: Blackwell Publishing, 2010.\nINTERNET RESOURCES\n\n**http:\/\/www.csulb.edu\/colleges\/cla\/departments\/americanindianstudies\/faculty\/trj\/**\n\nWebsite of the American Indian Studies program at California State University, Long Beach, which is chaired by Professor Troy Johnson. The site presents unique artwork, photographs, video, and sound recordings that accurately reflect the rich history and culture of Native Americans.\n\n**http:\/\/www.nativeweb.org\/resources\/**\n\nThis Web site features a collection of resources and links to informative Native American Web sites.\n\n**http:\/\/nmai.si.edu\/home**\n\nThis site contains fascinating information collected by the Smithsonian Institution about Native American history and culture.\n\nPublisher's Note: The websites listed on this page were active at the time of publication. The publisher is not responsible for websites that have changed their address or discontinued operation since the date of publication. The publisher reviews and updates the websites each time the book is reprinted.\nINDEX\n\nAleut,\n\nAlgonquians, , ,\n\nApache, \u2013\n\nArctic, , ,\n\nAtlantic Ocean,\n\nCanada,\n\nCaribbean Sea, ,\n\nCaribs,\n\nCayuse,\n\nCentral America, ,\n\nCheyenne,\n\nCora,\n\nCreeks,\n\nDelawares,\n\n\"Descent of the Gods,\"\n\nEuropeans, ,\n\nGreat Plains, , \u2013\n\nGuyohkohnyoh (Cayuga),\n\nHaida, \u2013\n\nHaudenosaunee (Iroquois), \u2013\n\nHopi, \u2013\n\nIncas, \u2013\n\nInuit, \u2013\n\nKanienkahagen (Mohawk),\n\nLakota Sioux,\n\nLatin America,\n\nMaya, , \u2013\n\nMexico,\n\nMi'kmaq,\n\nNative American families adoption, \u2013\n\ncaste system,\n\nclan, , , , , , , , \u2013\n\nextended family, , , \u2013, \u2013, , ,\n\nintertribal family,\n\nkin groups,\n\nnuclear family, , , , \u2013, , \u2013, ,\n\nphratries,\n\nNorth America, , , , ,\n\nOnayotekaono (Oneida),\n\nOnondowahgah (Seneca),\n\nOnundagaono (Onondaga),\n\nPawnee,\n\nSalish,\n\nSeminoles,\n\nSioux, ,\n\nSka-Ruh-Reh (Tuscarora),\n\nSouth America,\n\nSpanish,\n\nSun God,\n\nTainos, , , \u2013,\n\nThree Sisters, ,\n\nTimucua,\n\nUnited States,\n\nYouth's Vigil,\n\nZu\u00f1i, \nPICTURE CREDITS\n\n 3: Library of Congress\n\n 8: David and Peter Turnley\/Corbis\n\n: Library of Congress\n\n: Nathan Benn\/Corbis\n\n: Jim Richardson\/Corbis\n\n: AINACO\/Corbis\n\n: Library of Congress\n\n: (top) \u00a9 OTTN Publishing; (bottom) Library of Congress\n\n: Hulton\/Archive\/Getty Images\n\n: Hulton\/Archive\/Getty Images\n\n: Historical Picture Archive\/Corbis\n\n: Richard A. Cooke\/Corbis\n\n: Library of Congress\n\n: (top) Hulton\/Archive\/Getty Images; (bottom) Bettmann\/Corbis\n\n: Bettmann\/Corbis\n\n: Joel Bennett\/Corbis\n\n: Richard A. Cooke\/Corbis\n\n: Hulton\/Archive\/Getty Images\n\n: Jeremy Horner\/Corbis\n\n: Werner Forman\/Art Resource, NY\nCONTRIBUTORS\n\n**Dr. Troy Johnson** is chairman of the American Indian Studies program at California State University, Long Beach, California. He is an internationally published author and is the author, co-author, or editor of twenty books, including _Wisdom Spirits: American Indian Prophets, Revitalization Movements, and Cultural Survival_ (University of Nebraska Press, 2012); _The Indians of Eastern Texas and The Fredonia Revolution of 1828_ (Edwin Mellen Press, 2011); and _The American Indian Red Power Movement: Alcatraz to Wounded Knee_ (University of Nebraska Press, 2008). He has published numerous scholarly articles, has spoken at conferences across the United States, and is a member of the editorial board of the journals _American Indian Culture and Research and The History Teacher_. Dr. Johnson has served as president of the Society of History Education since 2001. He has won awards for his permanent exhibit at Alcatraz Island; he also was named Most Valuable Professor of the Year by California State University, Long Beach, in 1997 and again in 2006. He served as associate director and historical consultant on the award-winning PBS documentary film _Alcatraz Is Not an Island_ (1999). Dr. Johnson lives in Long Beach, California.\n\n**Colleen Madonna Flood Williams** is the wife of Paul R.Williams, mother of Dillon Joseph Meehan, and daughter of Patrick and Kathleen Flood. She lives in Alaska with her husband, son, and their dog, Kosmos Kramer. She has a bachelor's degree in elementary education with a minor in art.\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":"\n\n**EARLY BIRD BOOKS**\n\n**FRESH EBOOK DEALS, DELIVERED DAILY**\n\nLOVE TO READ?\n\nLOVE GREAT SALES?\n\nGET FANTASTIC DEALS ON BESTSELLING EBOOKS\n\nDELIVERED TO YOUR INBOX EVERY DAY!\n\n# Crazy in Berlin\n\n### Thomas Berger\n\n_TO JEANNE_\n\n# Contents\n\nCHAPTER 1\n\nCHAPTER 2\n\nCHAPTER 3\n\nCHAPTER 4\n\nCHAPTER 5\n\nCHAPTER 6\n\nCHAPTER 7\n\nCHAPTER 8\n\nCHAPTER 9\n\nCHAPTER 10\n\nCHAPTER 11\n\nCHAPTER 12\n\nCHAPTER 13\n\nCHAPTER 14\n\nCHAPTER 15\n\nCHAPTER 16\n\nCHAPTER 17\n\nCHAPTER 18\n\nCHAPTER 19\n\nCHAPTER 20\n\nCHAPTER 21\n\nCHAPTER 22\n\nCHAPTER 23\n\nAuthor's Note\n\nA Biography Of Thomas Berger\n> _Du bist verr\u00fcckt, mein Kind;_\n> \n> _Du musst nach Berlin..._\n> \n> You are crazy, my child;\n> \n> You must go to Berlin...\n> \n> \u2014Old song\n\n# _CHAPTER 1_\n\nIN THE TWILIGHT, THE bust appeared to be that of some cocked-hat Revolutionary War hero of not the very first rank, that is, not G. Washington but perhaps one of those excellent Europeans noted in fact and apocrypha for throwing their weight on our side, Lafayette, say, or von Steuben. _Fun Shtoyben_ was the right way to say it, which Reinhart knew and was certain that Marsala didn't, being his dumb but lovable buddy who was now gurgling at what was left of the bottle and would shortly hurl it away, maybe hurting someone, for a few Germans sat around in the park; he must warn him. But too late, there went the crash and narrowly missing a Kraut who merely smiled nervously and moved off, some difference from a movie Nazi who, monocled and enraged, would have spat in your face, and they were already taking a leak on Lafayette or whoever\u2014no, \"Friedrich der Grosse,\" the pedestal said, for Reinhart had a lighter that could be worked with one hand.\n\nAnd it was a gross thing to do, he decided in one of those drifts of remorse that blow across a drunk\u2014because he was just educated enough to recall vaguely old Frederick out at Sans Souci with Voltaire, writing in French, representing the best, or the worst, of one tradition or the other\u2014a part of the punkhood from which he had just this day legally departed, and which he was, in fact, at this very moment celebrating.\n\nFastening the fly, all one hundred buttons, no zippers in the Army because you might get caught in one as the enemy crept close, he said, just as sad as he had before been exuberant: \"What a way to pass your twenty-first birthday!\"\n\n\"Well,\" answered Marsala, twenty-four, looking forty, and always fit whatever his condition, spitting, not taking out his cigarette, and miffed, \"we could of made you a party from the messhall: them cooks are all my friends. What are you, griping?\"\n\nAs they turned to leave the park, a German nipped up and snatched the butt. There stood a woman by a tree. \"Honey,\" Marsala shouted, \" _schlafen mit_ me, ohhh won't you _schlafen mit_ me!\" A kind of music the making of which was his satisfaction, for having crooned it he moved on indifferently.\n\nOn the street they encountered a Russian soldier, far from home, needless to say unkempt and weary, destination unknown most of all to himself. In the friendly light of his hound's eye they accepted, and Reinhart returned, a salute; he went on in a hopeless, probably Slavic, manner. A two-car streetcar braked to a glide and they swung aboard, paying no fare because they were Occupation; and a good thing they hadn't to, for in a moment the son of a bitch stopped and everybody detrained and walked around a bomb crater to another car waiting on the other side, Marsala all the while looking truculently hither and yon: he was amiable only to his friends.\n\nThe ride on the new car Reinhart forgot even as it was in progress, for he had now reached that secondary state of inebriation in which the mind is one vast sweep of summer sky and there is no limit to the altitude a kite may go, the condition in which one can repair intricate mechanisms at other times mysterious, solve equations, craft epigrams, make otherwise invulnerable women, and bluff formidable men, when people say, \"Why, _Reinhart_!\" and rivals wax bitter. Here he was in Berlin\u2014the very name opened magic casements on the foam of seas perilous not two months since: Hitler was rumored to be still at large, the C.O. had been briefly interned by the Russians, and Art Flanders, the \"crack foreign correspondent whose headquarters were in the saddle\" and column in 529 dailies from Maine to the Alamo, had already called at the outfit for human-interest sketches.\n\nIndeed, the sheer grandeur of his geographical position had overwhelmed Reinhart until this very day, for he was an irrepressible dreamer. Marsala had been out screwing and playing the black market for a week, with already a dose of crabs and a wad of Occupation marks to show for it, and at the same time bitching incessantly that they might be stuck there forever\u2014and nonpartisan in his disinterest in any place but Home. No, he wouldn't have liked to be stuck in Calabria any better, besieged by his indigent relatives and wallowing in the dirt and backwardness for which no one could tell him of all people, his father having come from there, that Italy was not famous. \"I got your Roman ruins and your art right here,\" he would sometimes say, grabbing his clothes in the area of the scrotum\u2014the same place, in fact, that the Romans had had them\u2014\"You take that crap and give me the United States of America.\"\n\nNow, on the car, Marsala was once again the sound of unadorned naturalism, his hard voice, the one for enemies, piercing Reinhart's shoulder, for that was all the higher he came, like a rusty blade: \"You call it. I'll kick it out of you wherever you want.\"\n\nHis target was sealed with them in the crowd on the rear platform: an American soldier, between whom and Marsala stood, swaying with the general rhythm of the rocking car, a female citizen. Her visible part was a head of blonde hair, with a good washing probably as pale as Reinhart's own, but at present long estranged from soap and comb and as stringy as an Assyrian's beard. Notwithstanding that he had barracked with the man for two years, in whatever land, Reinhart supposed, first, a mistake, and, second, that Marsala was wronged, but these suppositions could not dwell long even in a flushed mind, for he saw the face of the other soldier charged with righteous outrage. A big man, maybe six even, with his weight from front to back, rather than in width, if one could tell from a limited view of his shoulders and fat, seedy head. He struck you right off as a lousy guy, a type who had been drafted from the driver's seat of a big-city bus, where he cursed _sotto voce_ at proffered dollar bills and depressed the door-lever on latecomers; a journeyman in the Shit-heels' Guild whose meanness was, after years, instinctive\u2014but all this was irrelevant beside the fact that in a quarrel involving a woman Marsala invariably stood on the bad side. He had surely with one of his sexual instruments, voice, hands, or groin, sought an unsubtle connection\u2014for him a crowded streetcar was as good as an alley and being caught out only a minor inconvenience soon adjusted in his favor: he had a friend, while the other man was alone.\n\nThus was Reinhart's euphoria wrenched away; what Marsala expected of him was by the known pattern of his friend's code so obvious as to go unstated. When the car stopped at the next bomb crater and the German passengers, all slumped and carrying bundles, duly filed around its margins to still another vehicle, the three soldiers and one girl drew apart and, out of a sudden sense of national delicacy, waited until the new car started away and the old reversed trolleys and started back. Then Marsala snarled, \"Let's get him,\" pitching in before the other man, now manifestly regretting where amour propre had led him as he saw Reinhart's large figure on the hostile side, had got ready: he was in the act of removing his blouse, newly pressed, perhaps by the girl, and bearing the triangle of the Second Armored Division which had fought all the way from Africa\u2014while Reinhart and Marsala were goofing off in Camp Grant, Illinois, Devonshire, and some tent city in long-liberated Normandy.\n\nAs a medic, and rear-area at that, Reinhart had no moral guts to oppose a combat man, even for cause, even when alcohol had anaesthetized his rational-young-man's disinclination to violence\u2014and as for two setting upon one, its morality threw him into a state of shock. He stood in his tracks, feeling undue exposure, lighting a smoke, and out of a complex shame not looking at the girl, and saw Marsala imprison the opponent's arms with the half-removed jacket and call: \"Okay, Carlo, in the nuts!\" Saw him, not able to resist his advantage until help arrived, give the man one with the knee.\n\nHis reaction to Reinhart's coming and pulling him loose was pure astonishment, hopefully as yet unalloyed with bitterness\u2014he must have supposed it the prelude to a more cunning mayhem\u2014and he had just time to begin \"What the fu\u2014\" before the freed adversary got a hammerlock on his throat and booted Reinhart from the field.\n\nThey fought on the site of a ruin. As Reinhart lay on the crushed-masonry ground, beneath a roof-to-basement cross section of fourteen flats, their cavities spilling tubs and bedsteads, he could not even have said where. On to two weeks in the city, and this was his first trip off base. His old buddy, for his birthday, had taken him to a black-market contact with Russian hootch to sell, his old buddy who in the grunting ranges overhead was at this moment being slaughtered. So he raised himself, hot and vital and clear, seized the traitorous and ugly bastard from the Armored by the back of the shirt-neck, turned him, and delivered two hundred three and a half pounds to the gut, to the eye and into the mouth. The man's meat broke wetly under his fists and yet retreated at one point to bulge at another, like some hateful sack of liquid, and it was for a time a joyful rage to work for a simultaneous and general recession. But where it took him was too terrible\u2014all at once he gave it up. The enemy, in a vast cobweb of blood, still stood. Odd, he appeared old, perhaps forty; his cap had gone, showing an area of baldness pitifully made conspicuous by a strand of hair deviated to hide it. He was standing\u2014but it was suddenly obvious that he was very dead.\n\nReinhart had broken both hands at the wrist. His lungs were gone, as well; his stomach was acid and his wit beclouded once more. It was so frightening that a corpse should remain upright. He watched Marsala come round and head-butt it in the midsection. It revived, and it fell, simply a beaten man, with an awful, beaten groan.\n\n\"Jesus,\" said Marsala. \"Not a car in sight. We might have to walk all the way back just because of this prick of misery. You did good, Carlo,\" he went on, rubbing his sore neck, which made a rasping noise, for he had an emery-paper beard. Kept rubbing, but he was in some awe.\n\nReinhart had not been in a fight since early grammar school and therefore had never known how it felt to kill a man and what, when done, was the peculiar scandal. He looked to the girl, who was some distance removed in the capacity of spectator, and who in return looked at him with stupid wonderment, and commanded her to approach. Which she did with a senseless caution, as if to ask: is my turn next?\n\n\"Why don't you attend to him?\"\u2014approximately; his German was at best uncertain and now surely further corrupted by the intermittent buzzer in his skull.\n\n\"Well, yes, if you wish,\" she replied, still showing wonder, and speaking from a face in which the ages were so mixed that one knew not whether oldness or youth was the essence. She knelt in worn clothing more suited to that attitude than the standing and examined the felled opponent, who even at her touch was coming painfully around. Who when he arrived came up slowly and resentfully from the supine, crying: \"Keep your whore off me!\" With more effort he was arisen and deliberately, crazily, gone across the ruin and onto the sidewalk, where it could be found and where not, the street, where, alone, he could be seen for a great time, despite the darkness now settled.\n\n\"Hadn't you better follow him?\" Reinhart asked incredulously. \"If the car does come he may be hit.\"\n\n\"Must I?\" She was nearer him now and, it struck him repugnantly, believed herself a transferred spoil of war.\n\n\"No, of course not, not if you haven't any _decency_.\" The last word in English; he didn't know it in German, and she didn't know it this way or, in truth, hadn't any, for she smiled.\n\nNothing smelled ranker than disloyalty. He had wanted so much to approve of the first German girl he met\u2014for this was she, not counting the women seen from train and truck on the journey to Berlin or the cleaning and secretarial help\u2014if for nothing else, as an act of anti-piety against the established faith. The very faith of which, curiously enough, he found himself at least a part-time worshiper, one of those half-agnostics who go to church without believing or stay home and believe; whatever, he had waited two weeks before going on pass, since this was the best manner in which to avoid Germans and still ache, with trepidation and even a kind of love, to see them.\n\n\"If I must go\u2014 _wiederschau'n_!\" She extended her hand in the genuine enthusiasm displayed by all Europeans, not just the French, upon arrivals and departures, as if for all their hatreds they love one another, or do for a moment at making and breaking contact, and at this first touch in ten minutes not motivated by hostility, Reinhart suddenly felt drunken again and feared that he might weep\u2014for the sore opponent vanished alone in the night, for his friend who did not understand fighting fair, for the girl now under his compulsion, and for the material things in waste all about them, all the poor, weak, assaulted and assaulting people and things, and of course for himself, isolated by a power he didn't want.\n\nBut certainly he did not cry. Instead he gave her his dizzy eyes and said:\n\n\"It's a terrible thing to desert a friend.\"\n\n_\"Bitte?\"_\n\nHe repeated it, as near as he could come, in German, and she replied:\n\n\"There was nothing else you could do. He would have killed the small man.\"\n\n_She_ was granting _him_ absolution! But his anger did at any rate conquer the sadness. He barked his ill will towards a woman who leaves a beaten man, and in a moment found his only ease in the thought that with luck his speech had been too bad for her full comprehension. For she had answered:\n\n\"I was not _with_ the soldier! Believe me, in all my life I have never before seen him!\"\n\nSo much for that. And Marsala, who had had his rest, was prepared to reassume the command so lately transferred; he might defer to Reinhart, from now on, in matters of personal combat, but surely never in affaires d'amour.\n\n\"C'mon, why mess with this one? A pig,\" he said without malice, perhaps kindly, if you wished to look at it that way, for there was no point in stirring up the girl's hopes, but anyhow with the candor of the unembellished man, which was just what Reinhart prized highest in Marsala and why he associated with him rather than with the refugees from college. The cruelty was an inseparable element of the greater value, a unique honesty and a kind of honor: Marsala never assumed an ethical superiority to anyone else. But he was generous in granting one, for now no sooner were his comments out than he showed with a bored jerk of the head that the girl's pigness was suddenly understood as Reinhart's precise interest.\n\n\"If the girl didn't belong to him,\" asked Reinhart, \"what in hell was the beef?\"\n\n\"How should I know?\" Marsala's swarthy head revolved in unworried failure to understand the provocations constantly offered; the world was full of enemies, that was all. You watched, you took care of them, they took care of you\u2014you did not look for a reason and you didn't actually feel any lasting grudge. \"There's all kinds of bastards around.\" He scratched his boot-toe in the rubble. \"If you really want to know, he called me a guinea.\"\n\nReinhart, missing the sly grin of mock piety and having learned Marsala's elaborate code regarding these nicknames\u2014Marsala himself habitually used them and especially those applying to his own kind, but denied the latter to non-guineas except people like Reinhart who held an honorary card\u2014merely said \"Oh\" and turned to the Kraut girl.\n\nAt close view he decided she was young and that her longitudinal lines of cheek and veteran eyes were from lifelong residence in a sanguinary country, but the darkness forbade one's being sure. She had merely come to watch a fight?\n\n\"One has to admit that it was interesting.\" She had moved very close to him, perhaps because of the dark, and there was enough light to see that just a chance remained to make her attractive, at least to get by. Reinhart would have liked to seize and scrub and comb and color and dress her\u2014to straighten her out; the world was filled with people who out of simple inertia wouldn't make a move to fulfill their own promise.\n\n\"But,\" she went on, \"you are a noncommissioned officer. Please, may I ask you: how does one get a job with the Americans?\"\n\n\"There are places for such things,\" he disappointedly replied. He hadn't known _what,_ yet had hoped for something other than the humdrum, perhaps an unexpected birthday gift. His parents' package had not arrived, very likely never would, the occasion being one on which their undependability was notable. Besides, the girl became more attractive as she talked; her voice was pitched low and had a melancholy music and her whole manner was submission to the male principle. \"You want me to get you a job, is that right?\" She was within a hair of contact with his belt buckle, and he had come under a compulsion at once to fuse into her body and not move his, which could be done by easing forward the belly usually, as a matter of vanity, held back.\n\n\"For Christ Almighty sake,\" said Marsala, in the testiness of one whose judgment has gone unheeded, \"the soldier has gone horny.\" He was right by being wrong; he assumed their conversation to be a bargaining.\n\nThey were now touching, the girl standing firm and, madly, as if unconscious of anything strange, pursuing her first interest: \"It's all so confusing. I am ready to do any kind of work\u2014as cleaning woman if need be. ... Do you have a _bottmann_?\"\n\nIt was much too rare for his simple vocabulary. He had not learned it in two years of college where he ostensibly majored in the language but in fact moped lonely around bars and crowded, smoky places with small string combos, with no real stomach for liquor and no real courage with women, drinking much, nevertheless, and fumbling at some tail. On the margin of a flat flunk he had enlisted in the Army. At any rate, he could deliver correctly not a single long sentence in German and could translate nothing beyond very short strings of words with exact English equivalents.\n\n_You are a bad man_ was maybe what she meant; if so it was a weak remonstrance, as when you are small and exchange exposures with the neighbor girl, who coyly says \"You are a bad boy,\" all the while pulling up her dress. He had slipped his arm into her worn coat, where a missing button made it easy, and around her narrow waist, and she came full into him, saying still, so madly!: \"Is a female _bottmann_ allowed?\"\n\nSuddenly and so nuttily did its sense at last arrive that he released her and retreated a step. _Lives of a Bengal Lancer, Four Feathers,_ \"but when it comes to slaughter you will do your work on water, an' you'll lick the bloomin' boots of 'im that's got it.\" When you were in the field against Mohammed Khan, Oxford-educated Pathan who returned to his mountain fastness to lead the tribes against the Crown, you had a batman; when, that is, you were a British officer serving Victoria, to whom you drank health and broke the glass, or for all he knew even at present, you had an orderly.\n\n\"Well, I'm going, _I'm on my way,_ \" Marsala groaned reproachfully, and hypocritically, for he scraped away only a short distance and sat down on a wasted wall, lighted a cigarette with a great flare and coughed.\n\nHer look had no defenses: \"I know just a few English words.\"\n\n\"That one is very rare,\" replied Reinhart with all his gentle forces. He added: \"I am just an _Unteroffizier,_ a corporal, a nobody, a silly fellow\u2014\"\n\nShe returned his smile in the exact degree of wryness with which it had been given her, aiding him, in tune with him, so that when the exchange was completed he had been purged of self-pity and satisfaction with the vision of himself as uncorrupted by efficacy; and furthermore was not made sore by its loss. He was forgiven all the way down the line, and most of all for thinking it was forgiveness\u2014she was far beyond that, standing there before him on the mound of trash, without vanity, making no judgments, facing facts.\n\n_\"Also,\"_ he said. \"You will have your job. You have my word.\"\n\nHis oath was no doubt meaningless in German; one certainty of alien languages was that each had its own way, untranslatable, for the moral expressions. But its effect was not needed by her, who it could be seen in the clearness of her eye admitted no doubt towards him.\n\nMarsala was back, seizing Reinhart's elbow and, this time with unbelievable modesty, whispering in his ear: \"You're not thinking of slipping her the tool? I mean, it's all right with me, I just wanted to get things straight, no sense for me to stand here, just gimme the sign\u2014\"\n\n\"Old buddy,\" said Reinhart, \"friends may come and friends may go and some may peter out, I know, but I'll be yours through thick or thin.\"\n\n\"Yeah, I know,\" came Marsala's hoarse whisper, which was louder than his normal voice, \" 'peter out or peter in.' Well, what will it be? It's boring to stay here. I mean, for me.\" \"Boring\" was a word he had learned from Reinhart, using it with weak authority and only as a favor to his teacher. It took quite enough effort, however, to have its power.\n\n\"You must come to see me at my organization,\" Reinhart told the girl. \"Now can you remember this? It is the 1209th\u2014but the number doesn't matter. We are a military hospital and are in a school building in Zehlendorf, at the corner of Wilskistrasse and Hartmannsweiler Weg. Across the street in a wooden building is headquarters. You come in the door and turn left. You go all the way to the end of the hall, to the last room, and there I am.\"\n\nThe language became easier to use as he spoke, and he found himself on better terms with talking than he had been in years; in German even directions were a kind of success, precise and scientific. Still in temper with him, the girl, now three feet away and in deep shadow, said: \"You have a good accent!\"\n\n\"Now you _will_ remember?\"\n\n\"Oh yes! But please, what is your name?\"\n\nHe had turned to leave with Marsala, like a monarch\u2014in all the world there are no good departures\u2014and now, kingly, gave: \"Carlo.\"\n\nShe was stepping towards him in an eager courtesy. \"As in Monaco\u2014I shall remember.\"\n\nMarsala grinned like a possum at the traditional repast; honor was being done his old rule: give them only your first name, which cannot be traced. His lack of civilization had suddenly become repulsive.\n\n\"No\u2014Reinhart, Carlo Reinhart. _Es ist ein deutscher Name_.\"\n\n\"Certainly.\"\n\nHe shook hands with her and in American fashion held it too long, so that hers wilted and sought to escape.\n\nThey were still a party of three at the streetcar stop. But before one came, if ever it did, a jeep throttled up out of the blackness, bearing MPs on their eternal quest for miscreants. Like all American police, they stayed at their remove of faint hostility even after Reinhart and Marsala identified themselves and proved blameless; indeed, even after the constables took them aboard for a ride to their billeting area, which since it lay off the beat was a considerable favor, it seemed needful for the sake of an institutional pride that all pretend it was a kind of arrest and sit silent on the way. The four men, that is, for the girl had not been considered, had not, properly speaking, been seen, the non-fraternization policy being neither quite repealed nor, beyond the flagrant, enforced.\n\nShe might stay there for hours\u2014this was a thought of Reinhart's, which he answered with the familiar indictment: so many millions of non-Germans would lie dead forever. Yet it had been so appropriate to pity her; he aggressively presented that claim to himself. \"Certainly\" was her answer to the characterization of his name. From birth he had been a good, sturdy _German_ type, lived in a solid _German_ house, on a diet of _G._ potato salad (with vinegar), _G._ cole slaw (with bacon grease), _G._ coffeecake (with butter-lakes), run on a regimen of _G._ virtue (bill-paying, bedding and rising early, melancholia), and whenever he left it was met by approving people who said: \"Ah! He's going to be (or is) a big _G._ like his grandfather.\"\n\nThe term, however, had a double meaning, which was honored even by near-illiterates; its other use was as synonym for a kind of foulness. And now there was a third, for here he was in the ancient homeland, and he was something different.\n\n\"Home\" was a compound in Zehlendorf from which the 1209th General Hospital had evicted the German residents, a block of three long apartment buildings arranged in an open rectangle around a private park. The latter, in some former time almost a university campus with green and wanton walks for rambling, had been converted at the order of the 1209th's commanding officer into a junkyard for the disposal of property the Germans left behind. The colonel was neither opposed to comfort for his men nor a partisan of pain and deprivation for the owners who after all would one day return; he was nothing, no Savonarola, no crypto-fascist symbol of the military mind, not even, because he was a medic, quite a soldier, nor, because he was commanding officer, quite a doctor\u2014but owing to this he wished grievously to be something, if only a converter of matter from one form to another. Thus he periodically had put to the torch, had resolved into carbon and the immaterial gases, the giant cairn of objects which Reinhart and Marsala now skirted on their way to the south building: couches and loveseats, dining tables, bedsteads, chaises longues, sideboards, three pianos, fourteen wind-up victrolas and two thousand records; eight thousand books; rugs, pictures, tablecloths, postcard collections, skis, jewelry boxes, letters, diaries, journals, manuscripts, apologias, Nazi party cards, memoranda, paper, paper, paper; and one little souvenir plaque from the Western Hemisphere: an electric-pencil sketch of a pickaninny sitting in a Chic Sale, inscribed \"Best wishes from Savannah, Ga.\" Another pile held the noncombustibles, mainly cooking utensils and fifty more or less complete china services from the royal house of an imaginary principality.\n\nFive men had been busted in rank when caught salvaging items from the auto-da-f\u00e9. On the other hand, the colonel did not lack in a rude sense of justice: if you could make away with an overstuffed chair or an alarm clock without being seen, it was yours and beyond all future confiscation.\n\nThe tenants of Building A, first floor right, had furnished a very decent little flat, the cynosure, as Reinhart might say, of all eyes in their section. Particularly those of Buck Sergeant Tom Riley, their next-door neighbor and late technician third grade, who had made so free in their absence as not only to enter their home but also to sink his big ass into the mohair couch and fall asleep. When awakened by the crudest means they could summon on such short notice, he arose complaining, \"You must of got your nose up the colonel to get to keep this furniture. Our living room looks like a Mexican cat house.\" He lumped fatly to the hall door. \"And why only two guys here instead of three?\" His swollen nose tensed with authentic peevishness, and small wonder, for he had been reduced one grade for unsuccessful pilferage from the trashpile; but more than that, he was by instinct a petulant man, with the face of an old baby.\n\n\"Don't be bitter,\" said Reinhart, who had followed him out. \"It's my birthday.\"\n\n\"Oh.\" As might have been expected, he missed the ironic import of the non sequitur; he would be resentful, thank you, on his own time and ground; instead, he grasped Reinhart's hand in embarrassed but genuine feeling, as you could tell by his nose, which went soft, saying: \"You don't mean to bird-turd me? Many happy returns of the day.\" And already at his own door, he turned: \"Ain't it sad? Here we are, getting older by the minute.\" Without change of expression or girding himself for the effort, he suddenly screamed, in a voice like a jazz cornet, an obscene epithet which, though it went up the concrete stairwell like a skyrocket, made no public stir, being heard all over the 1209th so frequently that it had lost its force as description: if you ever found that fellow to whom it was originally applied, you should have to think up a new one.\n\nBecause nothing succeeded like the envy of others, Reinhart returned to the living room in a, now sober, swagger. Off the top floor of the building lay an attic stuffed with furniture\u2014the colonel lighted the bonfire only after his space ran out\u2014and Marsala and Reinhart had picked the lock on its door and secretly helped themselves while everybody else was away at work. As to tenants, the orders demanded three per flat; given free choice, the buddies shrewdly compacted with Doyle, who three days later left on detached service.\n\nSo they had a proper home now, Marsala, a slum boy, confessing it was the nicest he ever had and the most spacious. Parlor, kitchen, and bath were luxuries militarily undreamed of. You could, see, get some rations from a cook, have a little lunch in the kitchen, then take your broad to the couch, knock off a piece, and then wash up in the bath. Marsala had indeed gone through the series three times in recent days, failing only in the last because he could not make a swift transition from pleasure to hygiene. Hence the jar of blue ointment in the bathroom medicine chest, yet another evidence the place was truly home.\n\nThe green tiles of the corner stove were still warm from a small fire they had built just after chow; July nights were cool this far north. A fall of maroon drapery concealed the big window above the couch, which in the daytime showed their private balcony and, beyond, a green promenade between their block and the next, an _all\u00e9e_ in the old, European sense, banned to cars and wastecans\u2014and to the colonel, for natives retained ownership of the adjacent buildings. The enormous sideboard on the east wall had almost ruptured them to carry, and had little utility when in place, but great authority. Central was a round table of oak and six attendant chairs. No tablecloth. Other deficiencies were: nothing matched; no pictures on the wall; no knickknacks placed around; no doilies to protect the arms of the couch; no magazine rack with _The Woman's Home Companion_ and last week's _This Week_ and the publication General Motors sends gratis to Chevrolet-drivers. But it was Reinhart's own home and he believed it was nice.\n\nHe seated himself at the table to brood on the folly of early-evening drinking, his close-cropped blond head propped on a red fist still tremulous from the fight, pale-blue eyes charged with red, one trouserleg loose from the knotted condom round the boot-top. Marsala, who didn't know it was not nearly time to go to bed, had ignorantly gone and tomorrow would awake extra soon and, it went without saying, loud.\n\nReinhart all his life had detested birthdays; they were like Sundays in the middle of the week, outlawing the ordinary by a promise of the special, never fulfilled. Until this moment, for he could never think while in motion, the twenty-first had been another of the same. But, ruminating, he saw now that it had, indeed, a touch of the exotic. He had drawn blood and spilled some of his own. He rose and went again to the hall mirror in which he had inspected himself on the route back from Riley's leaving. No, no hallucination: a nice scratch-cum-bruise on the left cheekbone, made easier to see if you tweezered your fingers about it. Riley, still sleepy, no doubt had laid it to shaving.\n\nIn addition to Marsala's salve, the bathroom cabinet held Reinhart's collection of medicines. Once every two months he had a slight complaint, each time in a different organ, never serious\u2014whichever doctor was on duty in the 1209th dispensary would smile, prescribe, and likely as not give in to the urge to punch the tight belly and caution him jokingly not to worry, the undertaker would be a stranger to him for years.\n\nThe large merthiolate badge had dried and was almost ready to flake before he finished his final self-examination in the bathroom mirror, in the course of which his spirits curved downwards again. The pompous, pink-and-blond-faced creep who stared back at him had been endured enough for one day. He got out his rubbing alcohol, cotton, and applicator sticks, and wiped away the crimson fraud, threw the evidence out the window, went to the bedroom, kicked his clothes in the corner, fell on the bed next to Marsala's, and was immediately in sleep.\n\n# _CHAPTER 2_\n\nFIRST LIEUTENANT NATHAN SCHILD, a traitor, handed a sheaf of papers to the German known as \"Schatzi,\" a courier to\u2014well, above all, to an impossibility, since the measure of truth is what a man will give for it and Schild would have walked to the noose to deny that this Thing had any existence outside the mind of a malignant halfwit. Schatzi himself was just barely possible, being a returned traveler from that until the twentieth century undiscovered bourne; the most efficient of men, who could answer all questions with: \"I was four years in Auschwitz.\" Behind that, darkness, and not, according to the code of the underground, to be searched by Schild. Although Schatzi wore the garb of a petty bureaucrat\u2014felt hat, stiff collar, briefcase\u2014he suggested a ruin; although the night was warm, he trembled and winced, as if the whole of his skin had been sandpapered and recorded in pain the blows of the air's molecules.\n\n\"What is this stuffing?\" asked Schatzi, roaming Schild's person with his free hand like a restless lover's, probing the fly-front of the blouse.\n\nSchild extracted a folder. \"I forgot it because it's more or less negligible.\"\n\n\"Needless remark,\" said Schatzi, pleasantly nasty. He struck Schild on the elbow with his finger-tips like a row of icepicks, of course hitting the nerve.\n\nIf a man could be said to have earned a broader latitude of eccentricity than most, it was Schatzi. He had once shown Schild the scars on his back, and if it had been day one could have seen the terrible commentary of his face, a kind of scorecard of the times. And that he had undergone torture and was not a Jew made it all the more criminal for Schild to detest him.\n\n\"Please,\" said Schild, with genuine, if exaggerated feeling, for, although it was not that important, neither was it of no matter, and Schatzi discounted precision, \"I must have this back by tomorrow noon at the outside. Captain St. George just asked for it.\"\n\n_\"Er kann mich im Arsche lecken!\"_ Sooner or later Schatzi related everything to himself, and scatologically, which was not perverse given his late experience of life reduced to essentials. Nevertheless, while understood, the common-denominatorship of Schatzi was hardly winning. Also in character, Schatzi walked in a cloud of food odors; tonight it was herring. But who was so degraded as to gainsay his right to courtly fare, let alone such simple meals as he was no doubt issued at some Soviet mess?\n\nThey stood on a strip of Wannsee shore near a wrecked pleasure pavilion, the salient feature of which was a tin Coca-Cola sign hanging crazily in the light of Schatzi's torch, the patented slogan of its own International in German here; downtown Schild had seen the red and gold standard of Woolworth's in a similar death-agony of capitalism. Beyond the symbolism it was a remote and even foolish place to meet. Two men upon a dark bench, one a German civilian... it was not Schild's job to pass upon the point of rendezvous\u2014while not forgetting for a moment that Schatzi was his superior, his mind was also wired in another circuit with the alternating current of forgetting and remembering\u2014but he did, anyhow, make his apprehensions known, and Schatzi suggested next time bringing a girl for protective coloration. Such was Schatzi's circuit: belly-rectum-pubis. The simplest interpretation was that he lived somewhere near the lake; perhaps, like a rat, in a hole just above the water line. Sometimes, in fact, as if caught by a sudden high tide, he appeared damp at their appointments. Schild bit his mind's tongue; at least Schatzi said what Schatzi thought, suffered no internal wrestling matches with an indestructible malice like an extra organ.\n\nIn a sudden surge of self-remonstrance, Schild said: \"We get a ration of candy, you know. In the American Army there are constant pressures upon the soldiers to be the same conspicuous consumers they were in civilian life. It's not enough just to fight a war.\"\n\nSchatzi took the chocolate bar from his hand, undid its wrapper, scrutinized it in the light's ray with an invisible jeweler's lens, tested its friability with a thumbnail.\n\n\"I really found one last week that had all of it been shaped from brown clay. Think on that! The astonishing industriousness required, it having been a first-order job. All that work for fifty mark and you Amis are burdened with actual ones that you cannot eat till the day of doom.\"\n\nHe pushed five ten-mark notes, already rubber-banded into that amount\u2014yes, the Japs held the Malay Peninsula, but his bands were pure gum\u2014into the hand of Schild which had come forward on its own volition, on its own idiotic hand's sense that it would be shaken, just as a foot will all at once assume sovereignty and stub itself as punishment for some foot-crime or kick the girl's shoe across the way out of some foot-lust. Schild's face meanwhile was performing, in a vacuum, a squalid drama.\n\n\"But, my dear fellow, you shall not get more than this at the Tiergarten and think on the length of miles from here to there. You are an actual Greek for business, comrade!\"\n\nSchatzi returned the candy and took back the money, signifying the end of his joke.\n\n\"I know people who are pleased at your work,\" he resumed, \"and if you are not so careful they shall give you one of these posterboards to take home to Tennessee: 'The Hitlers Come and Go Away But the German People Stay Always!' \"\n\n\"If you get some pleasure from insisting that I'm from Tennessee, go ahead\u2014\" began Schild, but the flashlight quivered and sank, and Schatzi groaned from the ground: \"I like the name.\"\n\n\"An attack of dizzy,\" he went on as Schild bent to aid, \"brought on by four heavy suppers every day and eight hours of sleep the night, still in a warm bed. _Gem\u00fctlichkeit_ is killing me. Give me some pills in the right pocket, they will make me miserable.\" There was nothing in either pocket but Occupation marks. \"Make all the money you canst,\" said Schatzi, on his feet again but breathing with a whistle and coughing bubbly.\n\nAt such moments the call of Schild's guilt echoed through the great tombs of the martyrs. Schatzi was indeed dying, yet he continued to serve. This, Schild knew in the final, serious level of the self, was why he hated him so: out of his own incapacity for a like magnitude of effort.\n\n\"You know,\" said Schatzi, shaking his body like a dog, blowing air from his nostrils, combing his hair, long as a woman's, with his fingers, \"when Kurt brought you first, to my opinion you were a double agent. Arrived at by irrational methods, it is possible, but there was something with your eyes.\" He took a flask from his briefcase and tasted of it. \"Ah!\" He spat. \"Good drink will make a cat speak! They are, isn't it true, simply myopiac? A fat small man, a little soccer ball of a man with eyes like that\u2014and thicker spectacles\u2014came into the K.Z. along with myself. I watched, in vainly, to see the existence there bring him down.\" He spat again, making a nasty sound on the sand. \"Ah! Cuts the flame.\" Schild preferred to assume his version of \"phlegm\" was a portmanteau word: he must be burning inside. \"One gets obsessions when you are a captive. But at the end of three months still he bounced. I never did see him on a work gang. He disappeared days somewhere but in the nights returned to the barracks. I had been convinced that he was a police spy and I am in fact yet. He lay in the bed each night end-to-end with my own bed and stared at me over his round belly and through his feet. It was terrorizing, I tell you, a man could never once find him asleep. When I awokened in the morning he looked, still; perhaps he did not close his eyes the night long. Because I do not know, you see, because I tell you I slept, I functioned as usually I do, under the watching of sixty-six devils I could do as always, because I tell you that beyond a club to my genital members there is nothing which a man can do which will touch me at all.\"\n\nSchatzi's voice had taken on the authority usual to his concentration-camp reminiscences. On Schild's refusal he pocketed the flask, but not before illustrating its quality, heavy silver; its feature, a spring cap worked with the thumb. As always, he withheld the d\u00e9nouement until Schild in the double dread\u2014the tedious responsibility of the auditor to help dramatize, the terrible certitude that the small fat man, whether bona fide police spy or hero, would like all the other creatures of Schatzi's memory meet an unspeakable end\u2014until, cold in July, he must urge him to go on.\n\nBut Schatzi had got a sudden subtlety. \"Is Captain St. George the ass you take him as?\" He pronounced \"St.\" as _Sankt:_ no cue for worry, a man fills out abbreviations in his native tongue.\n\n\"He's a Republican.\"\n\n\"Are not we all? What does this mean? I don't understand, I don't understand.\"\n\n\"I'm sorry, I forgot. He's nonpolitical, an aboriginal American type. I thought all the world knew. Let me explain: If I express so much as simple approval of a labor union, he will say, 'Well, I'm not against unions but you've got to admit sometimes they go too far. I understand if a light bulb burns out in a factory the place stays in darkness until an authorized member of the electrical workers' union comes to replace it.' But if he saw me leading a mob on the White House under a red flag he would lay it to money or some private passion. Do you understand now? We have billeted together for two years, he knows how I look in my underwear and that I use a soap stick instead of tube lather for shaving. He knows whatever my eyebrows do when I'm puzzled, the contents of my musette bag\u2014\"\n\n\"I understand now that _you_ are the ass. How does a police agent operate if not this way? Fritz, Fritz, it is a little wonder that after four years of duty you are yet a first lieutenant!\" It was not clear that Schatzi meant more than chaff. He had himself taken irresponsible risks near St. George, more than once lingering before Schild's billet on a bicycle. What was obvious now, though, was his unease at Schild's developing a point, hence the underground name, a remonstrating symbol of the overwhelming awareness and power which they both served and before which elaboration was ludicrously futile.\n\n\"With all this knowledge,\" Schild finished defiantly, \"what could not be forgiven? He would trust a man forever whom he had watched cutting his toenails.\"\n\n_\"Also,\"_ said Schatzi. \"I used to swim at this place but I do not mourn it\u2014any more than I need to play the piano again. Have I told you I once have played the piano in a splendid club where the tables were connected each to each in a system of tubes from which the air is exhausted\u2014what do you say for them?\u2014vacuum, _so,_ vacuum tubes, through which the people in this place could communicate on little pieces of paper\u2014this was the same place where Emil Jannings was controller of the W.C. Haha! Did you hear of this film _The Last Laugh_?\" He allowed the insatiable black space over the water to swallow his light's beam for a moment, then reclaimed it to thrust into Schild's eyes. \"You will never drown in the water to mock the hangman, not you. I will just as soon choke myself as to have you know my real name. Without respect for this famous na\u00efvet\u00e9, there is something sinister about an American.\"\n\n\"You seemed to have no worry about Kurt.\"\n\n\"Kurt lived until aged ten in Budapest, Paris to the age of eleven and a half, Budapest again for three years, then Rome to the age of twenty, and finally Washington. His father is in the diplomatic service, his mother is an Hungarian and the influence. Do you know Kurt's actual identity? In yesterday's _Stars and Stripes_ \u2014a queer journal, by the bye! What are these letters at the lower-left hand of page two, this so-called 'B-Bag'?\"\n\nThe damp had begun an osmotic affection for Schild's feet. \"Oh,\" he answered in a momentary quicksand of sorrow which sucked the life from his voice but was all to the good for the present purpose: \"That's supposed to be the uninhibited feelings of the enlisted men with complaints, the vox populi of ersatz democracy. The name comes from an expression, 'Blow it out your barracks bag,' let off steam, air your gripes. The enlisted men used to carry their gear in two bags, one labeled 'A,' the other, 'B.' \"\n\n\"I tell you that tells nothing. I have read a letter yesterday which said\"\u2014he broke off and produced the very clipping, holding the light for Schild to read:\n\n> You can search the whole Enclave until your goddam corns are thumping and you won't find one place where EM can get anything better to drink than flat beer that the Krauts made when Hitler was a PFC. Yet every ninety-day wonder in my outfit wallows in Haig & Haig. The chickens are getting bigger and I don't have to say what is getting deeper. Yours for World War III,\n> \n> T\/5 P.....-OFF\n> \n> _Bremen_\n\n\"Yes, that's the sort of thing.\"\n\n\"Do you ever use it?\"\n\n\"No,\" said Schild. \"As I say, it's essentially for enlisted men. Besides,\" smiling in irony, his profession, place, and time's surrogate for good humor, which Schatzi could not see because he was again being nervous with the flashlight, \"my complaints are not so simple.\"\n\nSchatzi laughed, for a change in a pleasant tone, perhaps owing to the fact that he had nothing to gain or lose from the passage: \"As to this B-Bag, obscure name still, I do not believe from a swift look that the code would be too hard to break. It is not a device without imagination, but surely American Espionage has better means for important messages. I think these are no more than general intelligences for each sector. However, it would be that one can do worse than to attempt to decode the letters signed Berlin, a damp finger to the wind, one could say.\"\n\nWhen Schatzi spoke like a neurasthenic spinster he was not fooling, even though it was only at such times that he amused Schild, an extraordinary achievement. In good Middle European style Schatzi was most suspicious of what was most innocuous, and perhaps the reverse, although in that he had not been tested. Almost to Schild's disappointment, there was nothing dangerous, complex, or oblique in the Berlin situation. As American Intelligence analyst, he inspected confiscated Nazi correspondence files; as something else entirely, he chose interesting items for transmission to Schatzi, the jobs meshing beautifully.\n\nBut Schild was a great over-preparer, despite the persistence with which, while he stood smeared with grease, Hellesponts shriveled to birdbaths. Having been alerted for his present function since he first reported to his draft board, having been, by unseen hands, guided to and through infantry OCS and later transferred to Intelligence by like means\u2014Schatzi could suspect American na\u00efvet\u00e9, Schild could not afford to: the Party, with all its resources, could perform the miraculous only with the aid of history's buffoons\u2014sent to France and then to Berlin with the first Occupation troops, having on a word from X, a nod from Y, and a furtive motion of the elbow joint from Z, been put in touch with \"Kurt,\" who conducted him twice to the presence of \"Schatzi\" and vanished forever; symbolizing in his very position at this juncture, this square foot of wet sand, the energy and infinite pains of the agency whose creature he was\u2014but that was just it, what small service he rendered! Two or three sheafs of trash a week, available to anybody who would walk into a bombed building and pick up a handful of scattered papers. Not to mention that the Red Army, which had got to Berlin a month before the Western powers, had surely missed little of consequence. Still, this seemed somehow his own deficiency notwithstanding the clear directions that limited him to the role, and he was conscious, in all the weak jealousy of the impotent, that herein lay another motive for aversion to his courier of the wide horizons.\n\nSchatzi left off his nonsense about the counterspies' use of the B-Bag, or what, had it not arisen from his total dedication, would have been nonsense and resumed his original aim. \"In any rate, in yesterday's _Stars and Stripes,_ on page number three, you will find a little item to announce the appointment of Nicholas G. Pope, civilian military-government official, as licenser of German newspapers in Bavaria. Kurt, Pope. The very man.\"\n\nHow loudly he spoke, how careless with the light. The very fact that the beach was abandoned and dark made it more conspicuous than the stage at the Titania Palast. Schild instinctively resisted the exposure of Kurt's identity, learned it, that is, and didn't learn it, a technique by which information could give comfort but not be divulged even under torture.\n\nFortunate in all his cautions and fears, for they served, after all, to give him a constant business that his larger function did not, Schild arranged with Schatzi for their next assignation and sought to move off towards the broken timbers of the pavilion and the jeep on the forest road beyond. Schatzi's hail was very like a shiv into the small of his back. As he turned to hear the not-forgotten-for-a-moment fate of the soccer-ball man, between the sound and the sense he saw in his memory Schatzi's earlier flashlight motions. Across the water lay Kladow. Who there received his signals?\n\n\"... so this guard made off with his cap and threw it over the top of the wire into this area that was not permitted for the prisoners and ordered him on the pain of death instantly to go and bring it back. The man climbed with the strange nimbleness of the fat, quite indifferent with the barbs going into the palms of the hands, got this cap, made it free of the snow with his underneath side of the arm, and then brought it down over his skull, which was of course shaven clean, down to the ears. On the climb again back, he was slow and breathed hard; on the top strand of wire, he let out some steam, for it was very cold, and at the time when just more than half of his weight was over\u2014the guard had planned it well, you see, to ensure that the fall might be on the near side\u2014the machine-pistol bullets released the air in him and the man did not fall as planned but shriveled and stayed on the wire like a soccer-ball bladder without the air. The wind even moved him. I think still he was a concealed policeman, shot in mistake. The guard vanished some time later.\"\n\nSchild's fingers crept to the button of his holster in a parody of a poorly remembered Hoot Gibson at bay. He would not really draw his pistol on Schatzi; for one thing, in the world outside the concentration camp this was not done, or at least not by him. If Schatzi were a double agent, the worst course was a show of violence; yet his hand would not cease its histrionism, did not indeed for some moments after Schatzi wound up the anecdote and went to the heart of the matter, for his private intelligence system extended even to the reports of Schild's nerves.\n\n\"Look,\" he said and boldly morsed his light at Kladow, from which, as if ignited by his, another was briefly born, died, lived, died. \"I go in a minute to Potsdam with a boat full of food from an American Army kitchen. For everything I know, this can be served to Herr Truman at Stalin's villa on the next mealtime. ... But please do not think\"\u2014he held the torch at the point of his chin, splashing the beam up across the peaks and declivities of his face, as a child might make a satan's mask in the mirror of a darkened room.\n\n\"Of course I didn't think\u2014\"\n\n\"\u2014that I could do this for anything but money.\" Upon this summit of innocence Schatzi snapped off and withdrew. In the willows by the water he made noises of effort; and well before Schild had got to his own vehicle he heard the outboard churn off in such a splash that his courier might have been on the way to quench Hell. And above and beyond the lovely organization of the jeep in first gear, he heard the boat engine climb hysterically towards its extreme velocity and, reaching it, miss and backfire and belch and puke, and his heart worked with it in the shore man's empathy until it eventually leveled into a continuum of asymmetrical impulses, like a laughter hopelessly mad, hopelessly free.\n\n# _CHAPTER 3_\n\nWHEN ONE WAS TEN, nobody, least of all the boys of German stem, served willingly on the Kaiser's side in war games. The little kids and younger brothers gunned Fokkers through the back yards and crashed flaming against the garage as Rickenbacker and his hat-in-ring squadron of Spads roared overhead piloted by the big boys. Then landing at the Allied aerodrome, which was quite a different thing from an airfield, and into the flight office (again the garage) swaggered they, tightbooted, helmet straps swinging free, demanding coggnack from the Frog wench behind the bar which without transition gave onto the office; while the de-Germanized younger brothers greased the planes, for this was also a hangar.\n\nShortly Richthofen might pay another call in his craft painted all checkers like a taxi, pitching to the tarmac a black gauntlet, showing a brief glimpse of grim but noble face, black-goggled, over the fuselage; mocking ailerons just clearing the high-tension wires at the field's end but not the undercarriage, which was severed. Jerry now could not land; with nothing to lose, this dogfight was for keeps. Inside the glove, which a mechanic fetched in, a note in Teutonic script: \"My compliments to your gallant command. I issue an open challenge.\" Cross of Malta. Signed, Baron R. Aloft, fabric tearing in Immelmann turns, oil-line burst spewing goggle lenses with black slime, Browning jammed, you dropped the foe with your sidearm and looked down in long salute at his incendiary spiral into the chrysanthemum bed. _Ave, atque, vale,_ brave adversary! I slew you as you would have slain me, your cause was hopeless but not contemptible, we share in that community which the whey-faced civilian regardless of nation cannot enter.\n\nTo be sure, not every enemy was a Richthofen. G-8 the master spy, commuting behind German lines in the limitless disguises from his armpit cosmetic chest, was certain to meet the pigface Hun, bayoneter of Belgian babies, violator of maidens; cabbage for a head, sausage-limbed, cheeks of ass like dirigibles kissing, he waddled in cruel insolence before the helpless or groveled in fright before his master. G-8, whose trunk formed a triangle standing on its apex, was right to destroy this creature if only for aesthetic reasons.\n\nReinhart's paternal grandfather, who looked like one of G-8's victims, with a somewhat better distribution of weight, was more charitably described as a double for Hindenburg, a sound man. He cut meat on weekdays and on Sundays read the _Volks-Zeit-ung_ and decanted in the cellar a thin, tasteless homebrew of which he was inordinately proud. He could support a leg of beef at full arm's length with one hand; he was a source of blutwurst slices on the sly; his place of work was floored with wood shavings and blood lay in pools on the butcher's block and dripped from the joints on the hook. He had left the Old Country to beat the draft; he had reportedly thought the Nazis were fools and was fortunate to have departed the world before they could disabuse him. These, and a small store of mispronunciations, were all Carlo could remember beyond an enormous, kindly, mustached face that smelled of beer and pipe, that was less articulate in the general tongue than himself at nine, that seemed, for all its implicit power and the massive hands that could not touch his shoulders so gently as not to bruise, a distant presence.\n\nWhen in adolescence Reinhart was suddenly overwhelmed with the purposelessness of the bleak journey from pablum to embalming fluid\u2014not for himself, but everybody else; he would somehow, alone, escape and was now investigating the various modes of exit\u2014he once asked his father, and querulously, because the reason he alone would escape was that he alone had the guts or intelligence to ask questions rather than weakly submit, just as the power of his will would protect him, alone, from eyeglasses, baldness, false teeth, poverty, a wife: \"Why didn't Grandpa ever go back to Germany?\"\n\nCould the Old Country, so remote, so rare, fail to exceed the here and now?\n\nHis father was shaving, or repairing the outside cellar door that hadn't been true to its frame for a decade, or washing the automobile, and perhaps before the answer came had done each of these tenfold, because for him a question must be repeated many times, by reason of his apathy, which was a superb thing in its way and could have been heroic if behind him Rome were burning or half of London keeling over with the plague.\n\nFinally, as he rose from whatever job, scant of breath, with stated or implied senility of leg, he replied: \"Use your head. What was there for him _there_?\"\n\nThere had, of course, been so much for him _here._ He hadn't even owned his own butchershop, but was wage-slave in a native American's, a man twenty years younger. He built a brick house in an end of town that shortly thereafter suffered an encroachment of lower-class cotton-pickin' refugees from Kentucky, know locally as Briarhoppers, with their rusty cars and back-yard shacks and incestuous five-to-a-room, brought in by an absentee landlord named Horace Remington, who everyone was sure had changed his name from Levy, although they had never seen him\u2014any more than they had seen for themselves that the earth was round. Grandma, native-born, whom he had carried off from a ten-dollar-a-week job at the pencil factory, survived him one year, and left material holdings of the house and two hundred fifty dollars. His one son, the man Carlo watched return with steel wool to the corroded hubcaps, was far from a raving success. This car, for example, was bought used with the two-fifty bequest\u2014which showed how far back it went. And as to the house, it had gone to join its neighbors in the pocket of \"Remington,\" who, despicable though he was, paid a third again as much as any other offerer and therefore was able to seduce even the good people into aiding his effort to destroy the respectability of such areas. Now if one passed the old homestead he heard guitar music and saw degenerate faces at the windows.\n\nCarlo left his father at the task\u2014he would have been glad to help on request, but would not volunteer; he received fifty cents a week in allowance, for which his obligation was to cut grass in summer and shovel snow in winter\u2014and went indoors, to the dark cavity at the end of the basement, which was really not so much cellar-end as dead space, a kind of tomb, under the front porch. Here in a cardboard box soft with moisture were his grandfather's few effects, having for half a decade been in chemical mixture with the insatiable air: a twenty-five-cent pipe, \"real bruyere\" stamped on the shank; a straight razor, broken; a dollar watch, scarred chromium, its intestines locked in rust; cufflinks with the Oddfellows' paralytic eye. A letter postmarked Berlin-Something, Berlin-Smear, April 12, 1927. My God, three years after Carlo was born; he was still astonished at evidence that the world had been up and around when he was so young. Inside, handwriting that not only was in another tongue but also in an alien alphabet, even the figures were queer. Finally, a single book, the leather of which some dry past time infected with an eczema that the basement damp had treated with a salve of blue mold. _N\u00fcrnberger_ something, the golden letters just visible on the granulated cover. Within, it was all pictures of that splendid medieval town of towers, castles, moats, rivers flowing through buildings, dolls' dwelling places hung over sallyports, and ironbound doors, four feet high, for dwarfs' abodes in the bottom of the city wall; labyrinthine ways among steep houses with a little extra roof sprouting over each attic window, the general roofs themselves nowhere true, everywhere splaying, overshooting, cutting back, growing dormers and loggias and lookouts and hexagonal capsules, restrained from soaring off their timbered plaster only by the weight of these execrescences and a million tiles fine as the scales of a trout.\n\nMagic and fabulous\u2014no, it was not so much these as the Ohio street outside his own window, with its covering of smooth tar down which if you rolled for ten minutes you would pass a flat, dun high school, a raw Presbyterian church without a steeple, and fifty lawns so level and unobstructed that you could some Sunday push a roller from one limit to the next and squash nothing but a row of homeowners trimming the edges. In N\u00fcrnberg female angels ringed the city fountain gushing water from their breasts, but what was extraordinary was that America could be so ugly-dull; that was the fairy tale, along with radio programs for the housewife, movie cowboys who never kissed a girl, public drivel about shut-ins, mothers, flowers, the favorite prayers of celebrities, ministers being tough guys and businessmen wise ones, the stupid arrogance of newspaper reporters who wrote \"grass roots\" and \"with the arrival of spring, usually blas\u00e9 New Yorkers set aside their sophistication and frolicked gaily as children.\" And sports. At the end of his sophomore year in high school he was the largest boy in the building and was invited to come out for football by the coach, a witless man adored by his teams apparently because he cursed them at half-time. He took Reinhart's refusal in good grace, and was clever to do so; Carlo had some time before sent away to York, Pa., for a set of dumbbells and was already more muscular than the coach, except in the head. In Europe they did such things as weight lifting and gymnastics, although he was a touch too unwieldly for the latter.\n\nHe thought about Harvard and Amherst, places of old stone and vines and fireplaces in each room and tutors, as at Heidelberg and Leipzig, but it was revealed to him his last year in high school that he must go to the nearest state university, on account of the free tuition. At this institution he was permitted neither a lodging in town nor a single in the dormitory; with the unction peculiar to the tribe, the dean of men said he must mix and placed him with a roommate who hung pennants on one side of their metal-and-concrete cell, worked a water wave in the front of his hair, and crooned popular songs in idle moments. When shortly he applied again for a single, he discovered it was already on the way: the roomie had reported that Reinhart didn't mix.\n\nAlthough the architects had designed the few single rooms to be a constant punishment for the social deviates assigned them, Reinhart lived happy in his. He had loathed the college before he saw it and after a month's residence knew his prior feeling as too mild: it was in sum a flat green mall overrun with round pink faces saying \"Hi!\"\n\nHe had read much as a boy, but only in the literature of the imagination. Expository writing was rough, almost impossible going; he had never been easy with the language of documents and directions on packages, and was not now with that of the natural and social sciences. Philosophy was somewhat better because it didn't, and didn't really pretend to, get anywhere. English was a book of contemporary readings about, on the one hand, the underprivileged and, on the other, initially irresponsible people coming to a sense of social obligation: there was a story, in the form of a letter to her parents, about a rich girl who married a labor organizer, the compassion going all one way\u2014inward, to the letter-writer and spouse\u2014and no passion at all. And German, that hard and very real tongue, proved difficult and dreary, with twelve cases for each noun, insanely irregular verbs, and perverse genders that made a door a female and a maiden a neuter, defying even that principle of nature by which, according to a neighbor in psychology, projecting objects seen in dreams are male sex symbols and receptacles female, for _the pen_ was in Deutsch as feminine as _the box_ was not.\n\nFor these reasons he grew fond of his little room, last floor back, next to the toilets, with an air conduit passing first over the ranges in the kitchen four stories lower, and came not to hear the staccato flushings and smell the lemon sauce for the semolina pudding. He sometimes hid out there all day, cutting classes on the motive of the little ills\u2014sinus, swollen Achilles tendon, foreign matter in the eye, etc.\u2014for which the dispensary would write a note, eschewing meals with the aid of Oreo cookies and those stale, soap-flavored cheese-cracker sandwiches one buys at the drugstore, and reading books of his own choice.\n\nHe had now grown to six-two, still an inch below his grandfather\u2014which he might yet attain\u2014and as much above his father as that mark exceeds five-nine. The set of dumbbells had given way to a barbell with changeable weights; in the \"clean-and-jerk\" lift he could handle two hundred pounds, five more than he weighed, yet he was inclined to solid beef rather than the sharp definition of muscle permitted more wiry types; and he was clumsy, tripping over roots on tardy runs to eight-o'clock classes, tending to enter a doorway with poor aim and collide with its frame, sometimes splintering the wood. A recluse, but when he emerged, a recipient of good will and that friendly fealty paid to large men in jabs-in-the-ribs and blows-on-the-upper-body, which along with the strain of trying to better his mark in the clean and jerk every afternoon kept him always sore of skin.\n\nThe books of his choice were _The Invisible Man,_ which he was at any given time rereading; a volume printed at the author's expense called A _Life in the Field,_ by an Englishman who had towards the end of the nineteenth century scouted both in Matabeleland and along the Big Horn River in Montana; and Middle European short stories in English translation, in which the characters tended to live in the mountains or the valleys between them, walking to school on rutted cowpaths, sometimes getting lost in the forest\u2014or had departed all this for the garish, quick life of the cities, which had gone to ashes in their mouths, and now yearned for the pastoral long ago forsaken; had a quiet but desperate passion for a girl who did not know they were alive or held them in sororal affection; attended day school, oppressed by a severe master and a fat bully; kept a faithful dog. Always a single sensibility, sometimes misunderstood, usually not even taken account of, by the insensate many; and in an atmosphere of mist, distant sounds, and if in the mountains, of course the silent, imperturbable snow, deceptively serene and treacherous, and on the glacier, a frozen rainbow. The stories were to be found in collections under one rubric or another but could take place in any of a variety of Central European areas at any given time under diverse political registrations: Bohemia, the Burgenland, Silesia, even Switzerland, anywhere that had a Germanic color and preferably a castle on some steep over placid water and in the foreground a cottage with a roof of straw.\n\nMeanwhile he was almost flunking out in his course of study in German. For one thing, it was at eight o'clock, and he was most nights up till three, reading; for another, the language as taught had no relations to the tales, being at first Herr Schmidt exchanging the time of day with his neighbor and then simple scientific excerpts for the premedical students, which the instructor decided it wouldn't hurt the few general people to read, either. At the end of the year he just, but made it in German and the other courses, low C's with the exception of zoology lab, where in the interests of a moody, fitful romance a girl friend had made his dissection drawings, upping him a grade.\n\nSimultaneous with Reinhart's entrance into junior year in high school, the Wehrmacht had invaded Poland; at the end of the term they took France; upon his graduation, entered Russia; just before his first-year college Christmas holiday, were at war with America. By one means or another, he was aware of these events although he never read the papers. He was furthermore aware that wars were wrong and foolish and the official ways of nations, always stupid and often wicked; that propaganda, regardless of side, was an absolute lie: for example, as everyone knew, the German \"atrocities\" of World War I were fabrications of the British and French, who moreover did not let up in the ensuing twenty years, thereby giving Hitler some excuse for his silly ravings. Hitler held no appeal for him, having an unmistakable aroma of the tramp and no dignity, and, discounting their portrayal in Hollywood movies, the Nazis _were_ preposterously vulgar; but opposed to the little, venomous, weak French and the British, thin and effeminate, they could hardly be assigned the exclusive evil in an intestine European quarrel over markets and territories.\n\nYet when America came into the war, it was a man's place to go soldiering, and the ideals concerned were not public ones dreamed up by journalists and pompous bores in high office but private matters. He felt himself a kind of German, yet he would cheerfully have slain the whole German army in fair combat and exposed himself to the same fate. On this principle he almost presented his person to the enlistment office early Friday morning, December 12, 1941; doubtless would have, had there been such a bureau in his little college town; but there wasn't, and the closest city, the place he crept alone every weekend to oppose his harsh weekday regimen with whiskey and coke, was eight miles off\u2014it was impossible to hitchhike there, enlist, and get back without missing classes.\n\nHis second thoughts were confirmed three days later when the mincing dean told the assembled men that being educated people they could better serve by pursuing their studies with renewed vigor. It was not only his idea, he averred, but that of the Armed Forces, who as reward would commission every man to graduate. However, six weeks later, when the first fine fire had cooled and it was too late to volunteer from a position of enthusiasm, the male students were reconvoked. Now anyone wishing to stay _out_ of the Army must _enlist_ \u2014in the reserve.\n\nReinhart called at the dean's office posthaste, already having been the target of remarks in bars, inarticulate grumbles by gray-sideburned potguts on the theme of why so much meat was not yet sacked in olive drab. The dean's secretary, one of those tight-rectumed persons whose every little motion is spite against some subject so long vanished that every other human being has taken on his-her appearance, after consulting the records told him with much satisfaction that the Enlisted Reserve Corps had a certain academic standard to which he failed to measure up. He cut classes and went to town and got stinking, which was not easy to do in an otherwise deserted tavern on Wednesday afternoon with no music. A fortyish waitress named Wanda some time in the next six hours told him _I knock off work at eleven_ and at eleven-thirty, in a one-room apartment where a leaky faucet dripped a quick rhythm to which no one could have kept stride, displayed unusually kittenish ways and a pair of thick thighs marbled with blue veins. The First Time he had ever really Got In; as usual the popular consensus, which in his dormitory held that the experience was persistently overrated, was a lie; indeed, it had been in all his years the lone achievement; a pity that our society offered no male career in that direction.\n\nIn the late spring, just before the end of the year, another alteration in his university's theory of the reserves. If they limited membership to the bright students, the campus would soon be depopulated by the draft; so now a simple passing grade became a ticket of entry. Reinhart was permitted to sign up and given a little wallet-card signed by the Secretary of War as an assurance that he would do his service in the classroom. Actually, he was still ahead of time, was still not old enough to register for the draft. He had been a clever fellow in grammar school, doing eight years in seven, before the rot set in, and was yet only seventeen.\n\nSophomore German was _Wilhelm Tell,_ tough to read, maudlin of sentiment. Reinhart now had a lodging in town and in consideration of the low rent went without maid service; a _gem\u00fctlich_ sty except on those monthly occasions when his nihilism grew strong enough to annihilate itself temporarily and he borrowed the landlady's carpet sweeper. He read _The Sorrows of Werther_ on his own, in English of course, and went so far as to get lent the German text by his professor, who after the fashion of the kind supposed that only good students had such ambitions and was at once wary, impressed, and all the more condescending for the pretense that he was not. But it was far too tedious to go line for line with the original; he pooped out on page two.\n\nAs to the other courses, American history was worst, debunking all the colorful legends and filling the vacuum so made with a thick Cream-of-Wheat of\u2014as usual\u2014economics; tariffs and taxes and indentured servants and land grants, and a general agreement that every one of the wars could have been avoided had these items not been mishandled by well-meaning but inept statesmen.\n\nAt the end of the fall term Reinhart made _I_ -for-incomplete in history, as an alternative to the F he would have received had he not one morning in February absentmindedly cut his toenail too deep, inadvertently generating a wound which kept him from the exam. Presently the _I_ stood for infinity: along about the beginning of March his gorge rose for the last time and would not come down; he went to the campus headquarters of the reserve and signed on for active duty.\n\nHis parents protested in their pallid way, finding everything a rejection of them and at a loss to see that their weak representations made self-counsel necessary; as if an impalpable father were not enough, he had a mother with whom nothing succeeded like failure. She would have preferred his staying in school, especially now that he was flunking. He tried to convince her that the Army life held promise of far more squalid drudgery than did college, that it was likely a person of his delicate constitution would collapse in training, and she was to a degree mollified.\n\nOf course he didn't really say this; he seldom talked to his parents at all, simply, on his holiday visits home, communicating silently through the shoulder blades, a language he had learned from his father. When he was a small boy Reinhart had often wished for a temporary catastrophe from which he could rescue his folks\u2014an unarmed burglar or minor fire\u2014not only to show he cared but also to see if they did, if they could honor triumph as well as defeat, but the occasion never came, and just as well, for it might have come during one of his frequent illnesses\u2014at which time, anyway, he _had_ their interest.\n\nThey were German too, one generation closer than he, and celebrated the fact in their tastes\u2014must have, because they could hardly have invented them on their own: heavy, flavorless food, limited ambitions, disapproval of the maverick, funeral-going, trust in people with broad faces, and belief in the special virtue of a dreary breed known as the German mother. \"German\" as a lifelong malady that was without hope but never serious; as the thin edge above want and far below plenty; as crepe-hanging; as self-pity\u2014yet from these compounding a strange morality that regarded itself as superior to all variant modes. He had been encouraged since infancy to think of himself as an average man, but in a harshly restricted community where some were less average than others; if wealthy, had immorally taken too much from the world; if very poor, were immorally lazy; if taking pleasure in the material, ostentatious; if ascetic, holier-than-thou. But never \"German\" as the lofty vision, the old and exquisite manners of prince and peasant, battlements and armor, clear water splashing down from high, blue rocks, wine named for the milk of the Virgin, maleness, the noble marriage of feeling and thought.\n\nBut they sent him to college, on an insurance policy which his father, being an agent, had sold to himself, and the premiums for which, lean year in and out, had claimed all their unencumbered money, and Reinhart had first opted for Liberal Arts instead of Business Administration and now left even that. As he departed for camp he carried, along with his toilet articles and change of socks in a miniature suitcase, an acute suspicion that he would come to nothing, and... a marvelous sense of relief.\n\nAt the induction center an interviewer saw the _B_ in zoology on the record and put him down for a medic, asking him first, though, for as a volunteer you had some faint choice. And he agreed, suddenly finding his bloodthirsty fancy had paled; a superior and sensitive person deplored violence; it didn't, as every retroactive commentator on past wars insisted, \"settle anything.\" He personally had made himself so strong with the weights that no one bothered him, and if they did, he generally gave way in the conviction that not only were they probably right but that also anger and hostility were degrading. Under the Geneva Rules medical troops were all but neutral, and in recognition of this were not intentionally shot at and if captured were obliged to go on treating wounded, theirs or the enemy's, it made no difference; they were above the taking of sides.\n\nThe Germans honored this convention\u2014that was admitted by the most rabid. For after he had been in the service a few months, Reinhart began to seek reasons why the Germans, while wrong\u2014they warred against the U.S., for one thing, and it was probably true that Czechoslovakia and Norway and Holland, little harmless Holland!, had inoffensively not deserved invasion; true as well that, even discounting for cheap newsmen and their \"copy,\" there had been regrettable brutalities by the extremist, Nazi units, although in view of the Belgian babies of World War I you should go cautiously here; they were surely wrong to torture Jews, who he had discovered in college were, at least in their American branch, a pretty good bunch of fellows given certain peculiarities, and who apparently had not during the German inflation of the twenties enriched themselves while gentiles starved, as alleged by Hitler & Co., although one must be careful here, too, in simple justice, for anyone who had ever traded in a Hebrew haberdashery knew the Jew as far from a na\u00efve man\u2014he had come under an obligation to find reasons why the Germans, though mistaken, though bullies, though bad, if you will, were yet not _bad,_ were not to be allowed that case which the greatest writers assure us even Satan has.\n\nThe Army, oddly enough, was filled with superior people, the universities being then in the process of emptying to that purpose. Every barracks had its circle of cultivation, and while its membership was still outnumbered by the gross herd playing cards, shooting dice, and shouting incessantly fuck this, fuck that, it in the strength of unity read newspaper editorials, went on pass to hear the nearest city's philharmonic, and discussed international political events. At every post where Reinhart served, this circle in fact had been semi-officialized, meeting at least once a week with the authority and encouragement of an intellectual officer. Since he was channeled in that direction by cultural imperatives and nobody else seemed interested in him, Reinhart willy-nilly frequented this society, attending a few concerts, where he felt unpleasantly conspicuous as the middle-aged civilian audience beamed benevolently on the display of high-minded soldiery, and sitting in on some discussions, quaking with terror that he might be called upon to add his half-cent. If that sum were indeed low enough to symbolize the content of his head as he sat surrounded by his frighteningly articulate comrades.\n\nThe prevailing sentiment was, as one intense, red-haired, hollow-cheeked PFC (they were all privates and PFCs) put it, \"just left of center, like FDR.\" Reinhart literally did not know what this meant, except that while in grammar and high schools, when he took his father's cue in politics, he had detested Roosevelt, had at campaign times worn little buttons against him, one for Landon pinned to a sunflower head of yellow felt, another reading simply: \"We don't want Eleanor either.\" And still, even after he lost all interest in that sort of thing, carried a vague distaste for the man which was renewed at every picture of the teeth, the cape, the cigarette holder, the dog, the wife melting in good will, the sons drooping in false modesty, the desk ornaments, and Sarah Delano R., the grim progenitor of all these. Yet it was not subsequently hard to swallow that he had been an improvement on old Hoover, starched-collar, pickle-faced, the personified _No._ And whatever left-of-center now meant\u2014he had always supposed it a kind of radical creed presided over by kindly-looking cranks like Norman Thomas who were understood to be not serious and a more extreme variety represented by Earl Browder with his mustache and dark shirt and faintly alien air, which might be sinister if it ever got its most improbable chance\u2014what it meant now could only be something respectable, if somewhat strangely motivated, for these young men professed a constant concern for victims of one social outrage or another, in which company they themselves could not be counted, so that it was not a demonstration of self-interest.\n\nReinhart was impressed, even cowed, by their easy yet earnest assurance and disturbed by the shrinking of his hitherto supposed wide horizon. How he had wasted his faculties to date! Even if his sympathies had been all along on the right side: these people too were opposed\u2014and from a far more intelligent point of vantage\u2014to the double-breasted, cigar-smoking deities of business, the devotional poems in Sunday supplements, Mother's Day, Congressmen, and the suburban imagination. In college he had been too apathetic to find this out, confined in the circle of self as he was then. Beneath the surface pall there was meat in the political and economic disciplines; as approached by these acute young men, they were adventurous and splendid and, he soon saw, were far fitter areas for the mature moral effort than the gross physical projects he had earlier honored.\n\nFor example, one's build. These men, by his earlier standards, were usually physical wrecks, if small, skinny, if large, flabby, shoulders slumped, belly, if they had one, bulging, the whole man hung with garments as a point of merit shabby as the Army would allow. And no pride of carriage even in the shower, where if he met one of them Reinhart was thrown into confusion: embarrassed by his undulating biceps as he soaped the scalp, yet unwilling to loose the arm's tension if there was also present one of the common sort of soldier who didn't applaud intellect.\n\nIt was stupid, perhaps mean, to be a good soldier in any manner, although he had been right to get appointed to the medics on motives of nonviolence. All these people had been drafted, so that they had no choice, but they _would_ have chosen the medical department. Some even had friends immensely admired who would not serve in anything but conscientious-objector enclosures; some others confessed that while that was going too far for them, it was a thing most noble for a man to hold fast at any sacrifice to what he believed right and true, against _the mob,_ by which they certainly did not mean _the people,_ who were always r. and t, but rather the crowd who ran things. Reinhart would earlier have supposed the latter meant Roosevelt and his entourage, with everything but Maine and Vermont, four terms without hindrance, no end in sight, but he soon found this a misapprehension, the situation being precisely the reverse, with all such good folk victims. Indeed, the persons to be admired were invariably victims, and the degree of their victimization was the degree of one's approval. The unfortunates even included some staggeringly rich men, who however were \"liberal\" and therefore smeared, earning the herohood into which poor men were enlisted at birth.\n\nReinhart had never used his head for much but dreams, he knew, and this new employment of the brain was exciting as well as good, for neither did it ignore the heart as it surveyed the vast panorama of the evil that men had made in the world and recommended sensible alleviations. The underfed coolies of Asia alongside the oversated warlords; the black and twisted miner deep in the earth's entrails, considered with the flabby oyster of a mineowner in his house on the hill; the poor little have-not, next to the arrogant, pudgy have. These contrasts were inexcusable in a world where education should be within everyone's reach, where it was now technically feasible for every man to be served by the machine rather than vice versa; they were wicked and what was worse, silly, most of the wrong people not wishing to be bad so much as not understanding what was good.\n\nYou take the Germans, for example, or really to test these intelligent new ethics, take Hitler. You at least had to grant that, terrible as they were, he had stuck to his ideals. If that awful energy could have been diverted into virtuous channels, if he could have stopped after solving the problem of unemployment and building the wonderful net of highways!\u2014No, you most assuredly did not take either the Germans or Hitler; and if you did, there were strong grounds for popping you in the booby hatch. At least, so said without words the faces of the others to whom Reinhart, breaking his long silence, introduced this application of the theory they had so generously trained him to use. The trouble was that they had forgetfully omitted one clause from the grand code: no Germans need apply.\n\nReinhart was quick to know the justice in this, too, for, awakening from his long sleep, he had begun to see the terrible landscape of actuality. It was false to think that the Nazis were an accidental, noxious but temporary weed upon a permanently rich German ground of the essence, which might one day be cleared. No, go as far back as you would, the wars of 1914-18 and '70 against freedom-loving, culture-cradle France, the rise of brutal Prussia, way back to the war lasting thirty years and further to the razing of the magnificent Roman civilization by the tribes which Tacitus had earlier observed as being without mercy. Martin Luther overthrew the wickedness of popery; Frederick the Great sponsored the culture of the Age of Reason; Goethe was spokesman for the liberties of the heart and mind; Schopenhauer and Nietzsche, revolted by their time's cruel and shallow materialism, drafted prescriptions for the free personality\u2014even these were but masks for more Germanic creeds, or the same old one, of tyranny, militarism, suicide, irresponsibility, and madness.\n\nWhen in the last months of the war American troops went choking through the fell streets of Buchenwald and other camps, passed the vast trenches of slack human skins, the bones inside all loose from their connections, and oven-grates of gray human ash, took in their nostrils that bouquet of burned man which for recognition it is unnecessary ever to have smelled before, and for sleep impossible to forget after\u2014when the pictures and accounts were published, for Reinhart as usual was not there\u2014the most malevolent indictment by the anti-Germans had not been enough, the righteous people who wished to reduce the land to a pastoral community were too mild, perhaps not even another Flood would suffice. For the outrage had been done to him, Reinhart, who had trusted in his origins.\n\nThere is no native American but the redskin; we others are something else at a slight remove, which cannot be changed; our names and looks and surely some complexion of the corpuscles themselves are to some old line peculiar, else we should blow away without identity. So he believed\u2014his only belief, along with an idea of the possibility of simple decency\u2014and thus, with his deep relation to what the superior, bright young men in the discussion groups were pledged to destroy, he disqualified himself from their company and took up instead\u2014well, what was fun, booze and snatch and other pursuits generally pointless and amoral, and was forever delighting such people as Marsala with his adaptability.\n\nHis one secret was that he liked the Army, where the petty decisions were provided and the major ones ignored, and where you could live as if you had been born the day you put on the uniform.\n\n# _CHAPTER 4_\n\nJUST AS IT HAD ARRIVED in England after the great mass of troops assembled there for the Continental assault was gone, so did the 1209th cross the Channel and proceed eastward against the stream of real soldiers returning. At the outset, the assignment to Germany was seen as punishment cruel and perverse. For a year they had run an enormous Nissen-hut hospital in Devonshire, tending casualties flown straight there from the fields of battle, wounds yet hot and reeking. They were veterans of the European Theater and should have been let to cross the water and swagger before the slobs on Stateside duty, to mix undelineated with the repatriated combat regiments, back in the frame where the greater category enveloped the smaller, overseas versus home.\n\nInstead, the score was to stay grievously unjust: for more than a year the 1209th had had to stand holding its portable urinals while patients lay smug with honorable wounds, relating the grand experiences denied to people of the rear areas. Charging the Siegfried Line; streetcars filled with explosives rolled down the hill into Aachen; the bridge at Remagen, with its sign: \"You are crossing the Rhine by courtesy of the \u2014th Infantry Division\"; the bombs falling on the ball-bearing works at Peenem\u00fcnde, courtesy of the Eighth Air Force; the Ardennes, where even company clerks and cooks took up their virgin rifles and joined the defense and even a general proved a hero, courtesy of the 101st Airborne Division; and at the very end, \"Germany\" itself made commonplace by courtesy of the Third Army, who got to Pilsen in Czechoslovakia and burst into the famous brewery to fill their helmets with beer. By courtesy of the 1209th General Hospital, Colonel Roy Fester commanding, one passed his water, told his stories, took a pain pill, and went to sleep.\n\nJust at the point, though, where the responsible latrine intelligence had disqualified the hysterics who insisted the 1209th would any day be shipped to the Pacific, and established beyond a peradventure that it would settle in the Helmstedt field where the unit was then resting as an alleged transient, and stay there forever\u2014just at this point where the wailing was loudest, there being nothing else to do except peer through the single set of field glasses at the nurses' tents across the meadow, came a courier of unquestioned authority with the word.\n\n_Berlin,_ it was to be Berlin, so long as something had to be accepted, a horse of a different hue from mere Germany; considerably better, in fact, since the combat forces had never got there. It would be at the courtesy of only the Russians, and the Russians themselves, with the Germans downed, were now a kind of enemy and face to face with their allies kept weapons at port arms. Already they had sealed the Helmstedt checkpoint, and when, after a week of negotiations, the colonel was permitted to pass with jeep, driver, and one aide, he made only fifteen miles before another Soviet unit arrested and held him twenty-four hours incommunicado.\n\nAll this, not to mention Berlin of the Nazi mythos: old Hitler screaming crazy garbage; creepy little Goebbels, dark and seamed, scraping along on his twisted foot; fat, beribboned Goering, more swollen joke than menace; swastikaed bruisers maltreating gentle little Jews; the Brandenburg Gate and Unter der Linden Trees; and acres of the famous blonde pussy, whom twelve years of Nazism had made subservient to the man in uniform: one heard that an SS trooper could bend down any girl on the street and let fly. And, once in the city, little work conjoined with a peculiar honor: the crap-house spokesmen who in England had been privy to a document from higher headquarters listing the 1209th as the biggest and best hospital in the Communications Zone, saw another now which said, approximately: the 1209th, selected because it was the biggest and best in the Communications Zone, would be the only general hospital in Berlin District.\n\nBerlin was not the worst place to end a war; better, surely, than the gooks in the islands or France where pigs lived in the same houses as people.\n\nAs Reinhart had promised the girl, he could have been found in the frame building across the street from the hospital almost any morning if the visitor came late, and any afternoon, provided the visitor came early; he put in a good four hours of daily attendance, give or take an hour either way, and had much impressed his superior, Lieutenant Harry Pound, by his drive. Pound was not properly a medical-administrative officer at all, but an infantryman, had in fact waded in on Omaha Beach on D-Day, H-Hour plus two, and shortly thereafter led a patrol into a hedge row filled with Krauts and their armament, collecting Mauser slugs and souvenirs of grenades in all four limbs and, later, the Silver Star. Under treatment by the 1209th he had healed into limited service and was transferred from bed to staff. Their job, Pound and Reinhart, was \"Special Services,\" recreation, diversion, amusement both for patients and medics, things that had meaning in the long, pastoral days in England but which now were needless, except insofar as they satisfied the rules of organization. However, there was in the works a plan for Sunday guided tours of the Nazi ruins; Pound ostensibly was always out somewhere arranging for permission to enter with a force of sightseers into the Soviet Sector but had not yet got even an admission that he existed\u2014if indeed he _was_ really trying, for he had a girl friend in the nurses' contingent and was often seen with her when officially he was understood to be elsewhere\u2014and besides, individuals could go across the border on their own hook without hindrance by the Russians, without the shepherding of Pound, which was to say he and Reinhart had no motive for an undue haste in consummating their project, especially since their desks were littered with schedules and itineraries and manifests and notes to show the colonel if he snooped.\n\nReinhart's obligation was to write up a guidepaper listing the principal Nazi monuments, their late tenants, and a fact or two, to be mimeographed and distributed to the tourists. He was not, at the outset of each period of composition, a facile writer, thinking first that here was his chance to show off, second that here was where he would be shown up, and third that it didn't matter either way because the jerks who went on the tours would immediately spiral the papers into little piccolos and toot obscenities through them at passing broads, if the experience at the Cheddar Caves and Exeter Cathedral had been representative.\n\nHowever, with stage three he reached the firm ground of the professional artist and could compose with enthusiasm. The only difficulty here was that when he got fluent, he inclined towards the poetic, and when that, put aside his proper work and began a letter to a female in the States who was at once a sort of girl of his and a kind of estranged wife of another soldier on European duty, as near as he could tell no precise love existing in either relation but friendship and interest all around: he always knew where Ernie was stationed and what he was doing, and vice versa, according to Dianne, and there was even some talk, now that the war was over, for a get-together between Ernie and him, arranged through their intermediary three thousand miles off.\n\nA week after his birthday, no more fights but a couple of drunks since\u2014now, he thought as he looked into the bathroom mirror that morning at the pouting aftermath of dissipation, you must take it easy, greasy, and you'll slide twice as far\u2014Reinhart sat alone in his office, with pen to foolscap, well into a new letter:\n\n> DI MY DEAR,\n> \n> I certainly understand why the Princess was late with my birthday present, and will look forward with lots of pleasure when it arrives in Berlin after a long transatlantic voyage, which will make it only sweeter to the undersigned. ... Well, I've gotten where I always wanted to be, Di, to the heart of Europe and just wish I could be holding your hand while we look down from the battlements of some old palace with the peasants going along with their oxcarts down below\u2014Ha Ha, the real peasants I mean, not the kind you always call me!! And I'd just as soon we left old E. playing baseball or whatever somewhere, because frankly Di, while I really like him, as you know, from what you tell me I don't think he shares our tastes and maybe that was the trouble between you. ... \n> \n> To go from the ridiculous to the sublime\u2014all pardons asked\u2014there are lots of exciting things transpiring here. The Intelligence Officer in our outfit, who is a friend of mine, is certain Hitler is still hiding somewhere around the city. I met a Tyrolean Count the other day, the kind of fellow you would love\u2014I hope not literally! With an ascot tie, and all. He invited me to hunt on his estate in Bavaria which perhaps I'll get around to doing when I'm not needed here\u2014but that will be quite awhile. You see, no one else in the outfit can translate the Nazi documents we captured. I'm just attached to this medical outfit now for eating and sleeping arrangements. I wish I could tell you just what my job is, but even though the war is over in this Theater, there are still plenty of secrets. ... \n> \n> Oh Di, when I look at your picture I think perhaps when I get home we won't be so platonic! Like to have your reactions to this. ...\n\nHe was moving along as magisterially as the Ohio River off Cincinnati, and as impurely\u2014but Ernie was in the paratroops and had shot nine Germans and taken as prisoner twenty more, and wore the Purple Heart\u2014when a spot of color not olive-drab came into the corner of his eye, stuck there, not moving but vital, and since composition was the product only of solitude, his drain was corked.\n\nThe color was yellow of hair and rose of skin on a girl, just plump and no more, like a peach, who stood diffidently in the doorway. She was small, wearing spectacles with lenses large and exactly round and an abundance of drab clothing, including high woolen stockings and thick, awkward shoes that made her walk as if deformed, for under his even look she had moved gimpily into the room. Rather, was moved: the thin arm of another party could be seen as far as the elbow, at which point it disappeared round the doorframe. An inch off the arm's furthermost extension she stopped and smiling as gloriously as one can and still show no teeth, said in a high-pitched and cowardly voice:\n\n\"Razher nice vezher ve are hoffing today!\"\n\nFrom behind the door, a whisper, and again the disembodied arm, this time making much of its hand, after a moment of which the girl moved by the use of her own muscles. Her walk was now pleasantly normal, if prim with perhaps an aim to restrict the swinging of her long blonde braids. The latter she caught one in each hand as she halted still far enough from Reinhart's desk so that he could see her down to the round knees which the skirt did not quite reach, where although at rest she yet maintained some slight side-to-side movement as if she were still walking in the mind. The effect was curiously provocative and perverse, for she appeared to be a kind of large child rather than a small adult, and he regarded her severely.\n\n\"Tischmacher Gertrud,\" was her next sound. Her little fist had come loose from the right braid and was available for the shaking if he so required.\n\nSomebody was pulling something weird. Reinhart rose and went around the desk, first going towards her to throw them off guard, and at the last minute executing a left-oblique turn of a smartness he had never been up to when in formation. Popped through the doorway, his head met that of the other girl, the one of the ruin, whose name he had not originally got and who now, though still nameless and taken in a suspicious act for which there was no apparent motive, greeted him like a friend and he had a handshake after all.\n\nHe asked her in and invited both of them, she and Fra\u00fclein Tischmacher, to chairs, of which they cornered the market, since there was only enough furniture in the shabby, rickety place to service his and Pound's narrow purposes. He even opened one of the French windows on the sand-and-crabgrass side lawn, to clear the air, for his series of cigarettes, the sine qua non for writing, had tinted the inside atmosphere gray-blue and it surely stunk to someone just entering.\n\nThe niceties owed to his guilt about not having turned a finger for her job. He had even \"given his word,\" he remembered, whatever that was; he said such things when under the influence he became formal and constricted. In real life, as now, he was, he knew, deft, volatile, witty. Sitting on an old wooden box, his legs up on the desktop, rough-skin boots, size 11-C, murdering the papers there\u2014oops! the letter to Dianne was ruined, but no matter\u2014grinning easily, he lighted another cigarette and blew a process of smoke rings, each smaller than the last and spurting through it, each round as Gertrud's eyes, as she watched them with honest awe.\n\n\"I am sorry I took so long to come,\" said the other girl, very slow and clear so that he could understand the German. Her hair sent no message of having had a wash since the night he first saw it could stand one; similarly, her dark-green beret and gray coat with breast ornamentation of Cossack's cartridge loops. But miraculously, the fresh sunlight which marched through the open window in a brutality that made Reinhart wince, was kinder to her used face than the night had been. Something could be made of her, if you took the trouble.\n\nReinhart had the courage to admit that he had not yet found the right thing for her, that he had of course been working on the problem for two weeks and would no doubt soon reach a satisfactory end. Not a day passed that he didn't arise painfully, come slowly through shaving, two portions of powdered eggs, a pint of coffee, and a lungful of Zehlendorf's pine air to health and good prospects and then feel drop over it all the shadow of his given \"word.\" The trouble was he never knew how to get things done, how to make deals, how to \"see\" people who could arrange. At the same time he had no hope that anything could ever be done in a straightforward way.\n\nThe girl spoke fast, and incomprehensibly to him, to Gertrud, and Gertrud then said: \"She vants\u2014wwants you to believe she is grrateful for zis. She wwants to say sank you.\"\n\n\"You speak English!\" Reinhart was not so astonished as he made out, but she was charming, although too young for one to admit to himself that he might find some use for the charm.\n\nHer eyes, bluer than the high, immaculate sky revealed when he opened the window, bluer than a broken bird's egg you might find if you went behind the building and searched the pine grove, than, if you walked far enough westward you would see, the Havel; blue, the quintessence of blue, so that if the color in all its other uses had faded, Zeus might take from Gertrud's store enough to renew the blue everywhere in the world and not leave her one whit of blue the less. These remarkable eyes, surely kept behind spectacles not because they were poor of vision but rather as protection against some thief who might pluck and sell them as sapphires in Amsterdam, showed their stars to Reinhart as, below, the small pink mouth said:\n\n\"Yes, yes, I know English zo wwell, having studied it zix yearss. I sink I do not too badly, do you?\"\n\nOh, marvelous, marvelous, he agreed, and would have preferred her over Churchill addressing Commons.\n\n\"You have acted so kindly to my cousin,\" she went on. \"Perhaps I do not seem especially rude when I ask, do you sink there is also available for me a chob\u2014do you sink for me\u2014do you sink there is also a job for me? There.\" Not covering her knees when she stood, her skirt did not pretend to when she sat but made a soft frame for the round thighs that it was no doubt a grave evil to look at.\n\nSo he looked away quickly, looked at the other girl's sad, sweet, and honest way, and suddenly heard his own voice saying: _\"Warten Sie eine Weile,\"_ Lovett, he would see a lieutenant named Lovett, who was chairman of everything out of the usual course, or if not he, then another officer named Nader, whose duties were similar. To the girls, however, he said only \"Wait,\" and in a tone which they considered too masterful to nod to, instead following his departure with heads neatly turning.\n\nThe building had no rhyme or reason. Nobody could tell what function it had served before the Fall; it may have been the only place in Germany where one could hide from the Gestapo, or perhaps on the other hand was a Gestapo-designed labyrinth through which their captives were permitted to wander free and moaning, madly seeking a nonexistent egress. Three weeks in Germany now, and Reinhart had yet to see his first right angle, true line, and square space. Outside, he regularly got lost en route to the Onkel Tom movie theater, ten minutes' walk away, and strolling of an evening over to the Grunewald park, to the body of water called by the Krauts \"Krumme Lanke\" and by the GIs \"Crummy Lake,\" he could not be less certain of his position in space were he in Patagonia.\n\nSomehow he reached the foyer and assuming the fresh soul of one who had just entered from the street, struck out to the right, passing the orderly room and detachment commander's office, a treacherous area in which, although he had a certain immunity from the worst of its menaces, it was not wise to linger. From there on, he looked in sundry doors, sniffed up divers halls, consulted with acquaintances encountered in passing, most as bewildered as he, and at length spied Lovett himself, the sissy, in a large room on the northeastern corner.\n\nThe lieutenant stood willowy beside an ancient desk to which a gnarled Kraut, in a peaked Wehrmacht cap, applied cloth and a white fluid from a long brown bottle.\n\n\"I want you to bring out the highlights of the _carving,_ \" Lovett was saying with his arbitrary, Bible-like stresses. And then, \"Highlow, Reinhart,\" although he had not yet looked up to see him.\n\n\"I am being willfully misunderstood,\" he continued, in a very lowww voice indeed, which quickly rose to a kind of screech to say: \"But who knows German?\"\n\nNader, dark and thuglike, sat at another desk and relieved himself of what, asking public pardon, he called \"The Return of the Swallow,\" by Belch. You seldom saw one without the other, and never saw either without wondering at their compact, which was surely queer and yet, on the same assurance\u2014namely, that you simply knew it\u2014was not _queer._\n\n\"Well, I do, somewhat,\" Reinhart admitted. He was not equipped to tell the man what Lovett wished, but ordered merely: _\"Polieren, polieren!\"_ which the fellow was doing anyway, and added \"please\" and \"yet\" and \"still\" and \"to be sure,\" the little words Germans hang on everything.\n\nSatisfied, even pleased, Lovett lowered himself into a chair in the way one might drop a length of garden hose and listened to Reinhart's requests with a crooked eyebrow, replying when they were done: \"Wanna come to a party tonight?\"\n\n\"Really?\"\n\n\"Certainly, really. Do you _think_ we are snobs? Of course we _are,_ but you look civilized. A little house-warming at our billet. American _girls_ \u2014if that's what you can call our nurses. Wine\u2014if that's what you can call this German cat-peepee. And songs. You know our place. Any time after eight.\"\n\nSince there was almost no finish left, it was impossible to shine the desk. The German knew that as well as anybody, but he kept working humorlessly as a sociologist, now moving right between Reinhart and Lovett so that they could see only unimportant parts of each other, and Lovett, usually so quick to be waspish, suffered the obstruction\u2014perhaps in the idea that any sound from him would be received by the dolt as a countermand of his previous order. Reinhart had begun to wonder about the man and what impressions he must receive, there with his bottle and rag between two aliens speaking of nothing\u2014for two words in a foreign tongue are double too many if you don't get their drift\u2014when Nader came over swinging his simian arms and said:\n\n\"Take off like a big-ass bird, Jack.\"\n\nThe German looked vulnerably from him to Reinhart, his nose long and tapered like a carrot, cheeks marred, black-brown eyes screwed in deep sockets. He was an old man, maybe fifty, commanding sympathy.\n\n_\"Er sagt, dass Sie herausgehen m\u00fcssen.\"_ said Reinhart, shrugging the blame off himself.\n\n\"You see, Dewey, that can't be polished,\" said Nader to Lovett, who flipped his hand negligently and then bit at a finger. All his nails were chewed down to the nub; the fingers were long and white and maneuverable as rubber.\n\nThe German put his cleaning materials into a wooden box, the contents of which on his route to the door he stopped to rearrange. The wine bottle, being too tall, gave him trouble; he transferred it from box to armpit, then had to lower the box to the floor for resituation. As he bent, tilting the bottle, the liquid poured off on Nader's desktop, and by the time he got his cloth to work, his head shaking stupidly, the papers thereon clung to one another in gluey fraternity.\n\nSo far as Nader went, what was done, was done. He calmly watched the man wad the papers and drop them in his box, mop up the excess fluid and then with a clean cloth rub up a high gloss, the kind Lovett had wanted on _his_ desk.\n\n\"Just _look_ ,\" cried Lovett, biting his tongue.\n\nThe German crept out, and upon his heels went Nader, returning shortly with the clotted papers, which he arranged for drying across an extra chair and table near the open window.\n\n\"The only thing that burns,\" he said to Lovett, \"is that that bastard could pull such a cheap trick and think he fooled me.\" He had not as yet recognized Reinhart's presence. Reinhart had no feeling towards him but distaste.\n\nLovett blithely ignored him and said to Reinhart: \"Send this woman to me. The nurses' quarters can probably use another maid.\"\n\n\"Course I coulda let him take this stuff for ass-wipe,\" Nader went on to himself, aloud, describing one document as a report to the colonel on how many butt cans had been placed around the area.\n\n\"And what about the girl, sir? She knows English. We could use an interpreter over in our office. For one thing, we've got this tour of Berlin coming up, and neither Lieutenant Pound nor I know anything about the city. She could\u2014\"\n\n\"Oh _God_!\" screamed Lovett. \"Is Pound going to start that awful Cook's Tour doodoo again? Tell him to forget about it, _please_! He'll lose twenty men, just as he did at Stonehenge and I'll have to go hunt them behind every Druid altar, or here, I suppose, falling down drunk with some filthy Russian. But then I suppose nothing _I_ say ever matters to that sloppy creature. All right, I'll see about the girl tomorrow, but if I ever come to your office and see you with your hands or anything else where it shouldn't be, I will know you for a deceitful person. Be at the party. Bye!\" His eyes closed like the lid of a rolltop desk, and when shut were as seamed.\n\nOn the return to his own office, Reinhart crept noiselessly the last fifty steps to the door and, unobserved, studied for a few moments the backs of the girls within, who had apparently not so much as twitched in muscle-ease since he left, and not spoken, certainly, which you could tell from the long-established set of their heads. Looking at the clean pink of Gertrud's scalp-parting which ran from crown to nape without a disordered hair, he regretted the evil will that had asked Lovett for her assignment to himself; she was probably about fourteen. Under civil law it would no doubt have been a crime to employ her, but then he was under the power of no such ordinance, and besides had no criminal aims.\n\nHe entered and stopped between their chairs, saying to the older, \" _Alles ist in Ordnung,_ everything is arranged. You must see Lieutenant Lovett tomorrow. Ask for him at the front of this building.\" Her eyes were soft brown over violet shadows as she showed a gratitude that made him as uneasy as if he were wearing sweaty underwear; it was too much, in the light of his mixed motives. And still it did not make her happy, but rather more sad. Indeed, everything about her broke one's heart to see.\n\n\"I hope you don't mind being a cleaning woman for our nurses. There was nothing else available, since you have no English.\"\n\nAnd now a kind of pride appeared for the first time, as she answered: \"No, I can do that.\"\n\nWhile he spoke, he felt near the back of his left hand the proximity of something warm and alive, not quite touching, but there: a piece of Gertrud, but whether hair, cheek, or hand he could not tell and did not wish to look. Finally, having finished his one report, he had no choice. It was her cheek, with its beautiful petal flush, extended in curiosity.\n\nHe teasingly seized the thick braid nearby and said in English: \"As for you, Miss Tischmacher, how would you like to help us here, in this office, with translations?\" And the soft young face moved sideways, towards a nest in his palm, but he had dropped the hand before it got there and went to sit on his box behind the desk.\n\nThere had suddenly come to him an explanation for the whole works, from start to finish, the perverse ways of this child, the other girl's melancholy poetry and strange demand on his conscience. They had successfully taken him along both roads without resistance. And the only sense it made was that they sought what could not have been gained in a direct and open appeal to the fixed authorities. Why else apply to a corporal, one lone and powerless jerk in an army of thousands? Because he looked first like a fool and second like a German, and because she, the older, was a Nazi who would have been put at picking street-rubble if she had made her appeal elsewhere. Perhaps it was even a kind of treason to get her a job under the cover of which she could hide from her proper deserts. It was what they had been warned against: the Germans did it before and would do it again if you were not vigilant, sack the world and then when beaten ask the pity for themselves, but this time we will not be duped.\n\nNow it was done. Lovett, particularly, was not the man before whom one could change a tune and retain face. Reinhart rubbed his head, sensing he had gone white from the discovery, and two short blond hairs drifted separately down the air past his eyes. He could see them until they reached the dark floor. For an altogether different reason he was going bald: you had constantly to wear a cap in the service, the hair couldn't breathe. And then he remembered another reason why he liked the Army: no cause was ever wholly lost.\n\nSimulating casualness, he asked: \"You know, of course, that you must fill out the political questionnaire, the _Fragebogen_.\"\n\nShe had arisen when he sat down, perhaps in a counterfeit respect\u2014which, if so, failed; it made him feel like a fool to sit before a standing woman, especially one so small and shabby, and the fact that Gertrud held to her chair meant that the other was the only adult present.\n\nBut he had got her, there. In a reflex of sudden worry, she turned to Gertrud and said something in a rapid German he could not make out.\n\n_\"Das schadet nichts\"_ the pretty girl replied, smiling bluely, guilelessly, at Reinhart.\n\nNo, it couldn't have mattered to her; she was luckily young enough to be disqualified from the rolls of mischief; but the other had been stirred. He knew, as she said \" _Komm,_ Trudchen,\" and walked slowly to the door, that he would not see her again. And well, in a way, it _was_ sad, and because at bottom he hated to win out over any person, he finally asked her name.\n\n\"Bach Lenore.\" It was Trudchen who answered. \"As wiss the great composer. Lori is a direct descendant.\"\n\nLori studied her in amiable suspicion. _\"Was hat sie gesagt?\"_ she asked Reinhart, and when he told her, said: \" _Es ist kein wahres Wort daran,_ there's not a word of truth in it. Trudchen is a good girl, but she exaggerates too much.\"\n\n\"Goodbye,\" said Reinhart, and despite himself, \"Good luck.\" As a pair they were at once pathetic and amusing. Now it was Trudchen who was all for going, and Lori who lingered.\n\n_\"Reinhart.\"_ In her throat was the rich and authentic quality with which the name had been spoken two generations ago. _\"Rrreinhaht,\"_ an old possession become new and attractive, suggesting ancient connections between them. \"It is surely a German name. Have you found any relatives here?\"\n\nIt was of course a new idea, to go with the name, exotic and adventurous; to find an identity in a far place, among the enemy. Yet here she was again giving him another obligation, goddamn her.\n\n\"Oh, I wouldn't know how,\" he said in weary helplessness. \"I'm not German any nearer than my grandfather, and it must be forty years or more since he came to the States.\"\n\nHe got up and reclaimed his rightful chair, booting the box into a corner filled high with similar junk and obstructing a closet door which if opened would reveal more. The buildings they had inherited hardly supported the Krauts' reputation for tidiness and order. The closet boxes held ream on ream of papers carrying the letterhead of something called the National Socialist Volkswohlfahrt. Bureaucratic crap, very like the material in the 1209th's own files. He had nevertheless informed Pound, who lazily said to see the Intelligence officer. This passed on to Lovett became: \"An _intelligent_ officer? Don't hold your breath till I find one.\"\n\n\"You don't care, then,\" said Lori, only to establish the fact, without a hint of reproach.\n\nTrudchen poked her arm. \" _Ach,_ they should be the ones to look for _him_!\"\n\nExactly so, but his answer was: \"Of course I care, but I don't even have their last address.\"\n\n\"Oh, then your family used to correspond with them? If you can just remember the city, you can apply to the burgomaster's office, who has records that date back, I suppose, to the Middle Ages.\"\n\nTrudchen poked her again. \"But if it is in the East Zone, Leipzig or Dresden, somewhere like that, he might as well forget about it.\" When she was serious, her little mouth puckered and extended like the jaws of a pink snapdragon.\n\n\"Yes,\" said Reinhart quickly. \"I'm sure now it was Dresden.\"\n\nOh, goddamn her sadness! When she heard that, Lori's eyes disappeared again into the heavy violet shadows. \"Then it is very likely they are dead.\"\n\nYes, he knew of the purposeless total bombing of Dresden, a nonmilitary target, and by not the barbarous Russians but the impeccable Western Allies. It was a very good place to have had relatives, and to have had them so disposed of, whatever their sins, by a crime of the righteous. Yes, if that was what she wanted, we are all depraved.\n\n\"I must get back to work,\" he said, and routinely added: \"Shall I see you again?\"\n\nTrudchen answered, in English: \"Shooly, I shall come to commence my job!\" She warded off his interruption with a small hand. \"After I shall have seen Lieutenant Lofatt first.\"\n\nHe had not really meant her, poor little instrument that she was. Besides, he realized now that she was too young to be hired, anyway. The morning which had begun so favorably with his letter to Di had ended in a thorough waste.\n\nLori said only _\"Wiederschau'n,\"_ and was almost gone before he called her back.\n\n\"Why do you always say that?\" he asked, irritably. \"I thought it was _wiedersehen._ \"\n\n\" _It's_ the same thing!\" she said in a voice bright with melody. And he wondered that such a small thing could lift her spirits.\n\nWhen they had gone Reinhart sought to recover the letter he had ruined with his boots, but no luck. He should have to re-copy two whole pages, as thankless a job as sorting used laundry. Better to start all over again. He never lacked in invention, with the right audience.\n\nHe had just taken out a clean sheet of onionskin from the office supply when the old German who had made the mess over at Lovett's stopped in front of the window to light a cigarette, a miserable stub of a cigarette that he had taken from a small tin box. He fired the match in trembling fingers which brought it so slowly to the butt-end that the contact was charcoal to charred tobacco, dead to dead. He stared witlessly at both for a time, then returned the stub to the tin.\n\nReinhart's sudden arrival through the window took him unawares. Scared, he hastened to leave, but his weak old legs were poor servants of his intent. His right shoe was busted out at the juncture of upper and sole, issuing a string of gray stocking.\n\n\"Don't run away,\" said Reinhart, jovially. \"I just wanted to give you these.\" A five-cigarette pack of Fleetwoods, the abominable brand included in K rations, which had lain in his field-jacket pocket since the first day in Berlin, when the cooks had not yet been set up for hot chow.\n\nWhat a shabby gift for such a wealth of gratitude! The man lost his speech, the corners of his mouth twisted in emotion, in awed delight he even forgot he was old and infirm, and disappeared round the corner with the vigor of a stripling.\n\nWatching him go, Reinhart thought, in satisfaction with his own courageous realism: certainly, he too could have been a Nazi, but now he was old and sick and defeated, become by the processes of cruel time himself a victim. Humanity is not the rights and wrongs of politics but a more general lottery of success and failure, and even more fundamental than those were youth and age and how one is constantly becoming the other.\n\nIf he had relatives they too would be old\u2014for he thought of them in terms of his grandfather\u2014and so far separated from him that the blood connections must be taken on theory... yet he was not a Laplander or Lestrygonian; if he had any structure beneath the meretricious American veneer, it was one he shared with them. If Nazism was a German disease of the bone, his own marrow, even at two generations' remove, could hardly be spotless. How many times had he felt within himself a black rage at existence-as-it-was and the eunuchs who prospering in it made its acceptance a standard of virtue?\n\nJust the other Sunday he had gone with Marsala out to Wannsee to prowl the deserted mansions on the lakeside. These had already been looted by the Russians, but there remained sufficient evidences of the genteel life: sunken bathtubs in washrooms as big as stables; roofed terraces of tile, for dancing; genuine oil paintings; one home had an iron portcullis which at the instance of an electric switch ascended from the basement to guard the door. The houses were in that intermediate state of ruin asking for more. If they had been untouched, he would have looked and left. As it was, the job needed completion. The Russkies had stolen rugs and furniture, roweled the floor, spattered the walls, had multiple diarrhea in the bathtubs and washstands. But still whole were most windows, the pictures, some glassware and vases and other fragile objects prime for the breaking. He smashed everything that came to hand, assisted only feebly by Marsala, who had been a juvenile delinquent when young and in America but here and now turned delicate, as if God were watching, and occasionally said, as he witnessed a crystal goblet pulverize against the fireplace: \"We maybe shoulda mailed that home instead.\"\n\nYes, that was surely Nazism, that passion to destroy simply because it could be got away with, because one had been trained all his life to respect and abide by the constraints and then found in a crisis that they held no water. Who wouldn't be a criminal if it weren't for the police?\n\nHe would find his relatives. If they were Nazis\u2014but why suppose that? Because, although otherwise so stupid, he knew one truth, knew it so well he habitually tried to evade it\u2014perhaps that is the definition of a dreamer, he thought, a man with an unusual sense of reality. Facts must be faced. There was such a thing as Nazism. It was a product of human beings, not some exotic heresy of the anthropoid apes that, owing to simian muteness, you must judge without ape-defense. The Nazis had first been clowns, and then almost without transition, devils. His parents, like their neighbors, had burned on sight the literature mailed by the Bund to German-sounding names, as they did the product of California box numbers which peddled data on the life-force; yet with match in one hand they might loosely say on the other that Hitler had a point when it came to the Jews. At college Klaus Greiner, a gentile refugee from Frankfurt\u2014his father had been some kind of political writer\u2014described his first two encounters with American strangers: a girl at a dance gave him an invidious lecture on democracy; a man in a cafeteria admired his being a national of the country that had at last settled the kikes' hash.\n\nBut whatever his relatives were, they were his. In almost every way but the accepted idea of common decency, he felt himself at odds with the world, a kind of Nazi without swastika, without revolver and gas ovens, without the specific enemies\u2014indeed, it was a crazy feeling, an apparently motiveless identification, for although it did not include the trappings, it did comprehend the evil, as when you awoke from a nightmare of murder and for hours afterward despite the evidence of daylight and routine believed yourself an assassin; and worst of all, coexistent with the guilt, the memory of a terribly depraved yet almost romantic pride: _once, anyway, you were not a victim._\n\nLori, with her quiet European authority, had no doubt known from the first that he would come to this. He must look for her again and say: I am neither pious nor indifferent\u2014he could even, as if from outside, see himself in the attitude of gentle yet strong and manly conviction and hear his firm voice purged of boyish tenor\u2014I will find my relatives, because no man is an island.\n\nThere remained a minor problem. His maternal grandparents, who had died when he was too small to know them and were therefore of no interest, came from what indeed was an eastern province, he was not sure just where but now in Soviet hands. His father's father had been native Berliner\u2014but where? He vaguely recalled the old letter in the box beneath the front porch, postmarked Berlin-hyphen-blot. Ah, it was hopeless. He went, anyway, back through the window to his desk and wrote a V-mail home, although it were more sense to poke in tea leaves or consult a necromancer than ask his folks.\n\nOn the way through the labyrinth to the mailroom he thought of Lovett's party and hoped he was not the only enlisted man invited; he might be taken for a fruit. And finally, another tinge of Trudchen: how old must a girl be before you may desire her?\n\n# _CHAPTER 5_\n\nA THIN DUST OF TALCUM lay on Lieutenant Schild's sallow cheeks, notwithstanding which the beard's threat was darkly manifest. He had shaved a half-hour earlier, taking his usual care at the sharp angles of the chin and the mastoid region, peering nearsightedly, vulnerably, into the magnifying mirror, studying the giant's face which regarded him with similar scrutiny. The steel-rim, GI-issue eyeglasses were back in place now, and with them the correlative look: tranquil, remote, mathematical, self-sufficient. He buttoned himself into the blouse, which, though it corresponded at all points to the measurements of his upper body, seemed uncongenial to it, and placed upon his curly poll the cap whose forward point was subtly out of line with the rear one. Finally, he folded the tie in a knot that was lumpily gauche.\n\nHis toilet was preparation for Lovett's party, which he assumed to be well under way, the time standing at 9:30. Only slightly acquainted with his host, whom he had met the day before in official work, he had delayed his arrival until it could be unobtrusive. After checking his watch again, he strapped on the pistol that Occupation rules required\u2014in this the medics, legally unarmed, had it better\u2014and left the house, conscious of the housekeeper's green eyes on him. She was a comely war widow in her late thirties and slept in. He would not acknowledge her as a human being,\n\nAs he descended the outside stair, his superior, Captain Roderick St. George, came bovinely up the walk.\n\n\"Hi, Nate. Goin' out cattin'?\" He had, it seemed, determined on the long ritual, not having seen Schild since just before evening chow. Schild muttered some half-audible nonsense, and it was all the same to St. George, whose low estimate of himself was necessarily transferred to his associates.\n\nThe captain withdrew a cigarette, fired his lighter and then held it aflame interminably without using it.\n\nSquinting, Schild made known a mild complaint, and St. George forthwith snapped shut the pigskin-jacketed Ronson. He disliked giving hurt, but took a modest pleasure in being an agent of mercy.\n\n\"Oh, _I'm_ sorry,\" he said, victoriously. \"Something exciting on the string?\"\n\nSchild received a malicious impulse, gave it its head.\n\n\"Look, she has a friend, a small blonde with fine skin and breasts like lemon-halves...\"\n\n\"Haha...\"\n\n\"You know these Germans are unleashing the bottled-up passions of years.\"\n\n\"Hahahaha...\" St. George thought this a genuine joke. He could not place himself in any kind of relation with illicit sex but the comic. Besides, he regarded all Jews as humorists.\n\nHe chuckled a stanza and then said sanctimoniously: \"No, Nate, you go and have fun. I've got work to do. By the way, you haven't seen, have you, a missing folder of Kraftfahrkorps correspondence?\"\n\n\"I'll look in my files tomorrow. Offhand, though, I can't remember it.\"\n\n\"No hurry. It was among that load I brought in today. I may have it myself.\"\n\nThe odd thing was that although St. George would have been a success as a civilian, he had never been one; not ever, if one didn't count his eighteen years or so as a legal infant, after which he entered the Point. He was now forty-five, with twenty-odd years of garrison and administrative duty in the States and the peacetime colonies behind him. In the war he led a small Intelligence team that during the hostile phase jeeped company to company on the Third Army front and interrogated German prisoners. At present its business was more sedentary. In many of the buildings occupied by the American forces there were great stores of abandoned Nazi correspondence. Somebody had to assemble and classify them: in the reams of paper that had fallen behind the police state like dung from a plodding horse, St. George and his little crew were put to picking straws.\n\nThe captain now reiterated his counsel about having fun and squished into the house on his crepe soles.\n\nIt had taken Schild months to accept the reality of the captain's stupidity, for despite Marx's and Lenin's examples to the contrary, Schild generally tended to overvalue people. But St. George's was far too crude a role for a double agent. And this was, in the smallest way, that is to say, personally, regrettable, providing nothing against which to sharpen the teeth.\n\nDarkness again, lightly flavored with the smell of growing things. He resented this street which showed no mark of war. Lovett's house across the way was marked by a globed light above the door, but the window blinds were drawn\u2014indicating, no doubt, the conservative character of a party made by medical men. At the gate, it struck him that he had no motive whatever for accepting the invitation. Lovett had rudely flung it at him as he was about to leave the office after speaking with Lieutenant Nader, a preposterous, almost illiterate officer who assured him that yes, the place was loaded with papers but he better claim them fast because the colonel had fifteen men on permanent assignment to burn all the useless trash in the building and they were already halfway through.\n\nNext he had gone to see the colonel, to whose inner office he was conducted by an insolent sergeant-major with a border-Southern accent who announced him as \"Child,\" and stayed to listen to his business. On his entrance the colonel, who had been sitting in deep study of the ejection device on a mechanical pencil, snatched up a huge bolo knife from beneath his desk and sprang to the open casement, screaming: \"Look sharp there, private!\" Handing the weapon to an unseen soldier outside: \"Here's the only thing for that crabgrass\u2014wait a minute, what are you doing with that butt? _What?_ Field strip it, balls! Carry it around to the can! Wait a minute, where's Lovett? _Where?_ An hour ago I saw, God damn him that nance, a lid missing from one of the garbage cans in back of the hospital. You tell Lovett to mince over there and find it. No, not you, _him_ \u2014a gold bar doesn't make him too good for that.\"\n\nThe colonel, Nader had told him, was scared shitless of anybody, even a corporal, from another headquarters, invariably assuming it to be a higher one that had him under surveillance for suspicion of untidiness. Schild's request to impound what remained of the enemy documents scarcely salved his nerves.\n\n\"Don't tell me Lovett hasn't been sending them to you all the while! That silly pimp!\"\n\nSchild sternly put down in himself the dirty little pleasure that it was probably not abnormal to feel at Lovett's being abused\u2014but why does the girl-man stimulate sadism rather than pity?\u2014and made a defense.\n\n\"That is true, colonel, today's the first time I've seen him,\" said the sergeant-major, neutral and hateful at the same time; he was that kind of man, just as he was the sort to turn accusingly a confession upon its maker. This worthy, it was clear, held the reins of authority; typical suburban, neat-haired, office-manager type, probably from some middle place like St. Louis or Lexington.\n\n\"I have it,\" said the colonel, nervously popping the eraser from his pencil, scattering across the green blotter the contents of the reserve-lead reservoir. \"I'll assign Sergeant Shelby here to complete responsibility for the allocation of whatever it is you require. Shelby's your man, Lieutenant Shields, want something around here, ask the enlisted men. My officers just weren't there when the brains were passed out.\" He retrieved the leads one by one, a neat trick with hands sheathed in white gloves. He answered Schild's stare with a smile that vanished as quickly as oil into leather.\n\n\"Eczema,\" he said ruthlessly. \"On all ten fingers.\" He tore off a glove and showed his right hand, which looked as if it were made of rusty metal. \"Neurodermatitis\u2014terrible for a man of action.\"\n\nShelby grunted \"Yeah\" and grandly proceeded Schild into the outer office where he imperturbably took a seat behind his desk and began to read Sad Sack in _Yank,_ from time to time calling one of the clerks to witness an especially funny turn.\n\n\"Sergeant,\" called Schild, after a few moments had defined the insolence, \"I want you to show me where the papers are stored.\"\n\n\"Well yes, I will.\" Not looking up from the page. \"If you'll tell me when.\" But already he was weakening, that shadow of the coward was stealing across his eyes.\n\n\"Now.\" Schild spoke it in his smallest voice, to demonstrate to the man and his lackeys what a small, two cents' worth of force was needed to bring him to heel.\n\nShelby sullenly arose and led him out, smelling of after-shave lotion. In the hall Schild told him he had changed his mind, would come another day, smiled, and left almost lazily.\n\nBut the outfit was a nest of madmen and clowns, a traveling medicine show rather than a hospital. And he realized, at Lovett's gate, that this condition of comedy was what lured him to the party, that he could handle it or let it go at his pleasure, without, as it were, a tab to pay. He had already freed the latch, was stepping into the yard, when a low, evil whisper, as if from the conscience, said: \"Enjoy yourself. Why not?\"\n\nHe drew away in the illusion that he had collided with a kind of animate bush which, weightless and retreating, yet aggressed with whipping branches in a hundred quarters, and although he stepped to the side, off the path onto the lawn, Schatzi continued to press him. Thus, without a word, he was forced to return to the public walk, where a hand jerked his sleeve in the direction of the street corner and left off, and he followed.\n\nAt the corner, where in sound underground practice they could survey all paths of approach\u2014or in the darkness, hear them\u2014Schatzi spoke in a queer tone that was loud while pretending to be low, an undertone which must have been audible behind Lovett's closed door a hundred meters off.\n\n\"Yes, my good sir,\" he said. \"I am authorized to buy from you five cartons of cigarettes. Payment on delivery.\"\n\nIf they were overheard, it was a black-market deal\u2014more than that, if an enemy operative lurked behind the tree, he was forced to hear what was after all the description of a crime towards which the Allied authorities were turning severe, and might ignore it in favor of the larger, for which he had insufficient evidence, only at the cost of his clear duty. The beauty of the method was Schatzi's acting in worse and more furtive conscience than when he met Schild unmasqueraded, as at the Wannsee contacts.\n\nHowever, having gone so far to establish urgency, stealth, and a suggestion of controlled hysteria, Schatzi began to talk quite banally of Lovett's party.\n\n\"I have sold them some glassware, very lovely crystal glasses which I am relying upon you to guard over. Some persons may get drunken, you see, and it will be a scandal to break these glasses which cannot be replaced all over Germany. I speak not of my own convenience, since they have paid me, but namely of the uselessness to destroy pretty objects which also have their place in the world, or don't you agree?\"\n\nThis preface out of the way, he thrust himself under Schild's nose and in a passion of distrust asked: \"What are your relations with Lieutenant Nader? I know yesterday you have seen him!\"\n\nIt was degrading that Schatzi, with his own active assistance, managed always to take him by surprise.\n\n\"He's Intelligence officer for the 1209th General Hospital and therefore the logical man to see about the German documents in their area.\"\n\n\"Of course, _Intelligence officer_ \u2014does not that mean to you something odd?\"\n\nSchild regretted saying \"German\"; he was commonly careful to use \"Nazi\" or \"Hitler,\" rather than the adjective that comprehended an entire people, not only because the distinction figured importantly in Soviet policy, but also because Schatzi was a non-Hitlerite German. And finally because he could not truly believe in the separation and clung to it all the more, in an effort towards self-mastery.\n\n\"As a matter of fact, it does.\" He made a joke: \"He has no intelligence.\"\n\nSchatzi hooked into his elbow with murderous fingers. \" _Was, was?_ I don't understand!\" And still claimed not to on repetition. \"Don't smile!\" he whispered angrily. \"If you do not think this is serious, something can perhaps be done about you.\"\n\nHe had never spoken this way before. True, he was Schild's superior, but for purposes of organization rather than discipline. And he was a German. ... How easily vileness slips in when one is momentarily weak with indignation! Yes, Schatzi was a German, a good one, which in his time meant a hero it was a privilege to know, an honor to be rebuked by, and thus Schild accepted the onus: What error had he made with Nader?\n\n\"The responsibility of an Intelligence officer is that of an open police spy, no?\" asked Schatzi. \"Therefore you present yourself to him conveniently. He can simply sit in his desk and you walk into his hands. This leads a person to say there are two possibilities: you might be a fool or you might be a counter-agent.\" He floated an inch away, and returned to his earlier, crafty voice: \"But I cannot pay more to you, since Captain Josephson of the Engineers Department has promised already to sell me all I would need for a thousand mark the carton.\"\n\nNot until he finished did Schild hear the footfalls, deliberate, soft, and yet massive as a lion's on the route of his bars. As they approached, the courier grew ever more spurious, and when at last the organism that made them, in his own agonizingly good time, arrived in closeup, Schatzi sprang dramatically to the curb and found on his forehead a sweat so heavy it required both hands to dry. Now the melodrama was inflated beyond all sane proportion, and it was Schild who felt wet all over in genuine perspiration, certain, in a dread moment as the newcomer stopped before him and he saw a face as puffed and insensitive as a medicine ball, that it was an arrest.\n\n\"Lovely evening, men. May I trouble you for a light?\"\n\nA great curved pipe like Sherlock Holmes's, like Stalin's, and by the flare of the match, a golden lapel-cross. He continued to intake and expel till the flame seared Schild's fingers, and then, with one last cumulus of smoke straight into Schild's eyes, he padded on with a clabbering \"good night.\"\n\n\"A holy man,\" said Schild derisively, regulating his breath as Schatzi returned. And then, as Schatzi said nothing, stood rather in silent, corrosive accusation as the minutes vibrated through the watch on Schild's wrist, up his forearm, biceps, shoulder\u2014 _\"Yes. That would be the perfect disguise!\"_\n\n\"Don't be ridiculouse,\" Schatzi answered in a very low voice. \"That was the Protestant chaplain for the 1209th Hospital. He is quite likely looking for girls, the younger the better, the dirty old man. ... You have then no explanation.\" It was not a question. \"Among the papers of Nader was concealed a memorandum which read 'Documents\u2014Schild.' They all go to him before you deliver them to me, yes?\"\n\nTo be frightened by a fat, buttery, strolling chaplain! Schild recovered so rapidly that he all but made another small joke. \"Ridiculouse,\" how ridiculouse it was. Schatzi was after all accusing him of treachery; of all imaginable moments it should have been the most terrible, yet he could barely withhold laughter. Nader, Lovett, the colonel, Shelby, the chaplain, and, in his own house, St. George, with their uniforms and pipes and insignia and parties and cleanup details and evening walks\u2014who but Schatzi could envision that fat, genial toad with the gold cross pinching some German teen-ager's behind, or Nader's playing the deep game?\n\n\"I had to go to Nader, you see,\" he whispered. \"Anything else would have been suspicious. I assure you he's a buffoon.\"\n\n\"Now I must not again hear you say that of anyone,\" said Schatzi, \"or I will know you for a traitor. I have told you those are the most dangerous persons. But even so, you do not have a connection with Nader, _you say,_ however, you go from him to the office of the commanding colonel and insult Sergeant Shelby.\"\n\nSurely he did not presume to direct Schild's official relations with enlisted men; he was getting now clearly beyond his limits, and Schild forbore from righteous protest only because his intuition told him Schatzi had not yet reached the serious argument of which this was preface.\n\n\"Shelby?\" Caution made him pretend briefly not to recall the name.\n\n\" _Shelby,_ yes!\" Schatzi's breath into his ear was like a long needle piercing the drum. \"He is a sympatizer, but he will not forever be one with rudeness.\"\n\n\"How was I supposed to know that?\"\n\n\"You might have smelled it\u2014but that is not the point. A source in the very headquarters of the major American medical hospital in Berlin. If Major General Floyd Parks becomes ill, where does he go? To _1209th_! If the deputy commander, Colonel Frank Howley? _To 1209th_! Eisenhower comes to Berlin, twists his ankle\u2014even you should see the actualities. There is no brains in making enemies of someone who has the slightest power. That is the first rule. The second is, give to a man a chance.\"\n\nGive to a man a chance! It was a touching slogan of wonderful, innocent charity, like the creed of some early social reformer, some Robert Owen, now outworn but fond in memory. He had not looked for such a sentiment in Schatzi and finding it was not quite sure he got its sense, unless beneath that scarred and charred carapace there was an old idealism that had remained impervious to the arrests and tortures and the subtler ravages of the illegal life.\n\n\"I'm afraid I still don't understand. Do you wish me to identify myself to him?\"\n\n\"He was told someone would come to ask his assistance.\"\n\nSchild did not think it wisdom to remind Schatzi his directions had been simply to go to the 1209th, with no mention of a source; the injustice being done him stirred more caution than hurt.\n\n\"Now they must give him another carton-box of vodka.\"\n\n\"He is bribed?\"\n\n\"To be sure, he is only a sympatizer and not under discipline. But tell me what time is it? Ah, so late! One more detail: in a room on the south front of Shelby's building is a closet filled to top with papers of the old _Winterhilfe_ \u2014this was a Nazi agency to deal with the poor, clothing and food for charitable distribution. In the last years of the war, one hears, they gave out clothing of the Jews exterminated in the camps, sometimes even forgetting to cut off the yellow badges. Haha, cynicism could not be carried farther on...\"\n\nHow innocuous Schild's own little joke had been in contrast to this, the authentic, vintaged gallows-humor.\n\nSchatzi continued: \"Now there is a boy in that office, with some kind of entertainment service for the Ami troops. A great lout, with him you would be correct when you said clown. Just go there and get the files from him, no need to let Shelby know.\"\n\n\"No need to let Shelby know?\" Schild could do no more than parrot the sentence.\n\n\"Certainly not! Anything you can get without him, all the better. One shouldn't wish that _Scheisskerl_ to become too self-important. As I told you, he is not even a member of the Party, he cannot, in the end, be controlled\u2014 _Achtung_!\" He reared back and harked with hand to ear. But it was only someone entering Lovett's door down the block.\n\n\"Isn't that a Wehrmacht cap?\" asked Schild, seeking a moment's respite, for prolonged exposure to Schatzi's undiluted presence was very like being worked over with a blowtorch; one had left only short breath, and that was filled with the smell of scorching. However, Schatzi's own habit of disregarding nothing was so influential that he found himself eager for the answer, for some clue as to his frequent changes of costume, which were more likely to achieve publicity than disguise.\n\nBut Schatzi gave every notice he could, in silence and darkness, that the question was a faux pas, social and not conspiratorial, nonetheless offending.\n\n\"Go now to your party,\" he whispered coldly. \"And for heaven's sake don't be rude to anybody. Have pleasure, dancing and drinking, show yourself to be a normal person. What there is to lose but your chains?\" With the latter he moved into better humor, saying in what no doubt was a friendly way: \"Here is a little gift from me to you.\"\n\nHe pressed a small, flat package in Schild's hand. What was it, rubbers? Schatzi didn't understand and Schild, laughing, didn't know the term of the German-in-the-street.\n\n_\"Empf\u00e4ngnisverh\u00fctende Mittel?\"_\n\nThe dictionary formality got a laugh even from Schatzi. \"Cigarettes of the Fleetwood brand. _Also,_ unless emergency, the usual time and place.\"\n\nHe left, or rather he was no longer there. Nor was there a sound that could not have been made by a leaf crashing onto a pillow of moss. The \"gift\" lying uneasily in his pocket\u2014as if it were soaked in phosphorous-water which when dry would explode\u2014Schild went again towards Lovett's gate. Just before it he met the stout chaplain, whose pipe had once more gone out, this time, however, without appeal. A soft girl of about fifteen and in long braids stood swaying at his side.\n\n\"Good evening, men,\" he voiced richly. \"I don't suppose\u2014no, I see you're busy.\" Peering. \"Oh, just one of you! Well, to the party, eh? I may look in later, but just now I must act the Samaritan to this child, who is out all alone after curfew.\" He reached for a braid. \"You don't suppose you\u2014no, go on in and have fun. This is what chaplains are for. But, I say, have you any idea where Jugenheimer Weg lies?\"\n\nTelling him, Schild thought he heard a distant, hideous snicker, a passage of air through corrupted channels; and so it was, and no more: the chaplain sucked on his dead pipe.\n\n\"Sank you from zuh bottom of my hot,\" said the girl, with a pliant little moue very visible in the glow of Lovett's porchlight.\n\nWere they all dead drunk or had he got the wrong night? He knocked interminably without result, and no doubt would have given up had he not received so many counsels, nay, commands, to go there and enjoy himself. At length Lovett unbarred the portal, showing a face painted by Dante Gabriel Rossetti, slightly under the weather, and donating three white fingers towards hospitality.\n\nIn the living room, which was the smaller and more airless for it, sat a number of guests in contemplation of their belt buckles. As Schild came in from the hall they looked up as one and stared ominously, hatefully, man and woman, and as quickly looked away in instant boredom. Lovett gave him a green tumbler, and Nader, who it appeared was also _en menage,_ presented a hard look from beneath the one long eyebrow like a caterpillar across his forehead, and went into a corner from which presently a phonograph began to bray. The company arose to dance claustrally, the rug having been cleared away but not the furniture. A nurse or two, lacking partners, watched Schild in a hopeless expectancy which soon settled into resentment, for he had discovered a sofa in the opposite quarter where one might settle to view the passing parade.\n\nAt one end of the couch sprawled a young man, who had managed by a disorderly arrangement of large limbs to command nine-tenths of the surface that should have been free; as if this were not enough, Schild was astonished to see he wore corporal's stripes.\n\nWith a failure of consideration he immediately regretted, since the fellow on his approach made ample room, he asked: \"Is this affair for enlisted men, too?\"\n\nTaking no seen offense, the young man grinned and waved his hand abroad. There were, in truth, several noncoms scattered through the crowd. A sergeant waltzed by at that moment with a bony nurse, in some danger of being impaled on her chin.\n\n\"Oh, I didn't mean anything was wrong. I've heard these medic outfits practice a good deal of democracy.\"\n\n\"More in the breach than in the observance.\" But the corporal's very impudence belied this. Schild anticipated trouble. He warily took stock of this soldier, whose olive-drab hulk slouched into the couch as if he owned it. Assuming comparable _sang-froid,_ Schild without looking lifted the drink in his hand and took a modest draught. It was not a green glass at all, but a clear tumbler containing a viscuous green fluid, an oleaginous, minty, sweetish ooze. His tongue curled in revulsion. While he fancied desperate measures, the liquid crawled across the palate and drained into his throat.\n\n\"God, that fool gave me a full glass of cr\u00e8me de menthe!\"\n\n\"That's probably all he had left. They pooled the officers' liquor rations for the party, but most of it was wines and liqueurs. I got Chablis.\" The young man, lips parted in good humor, lifted the glass that stood between his feet. \"It's awful, too, if that makes you feel better.\"\n\nStrangely, it did. There was a generosity in the corporal's ease which minimized his impudence. With a wry nod at his orders, and despite a sense of imminent nausea, Schild organized himself for fun. But when the opportunity appeared, it was in the corporal's name.\n\n\"Reinhart!\"\n\nA large nurse, constructed on the plan of Rubens' second wife, stood before them offering her heroic body with a slight upthrust of the hips. High above, gigantic breasts made bold, made brutal, and threatened the poor weak seams of her olive dress. One listened for the _ping_ of parting threads deep in her armpits. Very likely, said fun-loving Schild to Schild, she cocks her hips to balance the bulk of those incredible glands.\n\n\"Come on, Reinhart,\" she cried and rowdily assaulted the corporal's arm. \"Don't be sticky.\" She got him on his feet and into the amplitude of her fa\u00e7ade. From the phonograph wailed a niggardly statement of love denied. And Schild sat in his standard condition: alone.\n\n# _CHAPTER 6_\n\nNUESE LIEUTENANT VERONICA LEARY presided over the nut ward of the 1209th. Reinhart knew her by sight and name; was not, however, in the least acquainted. Were the standards of rank, which he approved, now to be swept aside?\n\nThis was his first mixed-grade party, and he had so far found it difficult to put off his snobbery, even though most of the officers were from the medical staff, which meant an amiable, unsoldierly, democratic lot whose professional view of man as viscera saved them from megalomania. The administrative officers, having got wind of the conglomerate guest-list, stayed away, victims of poor judgment. For of the enlisted personnel Lovett had invited only notorious brown-nosers whose obsequiousness no intimacy could corrupt.\n\nWith qualms about his own status, Reinhart had soon retreated to the isolation of the sofa. Now here was Leary, legitimizing him by her substantial presence, like Europa and the ox with functions reversed. But since he was, despite nature's perverse generosity, larger still than she, the issue was a push-pull in a progressively diminishing tempo, and a nettled comment, charged with liquorous and sexy odors, blown into his ear.\n\n\"Do you know, you're really a punk dancer.\"\n\n\"Never claimed to be a good one.\"\n\nWhich she went for in a large way, with a splendor of teeth and a marvel of air-blue eyes, in a demonstration of the frequently altering but at any given moment perfect dominion of her withal fragile, sentient face over the dumb classicism of that body.\n\n\"D'yuh know what?\" she asked, giddy again but kindly, \"Really, when it comes right down to it, you don't have much fun, do you?\"\n\n\"I'm having fun right now,\" he said, so pitifully that his heart cracked right through at the vibration and hung like a sundered glacier about to plunge into the sea.\n\n\"Aw, kiddy, come on and cheer up! When I used to see you I would think there's the very nicest boy in the 1209th. And also the saddest, because who knows what secrets lu-r-r-r-k in the hearts of corporals.\"\n\nThis was actually a horror to Reinhart: as he walked in dignity and rectitude, strange eyes had marked him, had abstracted a piece of him, as it were, that, insensitive fool that he was, he had never missed.\n\n\"All right, it was just an idea,\" she said then, surprisingly enough, eyes bright with the fool's-gold of ennui, mouth parodying good humor. This came from hither-and-yon; she was revolving her head, apparently surveying the room for another candidate to storm, who, not capitulating instanter, would get the same short shrift as Reinhart.\n\nFor he had her sized up, and stood enjoying bitterness confirmed. When a nurse smiles at a corporal, _caveat_ would-be lover! A nurse is an ill integration of woman and officer, with one of the roles appearing wherever the ordinary lines of human deportment would ordain the other; so that you are always puckering to kiss a golden bar or saluting a breast, a stranded sycophant between sex and power.\n\nThe music having suddenly pooped out, the rest of the crowd clogged the rear of the room, where Nader gave first aid to the record player with loud frustration at the complexities of wire. No man being opposed\u2014even the dark, nervous officer had vanished\u2014they returned to the couch, where Lieutenant Leary announced her name to Reinhart as \"Very,\" and plumped down proprietor-close. He had then, by default, been chosen.\n\nSince high school Reinhart had made it a principle to avoid really pretty girls, with their detestable and arrogant ignorance of the principle: they're all the same upside down. He played courtier to no one, and was gratified in college to see that the lackeys of the prom queens were to a man spectacled and pimply, usually students of science. However, although she was beautiful, Very was reclaimed by her size; it was a near-deformity, being almost divine, and made her human.\n\n\"Do you have the time?\" he asked, for in spite of all, he was horribly bored.\n\n\"Sure, but who'll hold the horse?\" Very answered brightly. \"An old joke that if my father's said once, he's said a thousand times. But I can't tell you because yesterday I sold my watch to the Russians for two hundred and fifty dollars.\"\n\nShe showed a fine, empty wrist\u2014at such narrowing places she was as slim as she was generous in the areas for expanse\u2014and went on to add that really the watch was sold through an agent, who no doubt had kept a sizable commission since timepieces went for about five hundred; but to her it was well worth the missing half: she feared the Russians, who were reputed to prefer large women.\n\n\"And I'm not what you'd call petite.\" Robustly she snorted.\n\n\"The Russians like 'em fat,\" Reinhart said gallantly. \"And that's not you.\"\n\nShe looked away with a hint of pain, as if the remark were out of order, and then returned to, anyway, do best by it: \"One thing I know, it's sure hard to lose it when you put on blubber. Cripes, you get so hungry, sometimes!\" Her extraordinary grin over nothing, open, unafraid, witless, was more splendid than anyone else could make for cause. Trying unsuccessfully to match it, he cursed the fate that had led him early in life and from a false psychology to cultivate the impassivity of an Oriental. Now, in a time to be bravura, he found himself instead sneakily edging his knee over against hers, laying his hand on the cushion where hers, he had observed, habitually flew at punctuations in her speech, studying the rich mouth as it carved words from the adamant of the northern Midwest. If he wished to touch her, he should do it; there was a bond between large people, as among Negroes, Greek-Americans, soldiers, etc., by means of which their secrets were kept only from the outside world; thus, if he had such a wish, she already knew it and sitting there unprotestant was not offended.\n\nBut there went the music again, and since girls genuinely like to dance\u2014so much so that they will partner another of their own sex rather than sit aside\u2014Reinhart patiently rose and returned to the grappling, this time, however, since he was prepared, getting the initiative before she did, encircling her waist with a tensed forearm the muscle of which, though she did not complain, surely put a rope burn in the small of her back, manhandling her, on the turns raising her whole weight off the floor on just that single arm.\n\nCoincident with her total surrender he went into tumescence and regretted that for the sake of slim hips he had worn the tight OD trousers which would show the most meager change of contour. He must hold his lower body away and cast the mind on some serene subject matter. The phonograph played \"Long Ago and Far Away,\" from some movie faintly recalled, abominably corny yet sad and sweet. No doubt most of them here were led to thoughts of home, and he was in this mood charitable, retaining for himself an achingly beautiful sense that it was he who was far away and long ago, like someone who lingers in the theater after the performance has ended, amid the discarded programs and slowly vanishing odors and the houselights extinguishing bulb by bulb.\n\nThus as the hour fled, when the record player broke down and they returned to the couch, Reinhart felt nostalgia for the dance, and when it began again to revolve and they danced, he thought of the distant perfection of the time on the sofa, and was always ready to pull Very one way or the other like a great anthropomorphic balloon, for she had become incredibly light on her feet. In these activities, he got his hands on her in various quasi-legal ways: against the side of a knocker, as they went off the floor; slipping down from the waist and swooping like a swallow across the buttock-swell as they waited, swaying, between records; up her grooved back to the hard metal juncture of the strained brassiere, over which slip, shirt, and jacket provided no more cover than wallpaper over the last tenant's picture-hooks.\n\nThe society of girls is a very delightful thing, as he recalled someone had told David Copperfield, not professional, but very delightful. Reinhart had not for years, excepting caf\u00e9 encounters and alleyway contacts with foreigners, which was something else again, had it to enjoy. Those American scents and sounds, one's own language speaking of nothing, but understood; the thousand familiar references in matter and spirit; the absence of ambiguity\u2014Europe was suddenly squalid, skinny, crooked, and dark, he would not have taken it for _eine Mark_ or _cinq francs._ With this Yankee smooth-warm cheek against his he thought of Lori and her little cousin towards whom as late as this afternoon he had had inclinations which, because he saw them now as a product of the time and place rather than himself, could be definitely labeled strange and discordant, the whole business devious and gnarled.\n\nHe decided he was in love, or that he would assume he was tonight and decide on its permanence the next morning. This, and the fact that no officer in the company looked disapproval\u2014indeed, in the crush on the floor none could have if he would\u2014the fragrance of cosmetics, the shadows when some excellent person turned down the lights for the dreamy songs, the warm wall of humanity around the tight little cell of their mutual interest, the yielding of his artificial will to the natural magnetism of her mass\u2014in the strength of these he closed with her all the way to the shins, lost false modesty and with his lower-middle, that had become sensitive as the tips of both hands, could feel the very mount of Venus, while his mouth in the movement of the music slowly followed the round of her cheek to the lip-crevice and made entry.\n\nThis bliss was disrupted when some bastard inaugurated a series of hot records on the turntable. Reinhart knew as he led Very back to the sofa that it was an opportunity, even an obligation, to take her outside, perhaps in supreme audacity to make a headlong rush through the back yards to his flat just around the corner, taking the tide at its flood. Yet his feeling was more delight than desire; he wished rather to prolong this time which had come fortuitously than replace it with his own initiative, which held no surprises at all.\n\nHow marvelous it is to be singled out, and spared the tight-wire balance of establishing favor! But it also makes a man a good deal more cautious than a shy girl would believe, forwardness in small things being a fortress against large. Girls who are bold can better withhold. It is as if the tiger dug the pit, fixed the net, arranged the camouflage, and crouched laughing by while Frank Buck stumbled through and captured himself. The other side of the coin was the pleasant fantasy that you could sit very still, coining banalities when necessary, but nothing coarse or even really interested, it went without saying, sneaking through the requisite time, playing cherry, so to speak, until the girl was so wild with unrequited passion that she would positively drag you to her bed.\n\nOn still another hand, Very bore all the moldmarks of a nice girl, the sort whose intimacies were flagrant because her intentions were innocent, like some Samaritan who courts denunciation as a pickpocket by reseating your slipping watch. She could very well get you all the way to the Beautyrest only to repair a loose spring, and nothing upset him more than basing an effort on principles not understood until its miscarriage.\n\nHe again could have stood a drink, and Very had just as soon, but a difficult negotiation through the dance-floor athletes who despite their average age of thirty to forty were astonishingly spry at the fast music, discovered only a wet table of empty bottles. He returned to see Very sharing the couch with a gloomy captain whose collar caduceus bore a _D_ for Dentist. He was known to Reinhart as a relatively good egg, as well as a painless practitioner, but he now wore the pious look of that partygoer who makes a fetish of his loneliness and searches grimly all evening for fellow worshipers, thus partaking in much more community than the busiest extrovert. Skinny and fuzzy, as if he had been twisted together from pipe cleaners, he sat grumbling in an undertone. However, he had dropped there only in quest of a seat, not trouble, and his scowl of greeting as Reinhart sat on the other end carried no hint of malice.\n\n\"You know,\" Reinhart said as she moved comfortably against his shoulder, \"I used to be air-raid warden in the nurses' quarters in England. Did you ever see me there?\"\n\n\"Gosh, I hope you didn't see me! I'm always a mess around the barracks, especially in England. Wasn't it awful there! The continual fog and rain, and that horrible tea all blue with milk, and fish and chips, and sausages filled with oatmeal. You know how many times I went to town? Once. Once, and I had enough.\"\n\n\"Weren't you ever to London?\"\n\n\"Oh cripes no. That was dumb of me, wasn't it?\u2014I should have gone to London, anyway, because as everyone says you'll never get the chance again. I bet you did, though\u2014were the Piccadilly commandoes really pretty? Go on,\" she dug an unbelievably hard elbow into his side, \"you can tell _me_.\"\n\nAt this the captain, whom he could see beyond her, ostentatiously repressed a grin and cast his eyes on the ceiling, and Reinhart was suddenly embarrassed at the public disclosure of her stupidity. A statistical friend once told him that one out of every ten girls is pretty, and one out of every ten girls is intelligent; ergo, one out of every one hundred girls is pretty and intelligent. Pooling the women he knew with those of the statistical friend made a grand total of eighty-five; they had had every expectation that somewhere in the remaining seven and a half to each man would appear the rare combination, but Reinhart had since lost track of the friend, in whose consignment the marvel would have to be, for his own quota was exhausted. As to Very, to balance the proposition she should have had to be a Mme Curie, a George Eliot, for only genius could be commensurate with her beauty, which he realized sitting there finding fault where none was appropriate, had become ever more glorious with use. She was fantastically beautiful, there was no other possible description, and comparable to nothing, lake, sky, gems, or flowers, but an until-now masturbation dream of the female essence.\n\nSo he began to lie, not grossly like a politician but subtly like a statesman, referring to his parents' street as a _road,_ and to his college as _school;_ spoke familiarly of dinner clothes, of riding boots, fencing, martini cocktails and the sediment of sherry wine, and of the possibility of buying oil paintings from ruined Germans for a song. He talked of love, not particularized but general, yet with a hint that behind him lay the wreckage of a hundred hearts, each keeping with it a piece of his own, for he was more passionate-impulsive than cruel. And finally, of the manly arts: boxing, judo, water polo\u2014and creeping through the poison-gas chamber in basic training.\n\nHe was about to bear down on the last\u2014and with justice, for it was quite true that his gas mask had sprung a leak, letting in the smell of deadly chlorine\u2014when he reflected that since nurses had had the same training, Very was not likely to see it as exotic.\n\n\"Well, _go on,_ \" she screamed as the story bogged, flashing the long lashes which had some time earlier\u2014it being, after all, a long evening after a full day's work\u2014begun to lower.\n\n\"It wasn't really anything\u2014\" On the contrary, he sensed, awfully, that it was the only thing for a whole half-hour that _did_ interest her, and, to a degree humiliated, he determined almost vengefully for once to give the banal truth.\n\n\"Why, the instructor said if we so much as imagined we smelled chlorine to get the hell from the shed. Which I did. There was some sand in the valve of my mask, it turned out.\"\n\n\"But were there any toxic effects afterwards?\" She pressed harder against him and seemed to study his right nostril.\n\n\"Just a little dizziness.\" Off on another lie.\n\n\"But you had a blood count, surely?\"\n\n\"Not exactly, but\u2014\"\n\n\"How long ago was this?\"\n\nChrist, he could smell it still, that odor of laundries and swimming pools, fiercely clean, implacably antiseptic, inhuman, the same stink outer space must have beyond the farthest planet. Three years ago, when he was a punk recruit, his suntans yet shiny, his fatigues still dark green, his gas mask clotted; it gave him no pleasure to dwell on that era.\n\n\"Oh, well then, I guess it wasn't serious.\"\n\n\"Of course not, that's what I said.\"\n\n\"No mental effects?\"\n\n\"Mental! You mean _crazy_? I hope not, nuts as I already am\u2014but you can't be serious. Chlorine attacks the lungs, if it gets you, and you are so busy dying you haven't got time to go mad.\"\n\n\"When you've been around as many weirdies as I have, kiddy,\" she said in a bluff, coarse way that made him recoil, \"you would know that many people don't have time for anything else.\"\n\nThis was a grisly turn indeed, and his feelings rumbled in his stomach as he pursued it. \"Seriously, can chlorine gas\u2014?\"\n\n\"Oh, you're not worrying now, after this long? There now, I've upset you. Maybe I was joking a little. To tell the truth, I don't know anything about poison gas except what they told us.\" She laughed a little too violently and a touch too long, and if at its peak you had taken a still picture with a very fast camera, you might have seen that she herself for a moment looked deranged. \"But are you aware that many kinds of internal medication taken to excess can produce a psychosis? Sulfa drugs, for example.\"\n\n\"They can!\" He said it in so terrible a voice that the dentist, still there on the other side of Very, jerked in professional, hypocritical dismay, as if his drill had slipped and lacerated a tongue.\n\n\"Well, only _temporary_.\" Into his face she had pushed hers wide with the most glorious grin of the evening, at once splendid and grotesque, and so near that with almost no effort he could have sunk his incisors into her velvet nose. Then she drew back and laughed, laughed, laughed. \"Oh, I've got you so scared! Now the next time you contract nasopharyngitis you won't take sulfa, and then you'll catch pneumonia, blaming it all on me.\"\n\nHe asked, somewhere between joke and real, \"Does that mean I'd be put on your ward?\"\n\n\"For pneumonia? No.\"\n\n\"I mean\u2014the other.\" He deplored euphemism, but he fancied that her mirth had become briefly acid with malevolence.\n\n\"Why not get to know me off duty, instead?\" She patted his hand, but it was not in the least provocative. \"I'm nicer then. Besides, we don't need you, we're all filled up, got more patients now than when the war was on. Bet you thought it would be the other way around. That's because it's never the real things that crack people, but the imaginary.\"\n\nThe music had at last become soft. Because someone tripped over it, lightly cursing, Reinhart crossed his restless, foot-tapping leg over the quiet one; his trunk inclined in a long plastic crescent: a smooth-leather couch would have ejected him to the floor. Very when solemn was not very Very, he said to himself, and to her: \"I was always in a funny position.\"\n\nHe was in enough of one now for her to hesitate and then produce a question he had not heard for three years, an idiotic cuteness nevertheless poignant, fragrant of Tom Collinses floating Maraschino cherries and cheeseburgers dripping catsup but with no onion, because of the necking to come, in some congested, clamorous pleasure palace on the great Midwestern plain.\n\nAnd when she asked \"Funny haha or funny peculiar?\" he was caught, with all the force of his past, in the iron fist of love, and would inevitably have been drawn sideways in a most funny uncomfortable position to crush the charming folly against her lips with his own\u2014had not the dentist at that moment peered ugly around her exquisite right breast and called:\n\n\"Hey, Reinhart, why don't you scout around for some hooch! That damned Lovett has some in the kitchen, I know. Do me a favor and go look.\"\n\n\"Why don't you go yourself?\" Specialist officers would accept almost anything that was simultaneously assured and good-humored.\n\n\"That lousy skinflint faggot!\" mumbled the dentist, and mixed himself again into the cushions.\n\nVery rolled her eyes. \"You were saying, when we were so r. i.?\"\n\n\"That I always wanted to be in combat, but frankly, I was too cowardly to volunteer for the infantry. What I wished would happen was that I would simply be assigned there through no voluntary act of my own. Then my conscience would have been clear, as it were.\"\n\n\"Conscience? Who lets himself in for danger unless he has to?\"\n\n\"That's it,\" he groaned. \"I'm very sensible. I _didn't_ volunteer, and I'm not sorry that I did not. My regret is that somebody else didn't make me. When I say conscience, I don't mean it bothers me now, but that it would have if I volunteered, so much so that I would probably have been killed.\"\n\n\"Obscure.\"\n\n\"Don't you get it? I would have felt I was committing suicide.\"\n\n\"Don't talk like that!\" She manipulated his hand, as if this perversion had settled in that member, and could be worked out, like a cramp. It was only too clear that he wasn't getting through, and he understood that he very likely never would. Anyway, her failure was in itself a kind of success. Having essayed this theory with others\u2014if you haven't heroism to bring to a woman, you have to lay your intentions at her feet\u2014he had tasted many times the ultimate indifference most people have to the imagination's projections, especially in the hypotheses of somebody else's morality.\n\n\"I'm sometimes embarrassed at fighting the war as a kind of Broadway press agent.\"\n\n\"Special Services are certainly necessary, or the Army wouldn't have it. Besides, think how human it is to entertain people. Think how fine it would be if each side fought with entertainers, with the victory going to whoever made most people laugh.\" It was obvious from the jolly bell in her own throat, which she now tolled, who would win. And Reinhart, with this revelation of the open secret of her force\u2014that she would always be victor, from an inability to imagine loss\u2014knew that he must have her.\n\nSo, with mock impatience, he said: \"You're not serious.\" And slid his arm around her splendid waist, as the captain's face hove into view once more, saying:\n\n\"You wanna dance?\"\n\nThree or four times, to Very's blind shoulder. When he eventually registered, she declined, and considering the situation, perhaps too rudely, Reinhart thought. To make up for which he grinned amenity at the man.\n\n\"I didn't ask _you_ ,\" the dentist groused, and ambled off in the half-bitter, half-stoical slump of a panhandler.\n\n\" _You_ wanna dance?\" she mimicked, and meant it, moving to draw Reinhart to his feet.\n\n\"How can we now, if you just refused him?\"\n\nBut she didn't, genuinely, see why not.\n\n# _CHAPTER 7_\n\nIDLY, BUT WITH GREAT care, Schild marked the room and its furnishings: solid pieces, dark; dual escutcheon lamps on the wall at various points in an academic rhythm: fireplace, for example, bracketed by a pair whose vertical members swelled like pregnant bellies to the points of the switches. A corner stove, ceramic, beige, built up of molded doughnuts of ever-diminishing circumferences, baroque welts and carvings, small black door amidships for introduction of fuel. Which was those bricks stacked neatly by.\n\n\"Compressed coal dust, very tidy,\" said Lovett, who had come up silently and followed the direction of Schild's eyes. \"These Germans are the most technically advanced people in Europe, damn them, if that's a recommendation. The throne room upstairs has a pushbutton flusher\u2014what I mean is, no chain!\" He threw himself gingerly on the very edge of a sofa cushion, giving the impression of artificial vivacity, and staring, said: \"No, I _don't_ know you\u2014you're surely new in the outfit.\"\n\n\"Look, Lieutenant, you invited me yesterday. Frankly, I wish you'd remember it.\" Schild spoke in the sharp tone of eminent reason. Yet he seldom used it for so slight a cause as this, and he wondered now at himself: whether his motive had been on Schatzi's example, or that from some hint of unconscious fear he had suddenly needed exterior proof of his identity.\n\n_\"Certainement,\"_ said Lovett quickly. \"You're the Nazi-hunter. I'm sorry. Have you met any of these lovely people?\" Upon the negative he rose, saying \"How lucky you are,\" and snatching Schild's arm, led him through the crowd to the kitchen, which was 1920's-modern, with a gas stove up on four legs, like the one everybody's mother once had, including Schild's, and a bright, yet enclosed breakfast nook sprinkled with painted rosebuds, fir trees, and goody-goody gnomes in Lederhosen and dirndls, a sovereign little house within the house. Peering inside, Schild made out the witch, a small worn person of feminine gender, smiling bereavement, expropriation, and sycophancy.\n\n\"Atrocious old bitch of a Nazi housekeeper,\" said Lovett. \"That's who.\" His attenuated index finger signaled dismissal, and the old woman trotted her carpet slippers up the back stairs to the second floor.\n\nWhen they were inside the booth Lovett produced, by an elaborate act of spontaneous creation, a full bottle of Scotch and two paper cups.\n\n\"And what are _you_?\" he asked without warning, lolling his head and transforming his eyes into little knife-cuts intended to symbolize high interest. \"I mean, what are you _really_?\"\n\nTo have reproduced exactly what Schild's mother had once asked, Lovett should have gone on: \"You are still a good boy?\" And should have been lying on a hospital bed, the white, segmented, cranked-and-rodded dais of pain, flanked by electrical nurse-alarms, half-filled vessels of water, folded cardboard sputum cups; should have worn magnifying glasses which projected eyes in terrible, bloated particularity, showing the iris as not a smooth round but rather an uneven burst of pigment threads darning into the void of the pupil, repeating silently the accusation so often voiced in earlier times of health: that their vision was lost in the pregnancy that engendered him. A queer, cruel, lifelong lie, that not until she was under ground did he, consulting the old schoolgirl snapshots, expose. Indeed, it was only by the spectacles that you could know her amid the anonymity of fifty middy blouses.\n\nCome tell me the truth, they ask, of which you are manifestly a walking denial: what crimes lie concealed behind your fa\u00e7ade, who are you to be closed when we, the rest of us, are open? And how determined they are to wonder forever, how implacable is their will to ignorance! \"I am nothing that I wished to be: chronologically, not a fireman, not a cowboy, not a gentile, philosopher, lover, nor revolutionary. But what are _your_ failures?\"\n\nNo purpose in asking that of Lovett, who was really a kind of success, who besides had wanted only a simple statement of civilian occupation, doctor, lawyer, Indian chief, against which to set his own probably rare, surely very dear calling. He saw in no pride that Lovett had chosen him, of all the crowd, for cahoots, just as the lone Negro in a company would draw to him, or the person with a lisp or one arm, the girl with the hair-lip, and it happened twice at parties for Russian war relief that he attracted the pariah of that context, the lost Republican who cornered him to trust, conspiratorially, that the aid would not strengthen communism in that forlorn country. Whatever the pariahhood, it unerringly found and clove to him: he must stink of separateness. From this final, subtlest of variations on anti-Semitism, which built its Dachau in the heart, there was no refuge, and he foresaw the day he would be assigned to infiltrate the B'nai Brith and at the first meeting be pulled aside to receive the confidence of some disguised Nazi.\n\n\"I was a teacher at a private school.\"\n\nLovett smirked triumphantly. \"In New York?\"\n\nWhere else? Schild felt himself capable of the accent of East Broadway and the Houston Street shrug, but was proved right in his restraint by Lovett's next question.\n\n\"Fashionable?\"\n\nPerhaps it was the Scotch which had sheared the falls and rises from the usually schizophrenic voice, leveled it into an even plain of clay, for what Schild heard was \"fashionable,\" and he was disinclined to believe it, even of Lovett.\n\nBut a timid knock on the back door freed him from the issue, a weak knock, but followed rapidly by an entry in the opposite character, bold, brutal, hinge-torturing.\n\n\"Oh, _why_ do they use the _yard_?\" Lovett wailed. \"We have a pretty john!\"\n\nIn a moment his despair sharpened into fright. A freckled Soviet face, mounted on tunic shoulder-boards and wearing a cap awry, poked jovially into the entrance of the dinette.\n\nAnd roared: _\"Herr Leutnant, ich bin hier. Was f\u00fcr ein Haus! Sch\u00f6n, Sch\u00f6n!\"_\n\nThe Russian was a little lieutenant of artillery, dressed in high-neck tunic, flared breeches like displaced wings, and boots. His good brown eyes searched for an object that did not elicit admiration, and failed. A line of dirt across his prominent Adam's apple showed how far he had washed. His hair had been shaved up to the temples, and obviously with a dull scissors, by himself and that very afternoon. He saluted Lovett, Schild, and the house. Saying _\"Verzeihung,\"_ he stepped to the sink and took a drink of water through his hand.\n\nLovett had met him on a black-market mission to the Kurf\u00fcrstendamm, picked him up for a souvenir, for who had ever known a _Russian_?; had written out the address\u2014who ever thought he would _find_ it? The only trouble was he only spoke _German,_ who could talk to him my _Gawd_! Finding that Schild could, Lovett sniffed in pique and vanished.\n\nIn the living room the lieutenant shook off Schild's patronage and charged the cautious company with outthrust arm, announcing \" _Leutnant_ Lichenko!\" And prevailed, pumping hands and snowing compliments, and when he had taken care of even the humblest, he turned the approbation on himself. He explained the three medals in a Venetian-blind overlap on his thin chest, the deeds of valor which they marked, and expressed curiosity that the Americans were not equipped with boots. His own, he averred, were of a superb workmanship and quality beside which the German-army issue could not dare to show its pressed-paper grain. He applied the same judgment to his tunic, breeches, belt, and cap. The latter he removed extravagantly for the ladies but replaced directly. He wore it as he and Schild studied the phonograph, which by means of a small device on either side of the turntable had knowledge of each record's duration and released new ones at the proper intervals from the stack it bore.\n\n\"Goes round, _herum,_ push button to play again, to puh-lay a-gain, pu-ush button. _Sechs_ records only, will it take. Compree? _Sechs_ records,\" said Nader, winking stupidly at Schild.\n\n\"What's that, Dwight Fiske?\" asked a thin dentist who had joined the elbow crowd. \" 'The Colonel's Tropical Bird.' There's a sex record for you, Leek!\"\n\nWho was a plump kibitzer of a nurse that threw him a dreadful smile and said, dreadfully: \"You're so-o-o-o gay.\" Pointing at Lichenko, she asked Schild, \"Suppose he'd like to dance?\" But Schild had already given her his back.\n\nLichenko took off his cap, scratched his head, inspected the fingernail, replaced the cap, and begged Leek's pardon. Throughout, his left eye, which seemingly he could work independently of the right one, was fixed towards a picture on the next wall, and his feet were casually screwing him that way. At last he was ready to go directly before it, to abrade its surface\u2014in an inconspicuous corner, so that if damage were caused none would show\u2014and to proclaim: \"A genuine oil painting. Oh, very _sch\u00f6n,_ indeed. Private property, yes? But roses in a bowl and nothing else! Where can the philosophy be in something like this?\" Did Schild know Repin? Oh, _ausgezeichnet,_ excellent, excellent!\" \"Ivan the Terrible Kills His Son.\" Bloody picture. _Angst, Angst!_ \"This we call the _Russkaya dusha,_ the Russian soul. Or did you know that already?\"\n\nWith the question, for which since he was not just making noise he wished an answer, he gave specific notice to his benevolent patron: \"You _do_ know, _das ist sehr gut:_ all these things can be useful for friendship. My German is fluent, yes? And my accent is unusually accurate. That is because I worked at it both in theory and in application. _Ach,_ it is not easy to do things the right way, but it is always possible, _ja_?, always possible, my friend.\"\n\nHe had said \"my friend\" and taken Schild's hand. Russian male friends kissed on meeting and walked hand-in-hand, yet since 1917 homosexuality had all but vanished in the Soviet Union.\n\nHis calluses torturing Schild's smooth palm, Lichenko approved: \"Your German, you know, is excellent. Was this learned in the wonderful American schools?\"\n\nOh, partly, and in part from a grandfather. Schild was pleased and apprehensive at once, the latter from questioning, any questioning.\n\n\"You are of German descent, then? Does it give you a queer feeling to return to your old motherland as an enemy? The Russian word is _rodina. Rodina_ \u2014motherland. I will teach you the Russian language in this manner, term by term, although I am Ukrainian. But Russian nowadays is more useful, yes? But you are German?\"\n\nSchild smiled lazily to let it pass, but Lichenko ripped at his fingers: \"Tell me, tell me!\"\n\nSneezes, orgasms, interrogations, their irrevocable end is ordained in their beginning.\n\n_\"Ich bin j\u00fcdisch.\"_\n\n\"I see, I see! Then it is not queer but pleasant!\" Lichenko grinned\u2014indeed, he had not stopped grinning: the ravines in his face were grin-grooves, his irregular nose was lumpy with grin, these along with his winged thighs making him a Mercury of mirth. It was, frankly, a private thing, which he could respect while not losing any skin from his own ass.\n\nAnd he was soon away to other pictures and _objets d'art,_ furniture, rugs, and the dark-blue wallpaper with its silver suggestions of flower petals dissolving in ink. He bounced into an obese chair, which bounced him halfway out. He sneaked carefully back into place, and the chair submitted to good manners. As for Schild, he sat crosslegged at its side on the floor.\n\nLichenko's German was very good, too, for he was an educated man, an engineer, in fact, although the war had caught him before he finished school. His intended specialty concerned dams and sluiceways, the diversion of streams, paradises from deserts, the transformation of the face of the earth, or anyway one-sixth of it. Nor was Soviet engineering a cultural Siberia. He slid easily from an apostrophe to steamshovels into American writing, where he was better than oriented.\n\n\"We read American books in the Soviet Union!\" he shouted happily, digging his hard heels into the floor. \"More than we do Russian. Also, more than you read in the United States. You know, of course, that American authors would starve but for the money they get from Soviet sales.\"\n\n\"I know,\" said Schild, who _did,_ at that moment; did, because fact can be countermanded by wish and hope and generosity and brotherhood, else we are lost.\n\n\"Have you read Dreiser?\" he asked.\n\n\"The greatest American writer,\" replied Lichenko. \"But Upton Sinclair Lewis is _sch\u00f6n,_ too, and Jack London's _Babbitt_ and _The Iron Heel._ \"\n\n\"I met Dreiser once.\"\n\n_\"Also\"_ Lichenko mumbled, removing his cap and testing his forehead with a sweaty palm.\n\n\"He spoke at the school where I taught. A great, majestic man, a champion of humanity, and a friend of the Soviet Union, as I suppose you know.\"\n\n_\"Es interessiert mich das zu wissen,\"_ said Lichenko vaguely, but hopped to his feet positively, and bowed. For there stood Leek.\n\n\"Now, you can't keep our ally out of circulation!\" she chided, and led Lichenko to the dancing area\u2014though not before Schild was constrained to translate some small-talk, including a Soviet tribute to womanhood in an ornate German that englished as something Albert might have said to Victoria; nor before he volunteered to hold the doffed but troublesome cap, Lichenko having been at a loss for a cache where that article would be neither crushed nor stolen.\n\nA universal sense of fun could not be withstood. The troublesome shortage of fuel reached Lichenko's apparatus, without benefit of Schild, and he laughed long and loud, tore himself from the Siamese coupling with Leek, and shot into the kitchen and out the back door. He reappeared with a shoulder sack of bottles: vodka, schnapps, whisky, and other fluids.\n\nGlasses flowed, music tinned, everybody danced. Reinhart, Schild saw, glided about as if on figure skates with the large nurse, in the perfect attitude of the adolescent sexual captive: closed eyes, back arched _affetuoso._ A more direct confirmation of the reputed egalitarianism of medical units could not be imagined.\n\nSchild thought about Lichenko, who had so little and so much. Throw the switch of the time machine and there he was, with his cartload of firewood, ankle-deep in mire, on his weary animal way to the sod hut, the black bread, and the cabbage; the trashy icons; the spent wife; the ravished, if pretty, the prematurely aged, if plain, daughter; swearing so vilely that if his master had the ill fortune to canter past, he might have got another crop's end for his lifelong collection of abuse. Born old, senile at twenty, dead at forty, without ever having passed through the human. A lump of dung, hating love and beauty and intelligence because he was defined by their absence. So, gorge the rotten potatoes, let the grease befoul the lips and drip from the chin, fill the gut with the stolen bottle, and when it explodes in the head, give the wife a fist to her decaying teeth and the daughter a hand between her thighs, because you are beyond judgment, beyond hope. But not beyond history, which moves not for revenge or profit or virtue, but for the negation of negation, the arrangement of disorder, above all, for an end to waste.\n\nThese things mature without ever having been formally born. Lichenko was, of a sudden, disorderly. Only a moment earlier he had displayed high, good, and legitimate spirits; now he had enrolled in that brotherhood of savage peoples from whom firewater should be, and often is, legally withheld. His maw sagged; his eye carmined; he drank as if, oblivious to the torrent that washed his face and gummed his tunic, he hungered for glass, and proved it by incising a piece of the tumbler's rim. A pencil line of blood traced out the groove of his chin, like the after-punch make-up of movie martyr-priests who may invite their adversary to put on the gloves but never return the favor _ad hoc._\n\nAmidst all those medics his wound went unattended, on the theory that if he lost enough blood he might collapse peaceably. But he had just begun to play. After checking Leek in an armchair, he detonated into the frenzy of a solo jackknife dance. The floor quaked, for although he was small, the boards were simpatico with his rhythm; the rolled carpet against the far wall, which was not, had its long, heavy belly rent by a boot-heel.\n\nWith such sport, with Lovett impotently aflutter, with Nader enveloping himself in the phonograph wires, with the awed company's disengagement, the room was progressively demolished. Lichenko's success with the carpet sent him to Leek's chair, which, after removing her, he ruined with a single jump, hard heels forward; he smashed the mantlepiece mirror, pelted coal cakes in black bursts against a carved lowboy, got a painting once out of six throws with as many tumblers, and shouted _\"Bezbol!\"_ Then, to Schild, he said: \"Fascists.\"\n\n\"Yes,\" answered Schild.\n\n\"Not the Americans.\"\n\n\"No.\"\n\n\"The Germans. Why should this house be spared? If you saw what they did in my country...\" He sank wearily into the chair and passed a hand across his face. He signaled to Leek, pointing at his lap. She sat there submissively, bovinely, as he read her idly in Braille.\n\nStill on the floor, Schild shifted his weight from left to right ham and adjusted his pistol belt.\n\n\"Will you permit me to see your weapon?\" asked Lichenko. He ejected Leek. He looked feverish as he palmed the Colt. A vein in his forehead pumped into prominence. He worked the action, stroked the barrel, warmed it with his cheek, and peeped down the muzzle. He found the clip, extracted it, loosened a bullet, felt its slug, replaced the bullet, replaced the clip, pointed the piece at the still proximate Leek, went \"Boom, boom!\" or thereabouts in Russian vowels, finger on trigger guard.\n\nIgnoring her squeak, squeaking himself in delight, he took out his own pistol and thrust it butt first at Schild.\n\n\"We'll exchange. Then we'll each have a souvenir of a time we will never forget.\"\n\nIt was what the Russians called a _Nagan,_ a cheaply made cap-gun affair, but Schild accepted it reverently, and, though he detested firearms, gave an earnest imitation of Lichenko's ecstasy over the Colt.\n\n\"You _agree_? You will _exchange_?\" shouted Lichenko. \"My dear friend, I salute you!\"\n\nOn his feet, he highballed with the right hand, a dwarf against the bas relief of the large Americans who had started to surge genially upon him through the dismembered furniture. Schild was rising in honor of the moment, at the very least to return the salute, when Lichenko began to discharge the .45. He perhaps intended to squeeze off only one cartridge as an additional salute to fortune, but the kick from the one convulsed his hand into another, and he was drawn _nolens volens_ into a full tribute.\n\nBelow the scored ceiling and within the vermiculated walls, Lichenko, now-spent gun drooping, sniffed the atmosphere of powder, appeared about to sneeze, did not, and pushed a reproachful lower lip like a coal chute at Schild.\n\n\"Ah, my friend, this American pistol!\"\n\nHe tore at his choker collar. \"Excuse me, Vasya is ill...\" And fell prone into the plaster, which, of course, was now the common ground.\n\n\"You win the medal,\" said Lieutenant Leek, an unjolly snowman, to Schild.\n\nHe blew clean his glasses and inquired silently with blurred vision.\n\n\"For Number One Horse's Ass, Berlin District.\"\n\nNader touched Schild's elbow and whispered: \"Look, Jack, Lovett went for the MPs. Get your ass-hole buddy out of here. We'll con them. He was just drunk.\" He knelt beside Lichenko and fingered back an eyelid, peered at the red orb. \"Drunk as a skunk.\" He ordered Corporal Reinhart to lend a hand.\n\nReinhart lifted Lichenko by the belt and pulled him over a shoulder.\n\n\"Veronica, why don't you go along?\" asked Nader. \"Jesus, maybe he's dead.\"\n\n\"O.K. Thanks for the party,\" said she. \"I had a lovely time anyhow.\"\n\nReinhart navigated through the rear door and into the garden. Already military-police sirens sounded in the distance. Through the back yards, having trouble at every sonbitching fence, and around the block to Schild's house was their silent way. Reinhart's calves were tired on the stairs, but he gripped the banister and made it in good shape to the room, where as his burden was lowered to the bed it came to life briefly, displaying a revolving eye, and returned to dreamland with a mouthful of bedspread.\n\nVeronica examined the body from a distance, found it hale. Reinhart said: \"You're a good fellow, sir, to do this for that Russian. If his army found out about it he'd be headed for Siberia.\" And Very seconded that.\n\n\"I think,\" said Schild, \"the American Army is what we have to worry about at the moment.\" He took a tiny package from his pocket. \"Can you use these?\"\n\nAnybody who ever opened a K ration had Fleetwood cigarettes to dispose of, yet Reinhart was sure these were his own come home. He was too weary, the evening had been too extravagant, to inquire by what route.\n\nNew relations consisting so fiercely in the precise time of day and the specific mise en sc\u00e8ne, the sudden dislocation of these threw both Very and Reinhart into a diffidence, especially now as, their task ended, they went out of step down the sidewalk to Very's house. From the side of his eye Reinhart could see her shoulder bag swinging off the divisions of silence. An occasional officer or nurse, not breaking the peace, breathed past them in the frenetic diaspora from the party. Down the street, its siren dying like a throttled pussycat, another MP jeep arrived.\n\nAt her door, Reinhart chickened out of trying for a good-night kiss, perhaps with a view towards establishing his independence, which, in the pale simulacrum of _post coitum tristis_ that was his after-party letdown, he felt had been compromised. Or perhaps it was a defense against the progressive frigidity she gave off as they approached the front step.\n\n\"Oh this is where you live?\" he asked numbly.\n\n\"Haha! Were you going to charge me with breaking and entering?\"\n\nThis cruel parody of his own earlier fantasies on the mansion of her person, despite the false laughter\u2014whose spuriousness was advertised by its miraculous lack of resonance; it was as if a great bell rang so shallowly that nothing trembled\u2014suddenly elicited his overdue response to Lichenko's rampage. To assault an entity of order, to register a spontaneous nay against the sanctioned and authorized; mean, but it were meaner than never to be so moved.\n\nBut Very skipped insouciantly inside the doorway. Shortly, her other end appeared, saying: \"See you in the funny papers.\"\n\n# _CHAPTER 8_\n\nCAPTAIN ST. GEORGE'S SURPRISE WAS limited. He had rapped at and opened Schild's door on his regular schedule of unnecessary morning information\u2014\"The bath is free\"\u2014and looked upon a scrawny, alien fundament. Lichenko, rump to door, was bent in a study of his big toe.\n\nSchild's guest had awakened with a refusal to recognize his benefactor. Something Schild however took in good grace and did not sully with a word as the Russian scratched an elusive cap-a-pie itch, lip-farted at his own image in the mirror, and spat a long drizzle of saliva out the window in droll reproof of the sunlight that made him wince. Then he turned, said with ill humor: _\"Da\"_ and undressed for an examination of his pelt.\n\nSt. George recovered with expedition. \"I thought you had a woman in here,\" he chortled to Schild, who was elbow-propped on the floorbound blanket that had been his bed.\n\nArising with the aid of the dresser corner, khaki undershirt and shorts clinging to him like old crepe paper, sallow, hairy, shivering\u2014Berlin's air in the shadows stayed cold till noon\u2014Schild said as St. George averted his eyes: \"So what else is new?\"\n\nHe watched the dull pain fill the captain's eyelids, distend his cheeks, sag the loose mouth, and lower the chin, going down like mercury in a chill. It was a kind of crying just beneath the epidermis; years of it had made his face one big bag.\n\nSt. George addressed himself to the oval mirror on the dresser. \"Do you know?\" His ebullience had left. \"Is it necessary to have an electric shaver honed every so often? Mine is beginning to pull.\" He held the device towards Schild, retaining the pillbox affair which made any current American.\n\n\"Duncroft,\" he went on, \"says it can't be done. He says the razor companies aren't going to sharpen old ones and thereby put themselves out of business. They're going to want to sell you a new one, he says. But he's always cynical.\"\n\nLichenko left off his big toe and went over the others, as if in count; midway through the left foot, he lost his sum and began again.\n\n\"Did you see a strange man as you entered this room?\" asked Schild.\n\n\"A refugee from the party, I take it.\" St. George twisted the top of a battered tin of GI foot powder, sifted a quantity into his palm, and traced rhomboids with his fingertip.\n\nLater, as he and Schild crossed the street towards breakfast at the 1209th officers' mess, to which St. George had got their small unit attached for rations, he said: \"Strange how when you meet a man who's naked you don't get to know much about him. Maybe we all rely too much on externals, but that's the way it goes.\"\n\nAt the mess Schild was daily juxtaposed with many of the to him anonymous faces of the party, and occasionally received a curious but cordial nod. He was also aware, from time to time, of the regard of multiple eyes and the drone of comment at adjoining tables as he forked in his Harvard beets and masticated the grainy roast, but was conscious of no ill will, nor, in his sense of the word, suspicion. Once he saw Lovett across the tent, fragmenting bread with neurasthenic fingers and spotting the pieces individually over his tray, which could also be interpreted as evidence of placidity.\n\nBut after one lunch, Nader met him outside.\n\n\"Did you pack off the Russky? Dewey's going to make trouble, mark my words, because the Old Man's about to hang it on him.\"\n\n\"I'll make it good,\" said Schild. \"It was my fault. I gave him the gun.\"\n\n\"Well by Jesus we'll put in a complaint through the Kommandatura,\" Nader said. \"Just write down his name and outfit. Did you get the outfit?\" He rummaged in his pockets for writing materials.\n\nBoth extremities of Nader's pencil bore chewmarks. His paper was the reverse of a snapshot carrying the pale-violet emblem of an Oklahoma developer. Schild wrote, slovenly: \"Lt. Krylenko, Engrs Corps, Red Army.\"\n\n\"I don't have much hope this will find him.\" He smiled commiseration. \"But you won't have to. Just let me know the amount of the damage, and I'll see you get reimbursed in full. I'll see your C.O. myself this afternoon. You'll be fully cleared.\"\n\n\"Now,\" said Nader, \"I know you're oke, but you'll do best by us if you crap out early. What I mean is\u2014\" He broke off until the pencil was reseated in his breast pocket and the flap buttoned. \"Let me as somebody who was soldiering when you, Dewey Lovett, and anybody else in this road show was still sucking titty. Know the Old Man since Jesus was a PFC: hates anything involved. We'll never find the Russian, but the thing will be wrapped up and Dewey will stop pissing and moaning.\"\n\n\"I thought it was simple decency to get him out of your place ahead of the MPs,\" said Schild. \"That officer fought all the way from Stalingrad to Berlin. It would be outrageous if his first defeat came from blowing out some German plaster.\"\n\n\"As long as we're off the hook, old buddy, that's all, as long as we've got something to hand them. The phony name you wrote down here will do as well as another.\" He showed his chipped teeth in amiable pride. \"What time I have left from being personnel officer, unit censor, permanent O.D., fire officer, postal officer, and post-exchange officer, I put to provost marshaling. You'd never make a successful crook.\" Nader's hairy wrist disposed of all possible demurrers, embarrassments, confusions. \"Hell, I remember his name, I just don't know to spell it.\"\n\nExposure of his minor deception freed Schild to submit the whole affair to a lens, under which he saw: being caught out by such a man and in such a way was not a demerit.\n\nNader pushed the snapshot at him. \"You still didn't look at the picture on the other side.\"\n\nA ripe piece of girl in her late teens sat on the first step of a rotting porch. In the background depended the rusty chains of an old slat swing; through one link, the shaft of a raffia fan. As she cuddled a stuffed panda, her deep lower lip sat in transitory melancholia, or what may have been counterfeit desire. Pleats of voile skirt fell gradually away at the thigh on the viewer's side, as if at the border of some proscenium arch through which shortly a young man with haircut, black suit, and cascaded necktie would heel-and-toe as commencement valedictorian. She was relaxed or prepared to spring, according to which evidence had more weight: the tension of the femoral muscles or the flaccid pubis in the valley that knew no drawers.\n\nThis was an exercise to put Schild on his mettle. How to communicate in the proper measure somewhere between coarseness and patronage. For Nader, in the classic manner of such picture-passers, watched him as a bank guard observes an unshaven man; that self of his which dwelt in Nader's mind was about to acquire a habitation and a name. Schild suddenly ached with regret that he could not miraculously reduce his size and quality to the mode of the image and plunge into that seedy, sweaty, alien world of desiccated lumber, rusty metal, the treasures of shooting galleries, the failures of fabric, unshaven armpits, sagging wash-lines, off-stage radios, that universe of the enervated Sunday, and make animal love to the girl. Not having that option, he grinned wryly and said: \"Choice\"; watching it join the community in the wallet. \"I believe the idea now is to ask who is she?\"\n\n\"You don't know any less than I do,\" Nader replied. \"This was found behind a chair after an enlisted men's dance in the service club at Camp Grant, Ill. I carry it for laughs.\"\n\nSchild returned to the tent for another cup of coffee, the dregs of which he hung over until the last eater had departed and it was seemly to draw and transport Lichenko's rations. He did not know why his guest remained, but it could hardly have been for \"his big brown eyes.\" A phrase from his father's code, applied to those business associates whose sudden appearance of friendship logic and experience exposed as conspiracy. A \"friend\" dropping into the office for a smoke was of course a spy who mentally photographed a new button and, within half an hour after his departure, set up machinery to reproduce the plagiarism in quantity, to steal the orders of the first party and libel _him_ to the stolen customers as a thief to confound.\n\nHe carried the laden tray towards the billet. It could hardly have been for his big brown eyes that Lichenko lingered. This old-Jew's suspicion would not be put down, despite his violent attempts at negation that, as he crossed the street, became exterior, the ultimate ineffectuality. He shook his whole body as if in a chill, and the spinach in the end compartment, having by nature no integrity, easily lost its coherence and slipped over the rim like a string of mucus.\n\nLichenko could be on furlough, on extended pass, on some perfectly uncomplicated special duty from which he had legally or illegally gleaned four days of liberty; he may have been lost, have searched in vain the wilderness of Berlin for his unit, temporarily have given up. He was perhaps a liaison man between Red and American Intelligences, who\u2014the Soviets being no fools in these matters\u2014could better prosecute his purpose by four or five days' discretion, especially around an idiot like St. George, who, it could quickly be seen by a shrewd fellow, would fly all to pieces at the first suspicion that his outfit was to have a serious role. There were, too, the possibilities of amnesia, outright absence without leave... and even, of course, desertion. Notwithstanding Schild's automatic rejection of anti-Soviet messhall gossip that \"hundreds\" of Russian soldiers had decamped to the Allied sectors, which if true would have been a lie, he was certain that it _was_ true in cases. It was something that could be faced without equivocation. Renegades ye will always have with you.\n\nIn the middle of the street, a two-and-a-half ton truck nearly ran him down, the driver leaning out to carp, spotting the silver bar, recovering. A fine midsummer sun crafted suburban shadows which lay only slightly to the northeast of their objects, the time standing not far beyond one o'clock; that extreme portion of the sky that to the grounded seems at last palpable but to the winged is merely the middle distance towards another intangibility, hung unusually high even for Berlin. A soldier in fatigues lingered on the stair of one of the officers' homes, in the grip of an internal monologue that he broke off to inspect Schild with academic superiority, which indicated he was on an errand for a captain or above. Shortly such a person, wearing a khaki undershirt, appeared at the door and bellowed: \"Bugger off, Wilbur!\" As Wilbur without acknowledgment merged with the shrubbery, this undershirt shouted: \"Bugger you, too, Rosenthal!\"\n\nOne thing was certain: Schild's eyes did not improve over the years.\n\n\"Can't you see? It's Young! ...Oh, I'm sorry, I thought you were Rosenthal. Rosenthal's a DOCTOR IN OUR OUTFIT.\"\n\nCollege Joe type with a grin. Back to bed, my boy, the world will run very well without you, or very badly; in any case, without you. An angular girl, with hairy legs, pumped decorously past on her bicycle. It was Schatzi in transvestite disguise\u2014of course it was not, but Schild, too, could be permitted an error of identification. In the past three days he had seen Schatzi in every bony face; he had recognized him falsely with greater assurance than he had yet seen him in actuality. It was only because the genuine article never appeared in daylight that the apparitions could be ignored.\n\nThe real Schatzi\u2014he had left him an hour before Lichenko had come to the party. Certainly if he, Schild, were Schatzi, he would not fail to trace a connection between these events, to draw up the disjunctive proposition so favored by his courier: either... or; either Schatzi knew of Lichenko or he did not. If he knew, there could be no doubt that what had happened was with his connivance. If he did not, all the rules commanded that he be told. But this clause was the emergency measure, necessary now because he had ignored the first principle of the code: never to get into such a situation. Thus to obey the second was to admit a transgression of the first, and Schatzi already suspected him\u2014or pretended to; in practical effects there was no important difference between reality and appearance\u2014of mishandling his contact with the 1209th, either foolishly or from a motive of treason.\n\nIf, on the other hand, Lichenko had been planted on him\u2014had _they_ nothing better to do than keep him under surveillance? It was a preposterous idea. Still, since that first morning Lichenko had been sullen and unresponsive, lurking in the bathroom when Schild was home and going through his belongings when he was away: a pair of OD socks left separate in the footlocker tray had been united in a neat ball some time between breakfast and lunch. Fortunately, Schild had long been in the habit of destroying his letters\u2014not that he received many; he had luckily cut off from Waslow when he went underground, Waslow who was not long afterwards expelled as an infantile leftist when he resisted the change of line from hard to soft vis-\u00e0-vis the bourgeois democracies; but he occasionally got communications from his sister, who typically had not only again changed husbands but again swapped gods, with the end of the war conceiving a perverse attraction towards the doctrine of Jung, whom she suggested Nathan visit, as long as he was stationed in Germany. Jung, the anti-Semite.\n\nAnd then Lichenko's queer behavior over the chessboard. His visible emotions while playing could only be called ferocious; he groaned cavernously at momentary setbacks, howled at each little triumph, and upon the general victory\u2014which he was never long in gaining, for Schild was not only an inferior player at best but would have been almost afraid in these circumstances to be a good one\u2014Lichenko became most invidious, arrogantly shoving the board across the table like a dirty cafeteria plate and rising to swagger about the room on hard heels.\n\nLichenko's larger game was surely something more than chess, and unpleasant as it was to think that in this, too, they were adversaries, to that degree the mind would not accept another possibility. As to the heart: it could not endure a second enemy among the two men with whom he held a common purpose. Whatever Lichenko's menace, Schild forgave him for it.\n\nWhy should a citizen of the United States of America be a Communist?, thought Lichenko, all itchy again, a quarter-hour after his fourth bath in as many days. He felt large lice loping on his back. Off came the tunic. Spine presented to mirror. Not a beast in view. Imagination. They would leave that final place when he next wore a civilian shirt, even a dirty civilian shirt, even a lice-infested civilian shirt. Did the old holy men really wear hairshirts? What then was their lie? Surely a truth was what you gave for it. Yet everyone, and from what he could see, particularly the big-spenders of belief, had their lie. Believe in very little, said his mother, and your disappointments will be as small. This had seemed funny to him when he was ten but had grown more grave with age. Old people know more than they can tell directly. His mother then had not been old in years, but some people are born old. He had seen many a baby of whom, if you squinted your eyes, you could get a picture as an old man with cap and pipe, taking the sun in the park.\n\nAs he returned from the bathroom, the German woman moved correctly down the hall, as if on little wheels. Sluts walk so, being so large between the legs that their organs would fall out if they took long steps. You see! he grinned silently at her back, there's no need to be so grand! Next time you pass, Vasya's fingers will pinch your bottom!\n\nHe had never, in his belly, believed in the existence of foreign Communists\u2014Communists where the Bolsheviks were not in power? No sense to that. Besides, foreign comrades were not taken seriously even by Soviet Party members, as he knew from his brother. The largest Party outside the USSR, the German C.P., had been puffed out like a match when Hitler arrived. And as to the Americans, hahaha! Who already owning an automobile, a ten-room apartment, a motion-picture projector, short-wave radio, and probably an airplane, became a Communist? Lichenko knew so much about America, had had so many fantasies about it, he oftentimes forgot that he had never been there and rather owed his data to the Soviet news agency's New York correspondent, whose dispatches he of course translated in reverse. Thus: the American worker lived like an emperor, and there was no U.S. Communist Party.\n\nSince moving into Schild's billet Lichenko suspected he had been wrong about the latter. After all, the Bolsheviks had not always held power in his own country; everything started somewhere; if necessary, before one's own birth. The old czars, he believed despite his mother's testimony to the contrary, had not been first-rate people. The last one, he understood despite the Bolsheviks' like opinion, had no culture and was ruled by a woman herself the instrument of a corrupt monk. Therefore the Communists: who had begun as a small, weak band of, he supposed, idealists and martyrs\u2014except that Stalin, even that early, committed armed robbery for the furtherance of _his_ ideals; and no sooner had they kicked out the czar and won the Revolution than Lenin and Trotsky slaughtered the Kronstadt sailors who had helped them.\n\nPerhaps there could be American Communists, for Nathan Schild seemed to be one: who else would consistently praise the Soviet Union while finding fault with his own country? A normal man bragged of his motherland even if he detested its superstructure, as did Lichenko, because there was a personal pride that took no account of politics. And some of the things Schild claimed to believe: that the Moscow treason trials were genuine trials and concerned with real treason\u2014he was either a lunatic or a Communist.\n\nMore likely, both. For what Lichenko would never believe was that a gentle, generous, sweet man like Nathan could, in his right mind, give allegiance to a pack of murderers. On the counsel of his affection for him, then\u2014the heart does not lie\u2014he did not abandon his plan to defect to the West, but added to it a finer purpose: he would also save Nathan. It would be a finer game now, with rewards or disasters of greater magnitude, but the very irony of his situation\u2014leave it to Vasya to choose as cover the one Communist in a division of Americans!\u2014contributed to his courage.\n\nBack in the room, he thought he might permit himself another tubbing. Immersed, he could cogitate better than in the liberty of the bedroom. He still had no concrete plan. Time grew no longer. The NKVD would have had his name for three days; perhaps they had already traced him as far as the house party. And as yet he had not found the propitious moment to begin his labor of truth and love with Nathan. The trouble was, these considerations made for anxiety, which was assuaged only in the bathtub's warm wet trough.\n\nBut he could not go now. There, he saw from behind the curtains, came Nathan with lunch, and an excellent lunch it was, although Nathan never gave it any importance. Indifference to the material conditions of life must be unique with American Communists. Certainly it was unknown to the Russian Party! This handsome house, for example, which Nathan treated as if it were a pigsty.\n\nLichenko knelt and worked out a cigarette butt embedded in a bedside circle of rug mangy with other burns. The Red Army destroyed many things but nothing that could be put to use. However, reason was a crime for which no American would ever be shot. Was it a matter of distance? Three thousand miles away. You could talk all you wanted about the universal force of gravity, the iron ball and the feather dropped from the same height hitting the ground together. Just try it: by the time the feather comes to rest the iron will be a ball of rust. So with an elephant and an ant. Density, not volume and weight. So with an American; try as you may to drop him, it will be a launching. Lichenko had been a mediocre student of physics in the Kharkov technical school and insensible at the time to its multifold uses.\n\n# _CHAPTER 9_\n\nON HIS WAY TO WORK the morning after the party, Reinhart strolled down Very's way. An irregular blob of olive-drab descending her porch was soon fashioned by his eyes into her form, but as it came towards him on the sidewalk he saw it was not Very but her antithesis: the lieutenant who took in drunken Russians.\n\nHe was rather shorter than the evening before and indefinably seedy, with dust on his glasses; yet he had a more assured address, hard and bright. He was the kind of Jew before whom Reinhart felt very vulnerable, as if somewhere back he had done him a dirtiness which he, himself, did not remember but the Jew never forgot. He felt this while knowing it was not true, for not only had he not done them wrong: he had never done them anything one way or the other. None of his best friends were Jews. The species was unknown in his home town, which had no foreigners\u2014just another reason for its unspeakable dreariness. At college there were some, who had their own fraternity and seemed to go around en bloc, occasionally sitting next to one in classes, where they were usually witty and always clever; and some girls as well, who were either remarkably beautiful or characteristically ugly, never plain, and it was a pity the lovely ones were off-limits\u2014there had been a girl, forever enrolled on his list of classics, with sable hair, alabaster nose, cheeks of white iris, and an exquisite name, Esther Rosewater, which he used to say underbreath when she passed oblivious, _Esther Rosewater, how I love you, Esther Rosewater;_ she made him weak in the knees, and never knew it. For that was the other thing about Jews; when they weren't eying you with suspicion, they never saw you at all.\n\nAs to this lieutenant, Reinhart thought: I could break him in two. At the same time, he was vaguely afraid of him.\n\nBadly returning Reinhart's salute\u2014his fingertips not quite making it to the inferior rim of his spectacles\u2014the lieutenant referred briefly to their mission of the night before. He had found upon awakening that Miss Leary had dropped a comb in his rooms, and he had just returned it. Palpably of small value but it was her property and women care about such things, don't they?, smiling in the condescending conspiracy of the males. He could have been lying. Reinhart, who was unusually observant, remembered no loss. Yet losses remembered are hardly losses; moreover, an officer, unlike a noncom, had little reason to dissemble in courting a nurse.\n\n\"Was Miss Leary in?\"\n\n\"No, I left it with her roommate.\"\n\n\"What's her name, by the way?\"\n\nBut Schild didn't know and cared enough only to ask: \"Don't you know? Isn't Lieutenant Leary your girl?\"\n\nReinhart had a tendency to toss the ball to his superiors, to tell an excess of truth that would confront them with the damning fact of their authority. When he said sorrowfully \"How can she be?\" the lieutenant's response confirmed him. He, the officer, showed not only understanding but sympathy.\n\n\" _I_ have no objections, certainly.\"\n\nNow it was his apparent approbation that made Reinhart uneasy. He would have preferred to leave while he was ahead, but the lieutenant hung on, walking with him towards the administration building.\n\n\"The Russian\u2014did he recover all right? He was a crazy little fellow. Sometimes I think all Russians are mad, or is that Communism in action? Have you seen what they did in Wannsee?\"\n\nHe fancied that with his first word the lieutenant had shot an angry look: of course, one's big mouth had not considered that he might be a Russian Jew. Then, too, he had earlier observed that any mention of Russians not obvious praise never sat well with \"liberals,\" and he would have bet his duffel bag, with all its souvenirs, that his companion belonged to that breed. He had, therefore, found his weakness; he no longer felt gauche; he could not help falling before the temptation.\n\n\"No one who hasn't seen them would believe what a bunch of dirty tramps the Russians are. When we came in on the autobahn and met that crew, we thought first they were slave laborers for the Germans, and then service forces, maybe. But no, they were the cream of the combat troops.\"\n\nHe saw pure hate through the lieutenant's glasses\u2014or was it agony?\u2014the eyes were all watery.\n\nThe hell with him. He was not an officer in the 1209th, and you couldn't be court-martialed for an honest description of what you, and no doubt he as well, had seen. Everyone had his own chauvinism, the sacred affiliation that he would not suffer to be questioned, let alone criticized. And how disgustingly stupid, for, in this case, was it not their very uncouthness that made the Russians' victory all the more remarkable?\n\nSo he said something to that effect, but even then the lieutenant's manner did not improve, and since by that time they had arrived in the front hall of headquarters, they parted coolly, no salute being necessary under a roof.\n\n\"Goot morning, a very nice day ve are hoffing!\"\n\nTrudchen sat blooming behind Pound's big, messy desk against the forward wall, except that it was not messy but rather a place of truly stacked papers, dustless, and with a little bouquet of yellow pansies in a jam jar. On his own desk, similarly impeccable, was a pink rose. She was already flying her own colors.\n\n\"You are surprised, yes?\"\n\nRight, but his habit was never to show it. He thought, for the first time, that she might be uncomfortable to have around.\n\nShe arose and came towards him, the thick sweater, unbuttoned, swaying in its two parts equivalent to the braids.\n\n\"You see, I work for no payment until the opplication is officially opproved. But I also cannot eat at the mess until that time. Perhaps you can bring me somesing at lunchtime.\"\n\nReinhart tucked his cap under the belt and drifted into his chair.\n\n\"What age did you put down?\"\n\n\"Eighteen.\"\n\n\"And they believed it?\"\n\n\"Oh, vy not. It is only two years a lie!\"\n\nSixteen\u2014even those tender years seemed too many, but they did put her under the wire. Through her sweater halves he saw soft little breasts, very round, under the crocheted shirt. She was the kind of girl who in a movie would be asked by the hero, do you really need those glasses? No, she would say and fling them away forever. But Reinhart rather liked spectacles on a pretty girl; they were vulnerable-making, sexy.\n\n\"Let's see now, what can we find for you to do?\" He fished through the desk drawers, coming first upon the last letter from Di, which when he had put it away yesterday, having finished the answer, was open, with its envelope paperclipped to the back. Now the former was inserted in the latter, as if it had just arrived; for a moment, until he saw the slit in the envelope top, he thought it had: the outside of all her letters looked the same, with \"Mrs. Ernest Cooley\" in bright-purple ink in the return-address space. Ah well, Trudchen had made it neat, which reminded him to write the customary \"Ans.\" and the date on the face of the envelope. He reached for the fountain pen habitually kept in the righthand corner of the central drawer, and felt nothing. Nor was it elsewhere in the desk or in his pocket, and Trudchen had not seen it when she policed up.\n\nThe loss was serious. What with the black market, the PX stock of pens was exhausted, and it was not seemly to sign correspondence with a pencil. Reinhart felt an ill mood come down over him like a sack. The worst thing was that he could not, with depressed senses, find any work for Trudchen. The map of Berlin, on which she could have been employed to trace a route for the tour of the Nazi ruins, had also vanished. And he dreaded the coming of Pound, whom he had not told of their new employee, for the excellent reason that he himself had not believed she would be hired.\n\nAs if his nerves had created him prematurely, for it was only eleven o'clock, he heard Pound's footsteps in the hall.\n\n\"Quick!\" he said to Trudchen, \"start straightening out those boxes.\" He pointed, without looking, to the chaos in front of the closet, and grabbing a fistful of papers from his now-tidy \"out\" basket, fell on them with knitted brow and deliberative forefinger.\n\nPound sounded two feet from the door when Reinhart realized that Trudchen had moved not to the ordered task but rather closer to him. She had removed her sweater and was flexing her arms in a most provocative, catlike manner, her pink shirt everywhere in undulation.\n\n\"What are you doing!\" he said furiously.\n\n\"But you see, already I have arranged those boxes this morning before you arrived.\"\n\nHow irrefutably true, now that the eyes were turned in that direction: rank on rank, they pyramided almost to the ceiling, with not a loose paper showing, not a cartonflap awry. Impossible that one small girl could have done all that in a week, but there they were.\n\nAnd here also was\u2014not Pound. The liberal lieutenant, with an ingratiating smile, stood in the doorway.\n\n\"Too bad I didn't know when we came in that you were the fellow,\" he said.\n\n\"For what?\" Reinhart stood up.\n\n\"Yes, and here they are.\" The lieutenant pulled a box from the left slope of the pyramid, weakening the whole organization so that if Trudchen had not sprung to the gap the work of her morning would have been at naught.\n\n\"You must replace that at once!\" she shouted, and the lieutenant, walking from the pile with his box, showed her a look he might have given some vermin too ripe to crush.\n\nChrist, didn't he even know the simple principles of stress and strain? thought Reinhart, whose height permitted him to get the topmost carton and fill the hole.\n\n\"Okay, this one is small enough to carry with me now. I'll send a detail over for the rest.\"\n\nHe was halfway to the door when Reinhart, standing high and wide, blocked the route.\n\n\"I'm afraid, _sir,_ that you'll have to tell me what this is all about.\" He weighted the title with deliberate provocation\u2014for one thing, because he was wholly in the right; for another, to break the officer's damnable insolence.\n\nFor a moment, and for all his natural, seedy weakness and his fake amenity, the lieutenant's eyes were hostile.\n\n\"Get out of my way\u2014\" This at once calm, masterful, and most persuasive, and Reinhart would have complied had not Trudchen rushed up desperately to add her small person to the barrier. Not even the lieutenant could resist this preposterous event. He smiled, albeit in somewhat ill grace, and set his box on the floor.\n\n\"Schild is my name, Army Intelligence. Would you like a receipt?\"\n\nNo wonder now at his sang-froid. Army Intelligence! The very title had a splendid, piercing authority, far grander, because including brains, than even the paratroops, Rangers, or fighter squadrons: keen, intrepid operators in the very camp of the enemy, many-faced, anonymous; if caught, standing before the wall with a contemptuous smirk towards the rifles; if successful, only the gratification of knowing oneself supreme; no vulgar show, whatever medals were due must wait perhaps ten years hence, and perhaps not even then, for the secrets of the bureau can never be revealed.\n\n\"I'm sorry,\" said Reinhart with a mouth of contrition. \"You see, I didn't understand. I couldn't just let anyone take these things in the absence of Lieutenant Pound. He's in charge here. Actually I don't care about the stuff at all, and neither does he. What is it, or are we allowed to ask?\"\n\nIntelligence. No sooner had he got in the medics on his own request than Reinhart sought to escape. It was humiliating to be the one kind of soldier denied a gun. Intelligence. He even knew German, or enough for a start anyway, the rest he could pick up quickly in a training program. Psychologically he had probably all his life been a kind of undercover agent. In high school he used to follow certain girls in their Friday-evening walks, trail them from nine to midnight, at a distance, in and out of candy-store doorways, and, with the aid of evergreen bushes, right to their front steps, all unbeknownst to them, sometimes forever, sometimes only until the next morning's study-hall revelation. Intelligence. Its operations turned out to be very secret indeed; in three years of service he had never so much as learned where to apply.\n\n\"Just routine correspondence of some German agency, I should think,\" said Lieutenant Schild, staring grimly at Trudchen, who kept leaning into Reinhart and kept getting pushed away. \"It's pretty tedious to have to go through it, but we must.\"\n\nTrudchen leaned against Reinhart again and said, with great, solemn lashes, \"Anyvay, ve should vait for Lieutenant Pound!\"\n\n\"Truchen, I want you to do something for me. Go over and sit in that chair behind my desk and _schweigen Sie._ \"\n\n\"Vy so _formal_?\" she asked pouting, but did it.\n\nJust as he had hoped, Schild's interest was caught.\n\n\"You are fluent?\"\n\n\"Not really, but I have enough for a good base. I'd like to have an opportunity to brush up my German.\"\n\nSchild leaned close and said in an undertone, jerking his thumb towards Trudchen: \"Where did you get that little tot?\"\n\nFor a moment Reinhart thought: oh, but she's not that young; then he realized that what Schild had said, in his Eastern accent, was \"tart,\" a term out of old plays, meaning \"whore\" or thereabouts, perhaps not so strong; what he always saw when he read it was a circular piece of pastry with strawberry jam in the center, and hence, a girl whose person might symbolize such a sweet. That was Trudchen all right. Yet he was responsible for her, in a way, and although it was funny it was also nasty.\n\nHis remonstrance was lost before he found it, for Schild, very certain, proceeded.\n\n\"Take my word and get rid of her before she gets you in trouble.\"\n\n\"But she's just a kid!\" He said it too loud and dared not look towards her. \"I swear I haven't touched her, Lieutenant, I haven't even thought of her in that way\u2014\"\n\n\"Don't be foolish,\" said Schild, sharply, \"I'm not concerned about her welfare but yours.\"\n\nSo he had made an impression on him! Reinhart was almost ready to say: I'll trade Trudchen for a transfer to Intelligence; perhaps now the war was over, some of Schild's men would go home on points and there would be openings.\n\n\"She was peddling her little ass up and down the officers' street last night. Finally she got her prey, that fat\u2014, well, it's better not to say. ... One of these days she'll turn up pregnant and I don't think you'll want to be made the goat.\"\n\nHurt, Reinhart grunted thanks; the lieutenant clearly thought him na\u00efvet\u00e9 incarnate; the trouble was, his complexion was too fair, there were no shadows on his face, no lines of character, and his eyes being pale blue looked stupid; he had labored his life long under the prejudice of his appearance. He was like a big, bland baseball bat; Schild on the other hand resembled a pair of scissors, ugly, black, incisive. How he envied him, even to the tarnish on his silver bar, the dried fog at the edge of his glasses, and the bulge in the flyfront of his ETO jacket that betrayed an undone button. And, as he watched him leave, perhaps even his dirty mind, which was a symbol of freedom.\n\nA sob from Trudchen drew him to her, more in curiosity than pity.\n\n\"What are you doing!\"\n\nShe was crying, had her spectacles off for that purpose, was flushed and dripping, and presented so much misery that, despite himself, he gave her his olive-drab handkerchief, which luckily was clean.\n\n\"He has told you somesing evil about me, that\u2014\" Whatever followed went into the handkerchief. One braid had got twisted about her neck like a noose, and Reinhart, leaning across the desk, returned it to order. The flushed face came briefly out of the cloth to say \"Sank you.\"\n\n\"Trudchen, where were you last night?\"\n\n\"Wiss my cousin Lori in her cellar. This is all the place we have to live, in a cellar which is all cold and wet and without light. The dampness comes into one's bones and most nights one cannot sleep because of the pain...\"\n\nSuddenly arthritic and conscious that the sun had some moments before left the big window, he sat down on the desktop.\n\n\"No,\" he said gently, \"I mean earlier, before you went to bed\u2014were you in this area last evening?\"\n\n\"Most absolutely n\u2014\" She started to speak into the handkerchief but emerged to study him narrowly. \"You won't think that I must be a foolish or superstitious person? ...I consulted with your priest.\"\n\nPriest. By chance he knew that the Catholic priest of the 1209th was away on leave to Rome; his assistant, Joe Para, who was one of Tom Riley's roommates across the hall, had taken a shower that morning in Reinhart's bathroom. Yet there was surely an unintentional error here.\n\n\"Well, then,\" said Trudchen when he explained, \"this was the Protestant priest, a very large man, do you know him?\"\n\nOf course, Schild's \"fat\u2014\"; things were linking up in sweet reason.\n\n\"I wished to see him for guidance,\" she went on. \"I am alone in the world, without father and mother, sometimes it is all so confusing. Do you believe in God?\"\n\n\"I haven't made my mind up,\" said Reinhart. \"But I don't hold anything against someone who does.\" It were cruel, if Chaplain Peggott gave her comfort, to abuse that great, grinning, flabby sententious ass, and it certainly had nothing to do with God, who if He existed at all, Reinhart was sure, was an It rather than a He and altogether neutral. As for himself, who had been as infant a Lutheran and then, when a schism developed within that congregation over whether or not the Ladies Aid should amortize the church mortgage by serving public suppers and his parents left with the progressive element, a Presbyterian. He believed that Protestantism was deadly mediocrity, Catholicism weak-minded, and Judaism alien\u2014and all harmless. He was incapable of bigotry, on the ground that it was a massive bore\u2014like the convictions from which it sprang. On the other hand, if it were carried to fanaticism, to that ultimate degree in which to advance his cause the believer was willing to destroy himself rather than other people: gone this far, it was, as with a Joan of Arc, a heroism to which the original motive was irrelevant.\n\nGertrud of Berlin\u2014it was scandalous to be with the force which compelled a small girl towards martyrdom.\n\n\"Look, I'll see if I can get you a better place to live. I think they have rooms around this area for civilian employees, maybe right in this building, God knows there's room enough.\" He revolved his head in disgust at a vision of a thousand rooms unoccupied while girls slept in wet cellars. \"And for Lori, too.\"\n\n\"Oh, but there is a reason that she cannot,\" said Trudchen, and immediately began again to weep softly. \"But your priest is not a good man. He tried to have his vay viss me.\" She reached to Reinhart's hand. \"He touched me\u2014here.\" She cupped his hand very neatly around one of her breasts and, even though the illustration was clear, kept it there infinitely. \" 'I just must see if you are wearing your medal,' he said. 'But perhaps it slipped down.' And then, so quick as one could think of it, he\u2014\" In the quickness she described, Trudchen had stretched open the neck of her shirt and inserted Reinhart's hand on the bare skin underneath. \" 'Vair is it?' he asked, with a very horrible smile. This must be it\u2014' \"\n\nWithdrawing so swiftly that he unraveled a strand of pink crochet, he shouted: \"It's a lie, Trudchen, it's a contemptible lie!\"\n\nPiggy Peggott\u2014he had many sins, but they were of another kind of gluttony: he was famous in the officers' mess for seconds, thirds, and fourths; but all one had to do was look at him to see that somewhere back home he had the inevitable preacher's wife in dowdy, unkempt clothing and disorderly hair, to whom he was flagrantly faithful; it was simply a matter of definition.\n\nNot to mention that: \"Protestants don't wear medals!\"\n\nIf she had earlier cried in soft self-pity, she howled now in the most violent hatred, her face red and ugly, swinish.\n\n\"It vas this Jew who turned your feelings against me!\"\n\nHe felt himself tremble fearfully, thought for a second that he had hit her; indeed, his big hand hung tremulously in the air between them as if it had bounced there off her small face. But it had not\u2014at the instant it would have struck, the fist had been seized by the mind, for Trudchen, in her temper, was not silent.\n\n\"They have no respect. Of course none of this did happen, but that was what he told you, was it not?\u2014only he made me the bad person, that dirty, filthy creature, that foul\u2014\"\n\n\"Don't say it, Trudchen, it simply is not said. He must have made a mistake, anybody could do that. You have to admit that there are German girls who might\u2014well, anyway, it had nothing to do with his being of the Hebrew faith.\"\n\n\"But it does have something to be connected to that I am a German. At least for him it does. Because the Nazis do not like the Jews, I am made to suffer. In 1933 I am four yearss old; in 1938, nine yearss. They did not permit children to operate the concentration camps.\"\n\nReinhart had a weakness in the small of his back, which standing up did not relieve. He wished he had a grievance; being without one in the modern world was disabling. How gratifying to be the lowliest Negro in Alabama, with no person alive who was not in your debt. How satisfying to be a Jew, with a two-thousand-year claim or, now, a German who had got his medicine unjustly. He should have been in combat and had his foot shot off, so that when he was brought a complaint he could point to the stump and say: obviously, I can do nothing about it, I can't even walk.\n\nHe produced a roll of peppermint Lifesavers and, thumbnailing back the tinfoil, offered the first segment to Trudchen. Shortly it could be heard clicking against her little rabbit-teeth.\n\n\"This is very sweet and not at all\u2014what do you say?\"\n\n\" 'Hot,' I guess.\"\n\n\"It is 'not so hot'? But that means 'no good,' yes? That is not what I mean. I like it better than ours, which are more\u2014\"\n\n\" 'Hot.' That's another usage\u2014the word is good for almost anything.\"\n\nSuch as her face, which now, with glossy lines of tear, was cooling. He should have liked to stroke it. She was so helpless, yet at the same time, if that were possible, indomitable. It was the same combination of contraries he had seen in Lieutenant Schild.\n\nIn the afternoon a PFC sent by Schild began to remove the cartons, antlike\u2014with small burdens and many trips. Pound slopped in at two o'clock, looking for his sunglasses, which after a moment's search he remembered he had sold, listened to Reinhart's explanation of Trudchen and account of Schild's mission, saying to the first, \"Why not?\" and to the second, \"Good deal,\" punched Reinhart in the belly, and left at two-ten.\n\nNeither Lovett nor Nader was in their office, owing, Reinhart assumed, to the catastrophic finale to the party; the colonel no doubt was grinding them into powder. About which even if he had liked them Reinhart would have felt rather more pleasure than pain, he being an enlisted man to the core.\n\nSince, then, official authority could not be consulted, he prowled through the empty rooms in the furthermost reaches of his own wing and found a little closetlike chamber that would meet Trudchen's want. It was already outfitted with a tiny stove and a naked steel bedstead and spring; from the 1209th supply room he fought a mattress and sleeping bag out of the sergeant in charge.\n\nDelighted, Trudchen threw her arms about him when she saw the new quarters.\n\n\"Do you need some help to get your things from Lori's?\"\n\n\"Oh no, you must not bother!\" A brief crease flew through her clear brow. \"I have almost nothing. You will not go there?\"\n\n\"Not if you don't want me to.\"\n\n\"Ah, not I. But Lori would be _aim_ borrossed.\"\n\n\"By the way, did she get her job?\"\n\nTrudchen showed a sly look. \"Do you know, she did not tell me! She is a very odd human being. One must accustom oneself to her strangeness, but she is very nice.\"\n\nLeaving her there, he returned to the office. Four o'clock. The PFC had disappeared, after having taken away all of three cartons. On the point of calling it a day, himself, he saw the heavy sweater that Trudchen had left behind. He carried it to her room, but already she had gone, either by the window or some secret back door off the hall, whose existence he knew not of. Folding the sweater, with a view to placing it on the bed, he felt a hard, cylindrical object somewhere in the weave. It was his missing pen, along the bottom seam of a pocket. So funny: she could hardly have stolen it and then permitted so simple a discovery. Must, rather, first have borrowed and then retained in a slip of the hand. Yet if he reclaimed it now, she might remember, look, find it again with him, think he had caught her in a theft but for reasons of his own would not protest, be discomfited. He placed the sweater on her pillow and left.\n\nHe was inclined to visit Veronica, but rather than search the hospital building for her ward, which in his imagination had acquired a sinister aura, he strolled again down the street of her billet on the chance that her duty, too, was done.\n\nThe salmon-colored gauze had been removed from the glass of the front door; on the inside surface an unseen agency, swift and sure, manipulated a cleaning rag. Its movements were mesmerizing; he had an impulse to throw himself on the grass and watch it as the warm-cool late afternoon relaxed into calm evening. Beside the door grew a bush bearing round, white berries like small versions of those pure-sugar jawbreakers with a nut in the center. There was a bush like that in his parents' front yard, and next to it a weeping willow high in which he had once established an outpost for General Custer. Alone among the men of the 1209th he had been in no hurry to get back to the States, had in fact long planned to ask, in rakish defiance, for permanent assignment to the Occupation forces, was waiting only until it could be more than an empty, sour-grape gesture\u2014for, without combat points, he was more or less permanent as it stood. Now, just now, watching the rag fly across the pane, seeing the bush, recalling General Custer, and with the sudden, almost unbearably dear smell of grass\u2014he had not at first marked that the lawn was newly cut\u2014he ached for home.\n\nThe door opened just as the general bliss had given into the deadly specificities. He had come far since his first year in the Army when he frequently had such seizures; yes, he had enlisted to escape, but there was forever another present to flee from; in the summertime, especially, one craved elsewhere. But he had nothing to get back to. In the most literal sense: already in September 1943 his parents had let his room to a man who worked an electric drill in the local defense plant, a man who had remained, had settled down, who surely had dispensed with the arrowhead collection and the stuffed bass's head on the bookcase. And college: he simply could not face that again after three years of the expansive life.\n\nThe door had opened and a figure in head-handkerchief and apron came onto the step, saying: _\"Sind Sie nicht wohl?\"_\n\nIt was not unreasonable, since he had, after all, fallen on the lawn\u2014an event thus called to his own attention. The person was Lori.\n\n\"No, I'm quite well,\" he said in German. \"It is pleasant to sit here. I see you have your job, come tell me about it. Sit down here with me.\"\n\n\"I cannot sit on the grass!\" she said incredulously. \"I am the maid.\"\n\nAt any rate, if she looked no happier now, she was no sadder. Since he was on their level, he noticed that her legs, though dressed in coarse cotton, were finely turned and rather long for her height. But there was also something terribly competent in her appearance now that she wore working clothes, a hint of hard strength that reminded him of his suspicions.\n\n\"There were no difficulties about the _Fragebogen?\"_\n\n\"What you wish to ask is whether I was a Nazi, isn't it? You are more shy than your fellow Americans. ... There was no such thing as a Nazi\u2014you should know that if you have asked any other Germans. In all this great country there were no Nazis; not even Hitler, as you would hear if you could find him.\"\n\nHe sat up, aghast at her change from suppliance to this arrogant self-possession. It was the famous German alternation from serf to lord, no doubt, and he felt it cruelly there on the fresh grass.\n\nGetting to his feet, he said braggingly in English: \"What the hell do I care?\"\n\n_\"Bitte?\"_\n\n_\"Mit mir macht es nichts.\"_\n\n\"I know,\" she said. \"That is why\u2014\" She took a deep breath and suddenly finished it in English: \"\u2014I love you.\"\n\nYou couldn't stay angry when that was said to you, but you could look insane.\n\n\"Have I said something wrong?\" She took off her dusting cap, and a wealth of hair came forth, and golden it was and clean.\n\n\"You do not know English,\" he said in a voice full of augury\u2014as if he were to go on with: you can say awful things in it. \"What you mean is that you like me.\"\n\n\"It is not the same as in French?\"\n\n\"I think not.\"\n\n_\"Also.\"_\n\nIn the distance he heard a laugh like a great bronze chime. Unmistakable. He felt criminally that he didn't wish Very to see him with this girl. But Lori, too, had heard and was even more anxious to flee from him.\n\n\"There comes one of my mistresses,\" she whispered, already in backward motion. \"I must go.\"\n\n\"Veronica Leary? Lieutenant Leary?\"\n\n\"I do not know the name, but the laugh cannot be mistaken.\"\n\nIt was heard again, turning the corner only a few yards away, and Reinhart audaciously pushed into the house after Lori.\n\n\"Ah, what are you doing here, you mad fellow?\" she asked in confusion.\n\n\"I'm going into the kitchen.\" And so he did, and sat silently until Very and what sounded like a roommate entered the door and went upstairs.\n\n\"Where is Miss Leary's room\u2014the laughing one?\" he whispered.\n\nIn frightful wonder Lori answered: \"In the rear. You will go there?\"\n\n\"Certainly not. Then I can leave by the front and she won't see me out the window.\"\n\nBut instead of moving on that plan, he looked at Lori and said: \"You've washed your hair. It is very _sch\u00f6n._ \"\n\n\"Thank you. I didn't have any soap until I started this work. ... But please go now.\"\n\nDidn't have any soap\u2014he was terribly touched by that fact. One thought of the bombings and fires and loss of loved ones, the _G\u00f6tterd\u00e4mmerung,_ but not to be able to wash your socks or bathe, that was degrading and mean.\n\n\"And where you live, I understand, is in some wet cellar. Let me get you a better place\u2014\"\n\n\"All right, but now you must go.\" She took his hand in her small but very strong one and pulled him from the chair.\n\n\"Tonight, as soon as you leave work, we'll get you a new room. I won't leave now until you promise.\"\n\n_\"Ach, was kann ich tun!\"_ she breathed in despair. \"I cannot.\"\n\n\"Why not?\" He tightened his hand on hers.\n\n\"For reasons too long to explain now\u2014\"\n\n\"Promise! After work. What time do you finish?\"\n\n\"Ah, what can I do?\" she repeated. \"I'll lose my job if you do not go.\"\n\n\"Come with me!\" Now it was he who impelled her, through the hall to the foot of the stair.\n\n\"Hey Very, are you decent?\" he shouted in a tremendous voice which agitated a small vase on the foyer table. And in no time his large friend appeared at the top, blooming lavishly in a powder-blue dressing gown, a dea ex machina about to catch the next elevator down from Olympus.\n\n\"Kiddy!\" she screamed jovially. \"Did you break in here to violate me? You-all ain't supposed to be in nurses' quarters!\"\n\n\"That's what your maid insisted.\"\n\n\"Well, get out then, you fiend. I'll see you after chow\u2014outside.\"\n\n\"I can't, I've gotta work tonight.\" He turned to Lori, who looked very grave, and said as quickly as he could in German: \"Unless you meet me this evening I shall cause you trouble. What time?\"\n\n_\"Um sechs Uhr._ I eat at your mess after the soldiers are finished.\" She turned away in shame.\n\n\"Okay then,\" shouted Very. \"Don't go away mad. Hey, where did you learn German? Wait a minute.\" She disappeared, and returned with a piece of olive-colored apparel, pitched it downstairs, it taking the air like a parachute and falling to rest at Lori's feet.\n\n\"Would you tell her to press it and be careful not to use too hot an iron?\"\n\nWhich he did, adding: _\"Um sechs Uhr,_ outside the mess tent.\"\n\nChow was SOS, shit-on-a-shingle, ground beef and gravy slopped across a slice of bread, diced carrots and canned peas, rice pudding filled with raisins resembling dead flies. Reinhart ate a grimacing spoonful of each and then smoked two consecutive cigarettes, his only pleasure the dropping of their butts into the swill.\n\n\"Anyone ever tell you you eat like a goat?\" he asked Marsala, who was stuffing down seconds.\n\n\"I've got a right to, I worked all day,\" his roommate answered on a rising, plaintive note, missing the point.\n\nAt the garbage cans were two small boys who had temporarily ducked the guard. As Reinhart prepared to empty his full messkit, one of them, saying \"Pleasse,\" took it from him, with a spoon flipped out the cigarette-ends, poured the contents in a tin with jagged rim, and began ravenously to feed.\n\nMarsala pushed his boy roughly aside. \"Go on, you goddam Krauthead.\" But there was nothing in his kit but three drops of gravy, and when the guard appeared, sweating and worried, with his switch at the ready, Marsala stared into his bland face and threatened: \"Go on, you fuck, or I'll take ya apart. How do you like that,\" he went on to Reinhart, \"those kids belong to his own country.\"\n\n\"Well, we hired him to keep them away.\"\n\n\"Yeah, but who would really do it except a German?\"\n\nTheir natural anarchism saved Italians. They were, after all, the original fascists, but even Mussolini had inspired more laughter than hatred. Someone should take the guard aside and say: Sit down, Hans, have a smoke. Now I'll give you the rundown on life. People are worth more than things, and abstractions have almost no worth at all. When you get an order your sole responsibility is to _act_ as if you are carrying it out. Hypocrisy is the better part of competence. It is foolish, I know, and defies everything you and I were taught; but in the degree to which you serve others and not yourself, the others will forsake you. However, comprehending neither Marsala's threat nor Reinhart's interior monologue, \"Hans\" had driven the children out of range, lashing their meager shins in the most dispassionate manner.\n\nReinhart had delayed taking his meal, and Marsala with him, until the tent was almost empty of soldiers and the queue of civilian workers had begun to form at the front flap, and en route to and at the apartment he dawdled for twenty minutes, part of which was aimed to bore Marsala with his company. It worked: the buddy at last drifted across the hall to needle Riley, and Reinhart returned to the mess area. Almost too late: the Army trucks used for workers' transport idled at the curb. He spotted Lori, carrying a small, lidded pail, about to mount a tailgate.\n\n_\"Also, Sie sind falsch!\"_ he accused.\n\n\"I looked for you,\" she stoically replied. \"I have either to ride this truck or walk many kilometers.\"\n\nWithin, the side benches were loaded with women who gave off chattering to stare at Reinhart.\n\n\"Go on.\" He lifted her up in one strong action, getting on his jacket a bit of splash as the cover jarred from her can, and vaulted himself in with a terrible noise on the metal floor.\n\nWhich prompted the driver to peer through his spy-window and call: \"Haul ass, kid. No riders.\"\n\n\"The Lover sent me, Eberhard. I have to get new quarters for this woman.\"\n\n\"Lovett never told me about it.\"\n\n\"All right, all you have to do is tell him when you get back.\"\n\n\" _You_ tell him, for Jesus' sake,\" grunted Eberhard, dropping the isinglass trapdoor.\n\nThey had squeezed onto the bench between a very fat girl and a very skinny woman, so that Lori was compressed and Reinhart slashed by sharp elbows.\n\n\"Tell me now,\" he asked. \"Why all the strange reactions? I think you should want to have a better place to live. Trudchen told me this afternoon about your cellar\u2014how she couldn't sleep there for the wet\u2014\"\n\n\"Trudchen? She doesn't live with me! ...I warned you about her untruths, but I suppose not enough. She lives with her parents in a pleasant flat, not bombed, near the hospital.\"\n\n\"And I got her a room in headquarters building! What game is she playing?\"\n\n\"That's just it, you see, a game. She is very young and willful. It is not easy to be an adolescent girl in the present time.\"\n\nNo, he supposed not; for that matter, it had not been easy for him to be an adolescent boy, five years and three thousand miles back, in a smooth place where the only craters were excavations for new bungalows. At least Trudchen had no pimples.\n\n\"And then, too, perhaps her family are not all that could be desired\u2014but that's another story. As to me, well, frankly, I have a husband.\"\n\n\"Oh, that's all right. You see, I'm not\u2014\" He had intended to say: interested in you in that way. But it would have been insulting.\n\n\"He is very strange\u2014as now it seems I am helpless to prevent your seeing for yourself.\"\n\nThe truck was under way, clanking, creaking, and in clouds of blue exhaust, which defying the principles was drawn stinking into their compartment. Under cover of his conversation in the other direction, Bony Elbows waxed friendly, cutting her sharp patella into the outer surface of his thigh. She was, he had seen on entering, at least forty-five years of age.\n\n\"Was he in the war?\"\n\n\"He had an odd role.\" That was her last word until a half hour later when, after various stops, one of which freed them of Fat and Thin at the same time, the vehicle came to rest at what seemed to him a purely arbitrary point in nowhere and she and he detrucked.\n\nThey stood before a hill of waste whose farthest margin must have, spilling over Asia's width, been forever eroding into the Pacific. The sun, elsewhere on this day so rich, voided this dark field, and the sweet air had long ago sold out to its competitor gases. On this range figures thin and slumped roamed crumbling through its Brenners, sack-bearing, searching, genitors of no sound. But on the summit a small girl, a ragged head above a cotton bag, called shrill and disconsolate to nobody below: _\"Wo is der Heinrich?\"_\n\n\"Behold,\" said Lori. \"N\u00fcrnberger Strasse.\"\n\nFive minutes' impossible trek and they teetered on the powdered brick at the entrance to a subterranean passage. Reinhart fired his lighter, but Lori hastily lowered its cap. \"There may be escaping gas.\" She drew him, now blind, down the prairie-dog way.\n\n# _CHAPTER 10_\n\nON THE SOFA LAY AN amorphous lump to which was appended a great pale ham. Lori slammed the door. A hollow groan issued from the ham, and two apertures appeared in its wan surface. After a time a mouth revealed itself, as if in one of those motion-picture cartoons where inanimate objects come to life through lines from nowhere, with the breezy implication that humanity is some sleight-of-hand. However, the present process was not flippant, but ponderous and awesome.\n\nLori put down her pail and fired more oil lamps, and in the richer light the great object rose gradually and with tremendous deliberation, like a sinking ship preparing for the final and irrevocable plunge, to an attitude of sitting.\n\n_\"Herr Reinhart, mein Mann,\"_ Lori waved loosely at the hulk.\n\n_\"Sehr angenehm.\"_ The voice was full, sonorous, making a grand thing of the words, and the eyes which the light showed to be as large and ripe as purple-black plums honored Reinhart directly and briefly, then shifted within the largesse of lid to Lori, who stood before the table, one hand at the base of a lamp, her left side from flank to hair bright in its refulgence.\n\n\"Here is your dinner.\"\n\nHe ignored her to revolve his head to Reinhart, saying in English without accent: \"Ah, this is your corporal!\"\n\nAs Reinhart closed on the cold sponginess of the extended hand, he felt with surprise that his own was not being shaken in acquaintance but rather used as a purchase whereby this large figure was lifting itself from the couch, and the weight was such as to compel him to throw his rear feet wide, lest he be toppled forward.\n\n_\"S'il vous plait,\"_ his burden wheezed with difficulty on the way up, and then, all at once, was upright before him, or rather looming over him, for the man was a good seven feet tall and bulky as the great Kodiak bear. Reinhart was cast into the, for him, rare feeling of slightness. The pull left the hand, but it stayed clammily and, oddly, weightless, in his own, until he opened his fingers and gravity, not its parent body, moved it to fall slowly away.\n\nUsing that language, Lori's man noted that he could speak English, and would, as a courtesy. Swaying a bit, he said that it was all but impossible for him to stay erect, but that he insisted on doing so until his guest was seated. Lori having furnished a chair, he sank again to the sofa, and drew the dressing gown that was his lone garment more snugly about him.\n\nLying still, pale, and full, like a sack of mozzarella, he tasted of the air with porcine nostrils, and began:\n\n\"Now we can converse at our ease. My name is Bach, which as you perhaps know, signifies 'brook' in German, and, naturally, to every German, and very likely to others as well, simply to utter the name is to conjure up the image of the master of the Thomasschule and the three most eminent of his twenty offspring\u2014for his loins were apparently as prolific as his brain\u2014who were also composers of a high rank, but not quite so well known outside their own land. So far as I know, I am not a descendant of that noble line. And you are called...?\"\n\n\"Reinhart.\"\n\n\"The name, of course, means 'pure of heart,' _Hart_ being the Low German variant of _Herz._ But I have a feeling that you, like so many Americans, have no great interest in etymology. Unfortunately, it is one of my many weaknesses. And I do have more than my share.\" He indicated his body with a sweep of the hand. \"The main among them being a physical impuissance, if you'll permit the word, in spite of a monstrous size. This misfortune has caused my energy to be diverted directly to my brain, which as a result is extraordinarily active and frequently denies me sleep, occupied as it forever is with a thousand and one theories, ideas, and bits of information which it should like to synthesize. I speak of this brain as if it acts of its own volition, has a life, as it were, of its own. For indeed it seems to have such an independent existence\u2014awe-inspiring, to say the least. I\u2014it is ridiculous, is it not, to speak of an 'I' separate from one's brain? but it really seems that way to me\u2014I conceive of my own identity as relating more closely to the emotions, for I am their creature and toil under the dominion of the harsh ambassadors they send to the external world, the senses.\" Here he snorted: \"Smell!\" Poked a pair of spread fingers into his eyes: \"Sight!\" Extended a fat, pink tongue, swollen as a bladder: \"Taste! And so on. Do I make myself clear?\" He stared for a while at Reinhart, as if he had forgotten him, then asked, shyly: \"I say, do you smoke?\"\n\nReinhart offered the cigarettes, saying, \"Please keep them all. I have many.\"\n\n\"Oh, kind, kind. I cannot thank you enough.\" He seemed about to rise, but decided against it. He dropped a tear. Wiping his nose on his dressing gown of dirty-orange cotton, he reverently chose a cigarette from the pack, called for a light from Lori, and getting it puffed luxuriously, his huge bald skull reflecting light like a mirrored ball upon a lawn.\n\n\"Now where were we? Oh yes, I believe some biography may be in order. Perhaps you would like to hear of my term of years in the Orient, where I served as cultural attach\u00e9 in the Embassy in Tokyo. A strange people, the Japanese, rather stolid, in spite of their reputation for wit. Their art is curiously constipated. Nevertheless, it has a kind of mordant humor all its own, in its juxtaposition of human limitation and the infinity of nature. But perhaps I'm doing them an injustice. They have, like all peoples, much to recommend them. Good clear skins, for example; one never finds them shriveling up in later years, and scrupulously clean. Absolutely no odor! This may owe to their arriving at puberty earlier than we. Our Western pubescence, which, although we think it consonant with some divine ordinance, is the slave of social, rather than natural, imperatives, has certain unpleasant concomitants: the foul stink of perspiration, for example. Children, you will note, never stink, even in the heat of strenuous play. The Japanese, arriving at adulthood still in the vigor of extreme youth, consume the life-stuff _in toto,_ while in us a certain excess accrues which maturates. Your excellent English verb, by the way, expresses beautifully both aspects of this process: the fructification and the rot. Orientals maintain that white men smell like corpses.\"\n\nThe slight movement of Bach's trunk, as he pitched the cigarette butt to the cracked concrete floor, where Lori stamped it dead, communicated a tremor to his lower extremities; the robe slipped away, exposing a view of verdigrised leg braces, complex in rods, wires, and articulations.\n\n\"The Japanese have an unusual poetry, which resists qualitative judgment. So long as a _haiku_ is written in accordance with the traditional seventeen-syllable form, it is the peer of every other constructed in the past, or to be constructed in the future. If it violates the form, it is not a _haiku._ A Westerner at his first exposure is nearly driven mad by the question as to whether this is the beginning or the end of art, not to mention morality and history. Of course, this question is of no concern to the Japanese: it simply _is,_ without qualification. They are wise and courageous enough to accept the given. Westerners can approach this knowledge only by burlesque, as when the Englishman says the great thing about the Order of the Garter is that no damned merit's involved.\"\n\nBach repeated the phrase, fondling it word by word, with the lust of a gourmand measuring off the links of a sausage, and developing an amusement which terminated in a high-pressure giggle, half-audible; the remainder being in the upper, silent-dog-whistle ranges, where it worked a secret violance on Reinhart's nerves, so that forboding ballooned the membranes of his heart as might a seizure of gas.\n\nBach gasped and grunted a tongue which Reinhart took for Japanese. \"Let me translate:\n\n> The snow crowns pale Fuji\n> \n> Here below, it is spring.\n\nThat is of my own authorship, but it will do.\"\n\nHe spoke Orientally again, in an altered voice.\n\n\"Chinese. Their verse is considerably different, but I am too exhausted to explore the subtleties of the difference at this time.\"\n\nDespite his growing nausea, Reinhart asked for a translation. He was determined not to permit this strange man to elude fact, believing that the secret of power lay in its mystery.\n\n\"Oh, yes, that is Meng Hsien-Wong.\n\n> Like a shimmer of bird calls\n> \n> The petals of the pear-flower drift\n> \n> Through the late clear air;\n> \n> Already since the morning rain\n> \n> The blossoms have grown older.\n> \n> So does the pear-branch, snow-perfumed,\n> \n> Hold a bright mirror up to man.\n\n\"You can see right off that this is not so pure as the _haiku,_ being corrupted with morality. You perceived the moral, of course?\"\n\nReinhart did not attend to this bit of malice. He had, at the mention of the \"pear-flower,\" discovered a primary cause of his illness: the room stank of rotten fruit.\n\n\"The latter was a tributary verse to an incomparable thirteenth-century painting by Chien Hsuan which I once owned but was confiscated, supposedly for some use in the advancement of the war, but how such an item could be used for such a purpose, I have no idea.\"\n\n\"No, Bach,\" said Lori, still standing by the table. \"You sold it, don't you remember?\"\n\nHe narrowed his eyes at Reinhart, and his massive face became mean, piggish, as he spoke to Lori in German: \"Manners, manners! We here speak the language of our guest.\"\n\n\"But I have no English, as you know.\"\n\nReinhart, working at a piece of gum, felt slightly relieved. He explained that he knew German and suggested that it be spoken for Lori's benefit.\n\n\"To be sure,\" said Bach, \"I am at your command. Yet, I am about to tell you something in confidence. However, I wonder if I dare? She understood enough of my comments on the painting to correct me.\"\n\n\"You probably have told the story before,\" observed Reinhart, in a schoolmasterish voice.\n\n\"Of course! That's exactly it.\" He peered sagely at Reinhart. \"You look like quite a decent fellow. Tell me, how many Germans have you shot?\"\n\nReinhart enjoyed a brief daydream of cutting down rank upon rank of blond men with a Thompson submachine gun. But he lacked in nerve to carry it off. He sheepishly admitted:\n\n\"I've never fired a gun since I put on the uniform. I'm a medic, a sort of half a soldier. Geneva Convention...\"\n\nBach made the best of it. \"An appropriate office for an American, really; an exemplary role.\" With a beatific smile, \"A marvelous people: one-hundred thirty millions of decent chaps spread out across that strange Siberia. I have been there, of course, so I will not amuse you by asking if you know my friend Smith in New York.\"\n\n\"My home is in Ohio,\" said Reinhart, dolefully.\n\n\"Quite so. Very near Chicago. You see, I do know. I once, with a friend, took a motor trip from that city to Michigan. We passed a number of persons who hailed us with leafy stalks, and felt like Christ entering Jerusalem through the palm branches. However, when we were eventually brought to halt by an exceptionally violent signal, we were asked to purchase celery. But excuse me for a moment, won't you?\"\n\nHe called Lori, and with the same kind of help Reinhart had rendered earlier, performed the impressive ritual of rising. By a tottering, brink-of-disaster, Humpty-Dumpty locomotion he arrived at the door, where he leaned briefly against the jamb, while that frail member moaned at the weight, and then went out. The door stood open. His voice boomed in the hall in a complaint about the lack of light, and another door could be heard to open, but not afterwards to close. The rich rush of his water was audible.\n\nLori sat on the edge of the couch, extending both hands in supplication. \"I fear he's been drinking. It's horribly embarrassing, you must forgive me.\"\n\nReinhart was also embarrassed\u2014for his own membership in the sex that made noise at the toilet. To cover up, he said, \"It's true, then, that he knows Chinese, and so on.\"\n\n\"Yes,\" said Lori, smiling wearily. \"For some years he was assistant curator of Oriental art at the museum. I am sorry we have no paintings or china left for him to show you. He can be very illuminating. But most of our own collection had to be sold and what few things remained went to the incendiary bombs.\"\n\n\"You sold them to pay for his medical treatment?\"\n\n\"Oh no\u2014it is another long story.\"\n\n\"You have so many.\"\n\n\"Yes, life is merely several long stories laid end to end.\" She reached across and patted his knee maternally. \"They must not trouble you.\"\n\nAlthough they should have, at that moment they did not. His distress owed rather to the dreadful odor, which was on the point of laying him low. Life takes precedence over courtesy.\n\nLori shook her head at his apologetic question. \"That is one of Bach's conceits. He read in Eckermann that Schiller was stimulated by the aroma of rotting apples.\" She opened a drawer in the table. _\"Voila!\"_ Exposing, sure enough, three blackened, scabrous fruits.\n\nBach was missing for a long time after he could no longer be heard. When he reappeared he stated that, having taken the air, he was much refreshed, which claim was supported by his looking a shade stronger on his pins, though still not by any means competent.\n\nReinhart was not sure as to what proportion of Bach's weakness could be attributed to gigantism and what to drink. Indeed, the drunkenness referred to by Lori had taken Reinhart by surprise, for Bach, given his odd body, had not spoken in a way that would have seemed, to Reinhart, out of consonance with it had Bach been sober.\n\nAt any rate, Bach swayed in, regained the sofa, where now with his new-found strength he sat rather than reclined, and confessed to copious draughts of potato schnapps; had, in truth, drained the bottle, otherwise he would have offered some to his guest. A pity, grievously hard to get; for the past few years in Germany, there were few potatoes to eat, let alone drink. He gauged the present state of his inebriation to be at the half-saturation point, but rapidly clearing.\n\n\"If you stay with me throughout the period of sobering, you will no doubt see the engine run diminuendo and eventually cough dead, so I had better make the most of what articulate time's left.\n\n\"Now I am not unconscious of my failure to ask you of yourself, but your status is not in question. I have reason to believe that the American Intelligence, when it finds time, will be unusually interested in mine. You see in me one whose only engagement for the future is with Judgment Day, for, frankly, I was a National Socialist.\"\n\nReinhart straightened in his chair, crossed his legs the other way, tugged at the margin of his jacket, and checked his buttons. How seldom we meet the real thing!\n\n\"It would be silly for me to do anything else, my record being readily available. For I was no more tepid in my political convictions than in anything else. In short, if I was a Nazi, I was an absolute one. My only wish is to tell my story without rancor, without extenuation, and submit myself to your mercy. Will you, as a matter of simple humanity, grant me this favor? _Hier stehe ich_ \u2014\"\n\n\"Only you are reclining, Bach,\" interrupted Lori, with a foolish giggle which made Bach frown and even Reinhart to turn his head in impatience. She had brought up another chair when dispossessed of the sofa, and slumped there like a discarded rag doll.\n\n\"Please, please,\" Bach replied in German, \"none of your _Quatsch._ This is a sober affair.\"\n\n\"How can I hide it?\" asked Bach. \"What is done is done. Nazism might be defined as an extreme attempt to alter the relations of Jews and gentiles, in the latter's favor. All the other involvements start from this, and this is one of those sublime simplicities that achieve the miracle of fecundity in reduction, like the Cartesian _cogito._ It requires the utmost in intellectual courage to accept the proposition that all human beings are either Jews or non-Jews; with anything less, the whole thing collapses into absurdity.\n\n\"Yes, exactly, you smile. So should have I genuinely, not too many years ago, and so do I now, with the hypocrisy of courtesy, and also with real sympathy, for I can deny myself no indulgence in my present state. But I did not begin life as an anti-Semite. There were no Jews in my birthplace, a small village in Bavaria, and it was not until I entered the Gymnasium at ten years old that I ever saw a Jew, and not until I entered the university that I ever, to my knowledge, heard Jews remarked on in a special way. In short, for many years I thought of Jews as simply Germans of a religious persuasion different from my own. Such hostile attitudes towards the Israelites as I came across from time to time, I believed to be the by-products of doctrinal differences of the sort that obtain between Catholics and Protestants\u2014of which I was thoroughly aware, as a Protestant Bavarian.\n\n\"I continued in my na\u00efve tolerance throughout the university years. A force to support it was my personal status as an aesthete. I avoided the drinking and the fraternal societies and the other nonsense, and consequently did not escape being marked as an odd one. Finding myself in the same category as the Jews, I went so far as to make some friends among their ranks. They were, naturally, excellent scholars, and their scholarship was conditioned with the sort of finesse that is so sadly lacking among the Germans. In my reaction against _Spiessb\u00fcrgertum,_ I shortly became infatuated with the Jews, and with their culture. And surely no culture is more attractive to the young man than the Jewish, just as there is no more repugnant than the German. Besides, Orientalism was my pursuit, and the Jew was the earliest flowering of the East. I gradually became aware of the indictment brought against my pets by the Germans, in all of its ramifications, but I still was not be moved. Indeed, I became more pro-Jewish than before. And I did this in an unusual mode. I accepted the accusations as truth, taking issue only with the interpretation. That is to say if the charge was that Jews owed allegiance only to their international Jewish state, I agreed and approved. For, thought I, what else could they do, when throughout history they have been rejected from the Christian society they sought innocently and sincerely to join? In the Twenties, as you may know, the Germans were in narrow straits, while the Jews allegedly flourished. Now it took some nerve to hold, as I did, that it was natural and just that they should tighten the screws against the gentile, for would not the latter have done so had the situation been reversed? I could never see anything peculiarly evil in the Jew's economic behavior. Should the executioner be blamed for the practice of hanging?\n\n\"As for the arguments on racial grounds, they were sheer foolishness, only to be believed in by the kind of people who take up vegetarianism, Rosicrucianism, and other crackbrained schemes to evade paying the piper. I paid little attention to them, and I think this was also true of most convinced anti-Semites, whatever certain loudmouths said. This phase of Nazism was sheer spectacle; this was the Nazis' analogy to Christianity's graven images, saints' relics, etc., and a central vulgarity on which Protestants and Catholics could agree. Never since Luther, whose nationalistic fury vis-\u00e0-vis Rome withered his sense of psychology, had the national appetite for histrionics been so appeased.\n\n\"Well, then, in the light of all this, why did I eventually reverse myself and become ineluctably anti-Semitic, even to the extent of joining the National Socialist party, which I had from the first abominated as an unholy alliance of gangsters and buffoons? I became an anti-Semite, not for the usual reason\u2014because of the anti-Semites\u2014but because of the Jews, and I joined the united front against the Jews because there was nowhere else to go.\n\n\"When I emerged from the university into the great world, moved to Berlin and entered its intellectual life\u2014which in that time was almost uniformly Jewish\u2014I did not change my stand. I still baited the anti-Semites, and, as one will when in the grip of a self-righteous obsession, in the absence of suitable adversaries engaged in dialogues with myself, acting first as _advocatus diaboli_ in the presentation of the strongest possible case against the Jew, then demolishing it with my better arguments. I would probably never have had cause to change had I kept company only with gentiles, and certainly never, had my associates been anti-Semites. But I found myself in ever-closer relationships with Jews, whom I attracted as my philo-Judaic position became known, and whom I of course sought out. And thus the foundation came to be built, stone by stone, for the mansion of knowledge. For I found that no matter how well disposed a gentile is towards a Jew it can never be sufficient, for the Jew will not stop short of the total debasement of his friends. The Jew does not want, and does not ask for simple understanding. He craves only total victory, and rewards anything less with corrosive hatred.\n\n\"I was not permitted by the Jews to deplore the persecutions they had suffered at Christian hands. In their arrogance they asserted that this very act of deploring was a form of anti-Semitism because it credited their enemies with efficacy, and no matter how superficially well-intentioned the gentile who entertained such sentiments, he could not avoid unconscious _Schadenfreude,_ no more than can the athlete who sympathizes with the cripple.\n\n\"This is an excellent example of the Jew's ability to pursue his end by contradictory means. Sometimes he will object to the very designation of 'the Jews,' maintaining that no such racial, cultural, religious, ethnic, or whatnot entity exists, that it is the sheerest invention, the most fantastic lie. If you point out that if this were so, anti-Semitism would also be nonexistent, he will say, 'Exactly, that supports my claim that the whole affair is simply the eternal struggle between the mob and the elite, with no relation to Jewishness.' At other times, and under other guises, he will present the argument that only the Jews exist, and no other people, because of all the peoples of the earth, only the Jews have been able to preserve their identity in every milieu. He can disclaim Jewish influence on any culture, or assert that the Jew is the _Ern\u00e4hrer_ of our heritage, and cite Abraham, Moses, and Jesus. Yes, he will cite Jesus with the composure which is his forte! The modern world is, for him, a theater in which the Jews are anonymous members of the cast\u2014unless the situation requires the reverse strategy, in which case he produces a list of leading performers beside whom the gentiles are relegated to the beer-hall stage: Marx, Freud, Einstein.\n\n\"He can assume any position at will, for he believes in none. And he hates the sympathizer because sympathy implies melioration, and melioration is change. The Jew's real aim is to bring Time to a stop. Like all Asiatics, he has a horror of motion, process, becoming\u2014whatever name you like\u2014for us Occidentals, the superior Deity. When _is_ replaces _to be,_ he will have won. Humanitarianism, liberalism, evolution, tolerance, understanding, these he rightly sees as temporal devices to frustrate him, whereas he delights in the antagonism of fanatics. The anti-Semite is his darling, just as the atheist is the theist's sweetheart, the murderer the victim's beloved. The Jew would be a god. How near to success is he then when called a devil! And how he writhes in hatred when a slobbering, mealy-mouthed humanitarian addresses him as Man!\n\n\"Totalitarianism provides his most congenial society, with its stupid calls and alarms, its aping of the Jew's own tricks, such as the obliteration of time and the fierce attack on moderates, and\u2014 _its persecution of the Jew!_ When he becomes an obsession, he is on the threshold of victory.\"\n\nBach retracted his big head into layers of neck-flesh, recovered, then began again, right forefinger extended:\n\n\"I do not mean to claim that I quickly saw the light. Young and innocent as I was, I determined after each rejection to redouble my efforts at understanding, feeling still that it was _our_ responsibility that this strange people faced the world in a crabbed, distorted way. How very close was I to the truth! A human being if thrown into water at birth can swim. A few years of growth and this talent is gone, to be regained only by artifice. Yet, this is as it should be. Artifice is what makes us human. It is morally necessary to withhold this function from a child until he has lived long enough to learn the properties of water and the human body, and to experience a sense of achievement in placing them in a new relationship. So with me. By the heart, I had arrived at the proper relationship with the Jews, the masterly one, but I was condemned to tread the earth for some years in ignorance before returning to it by ratiocination.\n\n\"But, to proceed. I told myself again that the Jews had no reason to think kindly on their oppressors, and that it was only natural they would out of pride decline any aid that tended to imply a lack of self-competency on their part. I summoned up my resources of love, decency, intelligence. They might deny me, but I would not deny them. I suddenly took on, through the force of my commitment, the identity of a Jew; and the soma reflected the psyche: the cartilaginous tissue of my nose thinned, my eyebrows thickened, and my shoulders developed a nervous twinge.\n\n\"At first, my gentile friends derived much fun from this state of affairs, and would jokingly call upon me for the Jewish point of view on every question (this \"Jewish opinion\" is a favorite delusion of gentiles, and one which while ostensibly deploring, Jews enjoy enormously). But it did not take long for them to discover that what was an idle jest to them, was deadly serious to me. As my philo-Semitism became firmer and firmer, I felt a wall rising between us. The last brick fell into place when a story began to go around that I was really half-Jewish, and had thrown my lot with the alien part of my heritage. This fiction, I realized, was only their defense against accepting the terrible fact that I had, in free will, abdicated from the gentile's estate.\n\n\"But, of course, neither was I received as a fellow by the Israelites. Here there existed no solid wall\u2014this people could not have survived all those agonizing centuries by material means. (The Jew, by the way, has always deluded his enemies into thinking he is materialistic. Nothing could be farther from the truth, which you can appreciate when you observe that he has flourished in the West under capitalism, a philosophy which above all others is abstract and visionary, and based on the intangibles of faith and spirit. He is, however, naturally opposed to the recent developments of capitalism. If it becomes humane, that is to say, evolves into true socialism\u2014which is absolute materialism\u2014we have a chance of conquering him. Vain thought!)\n\n\"So I was with and around the Jews without being of them. Oh, they don't hold secret meetings, like the mythical Elders of Zion (that wonderful legend, which is far too gross to be of Jewish origin\u2014you know they, themselves, 'plant' most of the anti-Semitic fairy tales\u2014is an example of the gratuitous aid they are often rendered by moronic gentiles), they have no arcane signs or handgrips, no insigne. How they communicate their identity to each other is so mysterious that it exceeds mystery, as does the manner in which a single spermatozoon out of ten thousand penetrates the egg. The important thing is that it happens. And, if _we_ cannot grasp it, no Jew can fail to. Which is why no Jew can truly forsake his people, and why the Jews display that odd combination of mockery and pity towards those of their fellows who vainly toy with religious 'conversions' and facial surgery.\n\n\"The great reversal (from philo- to anti-Semitism) came, as those things do, all at once. I was in the habit at that time of spending the evenings with my Jews in a cellar-cafe where over a single glass of beer or cheap wine we would exhaust hours talking art, literature, philosophy, and those other diversions of the young, including politics, of which ours was, in that day\u20141927\u2014communism. All in what I cherished, despite numerous disillusionments, as the intimate atmosphere of brotherhood. One evening a newcomer appeared at our table, a fierce, hideous, wooly-headed young Israelite, looking like the pictures one sees of Trotsky as a youth. He was discoursing passionately on some topic, political I should imagine, but as I took a seat, he terminated abruptly. 'It's all right,' one of the others told him, 'Bach is all right.' He nodded amiably at me, and rather transparently began to comment on inconsequential matters. Later, when I had left the table briefly to speak with a friend across the room, I saw on returning that he and Schwartz, whom I regarded as my closest comrade, had their heads together, snickering. The object of their amusement was obvious. Now, lest you think me hypersensitive, I must explain to you that the Jew's humor is concerned solely with satire; he does not laugh at things, but always at people. That is to say, he finds funny not what occurs by chance, such as a stout man's tumble on the ice, but what has taken place by human will, and the involvements therefrom, such as, say, a gentile posing as a Jew. This temper stems first from the Jews themselves having suffered too much from chance to find comedy in the fortuitous, and, second, from their great reverence for the given, the inanimate, the timeless. One might almost say the Jew would see the ice mocked by the stout man's hindquarters.\n\n\"I felt a rush of loathing at that moment, as one about to vomit feels the bile-bitter fluid rise in his throat, and not at the Jews, but at myself. For a moment I had seen in those mirrors of degradation that dreadful, abominable specter that no one can face with composure: my naked self. But I choked it down and took my seat, for the deepest self-knowledge bears with it the deepest cowardice. The impulse to action was to come almost an hour later. The conversation had continued in the same silly direction the newcomer had indicated: tastes in wine, the beasts at the Zoo, a job a friend had lately got on one of the Ullstein papers\u2014 _B.Z. am Mittag,_ I believe\u2014and so on. Finally, the group began, only half-seriously, to plan an outing in the next week. Half-seriously, I say, because we were all unemployed, and could not have raised the money for the elaborate refreshments listed as the minimum fare. 'Where shall we go?' cried Schwartz. Someone named a favorite section of the Grunewald. The eternal dupe, I had been swept up again into the warmth of the fraternity, and was adding my bit. I noted with good humor that we should avoid the spot named, because on a recent Sunday stroll I had marked that it was uncomfortably crowded.\n\n\" 'Yes,' said the young Trotsky, 'too many Jews.' I think now that he was merely passing a harmless, if masochistic jest, as Jews often do, but, then, it struck the spot that had been worked raw by the earlier incident. I broke down and wept. God, there is nothing more terrible than a young man's sorrow! But not even that will move a Jew! I sprang to my feet. 'Yes,' I sobbed, 'just as here,' and fled from the caf\u00e9. From that moment on, the battle was joined.\n\n\"I had been a fool, but my greater folly was yet to come. I fell prey to the subtlest device of this devil, and joined the ranks of his greatest ally, the National Socialist Party.\n\n\"To war on decency, love, truth, freedom, is to permit the Jew to mask himself with the Good, and thus to embrace him. Through our aid, the Jew was able to achieve what in all the anguished millenia before he was not. Si _monumentum requiris, circumspice!_ We weeded out his weaklings, while increasing his moral capital with every one we destroyed. We hardened him with our tortures. _We_ tempered him, refined him in our fires, _we_ polished him down to the indestructible core. Today you can see the results of our craftsmanship: he is pure hard diamond, and his radiant leer sparkles in triumph over his fallen forge-slave.\"\n\nIn conclusion Bach reached over and dropped his hand on Reinhart's knee with a startling weight. Startling because when he had held it earlier in greeting, it was light, and since it was clammy as well, reminiscent of a damp sponge. Now it hit with a _plop_ like a waterlogged sponge, and, sure enough, when Reinhart looked down he saw a faint wet stain melting the crease from his trouser-knee. This oddity was as full of liquid, it occurred to Reinhart, who remembered both the tears of gratitude at the cigarettes and the weeping in the story, as a cheese is full of \"whey\" in all the best fairy tales. As the first occasion on which he had come across anyone whose hands genuinely dripped with perspiration, it was worthy of cataloguing. Then too, in this damp cellar nothing dried. His own sweat, while not as plentiful as Bach's, sheathed him like a trout's mucous envelope. A strip of stagnant water lined the base of the wall; the concrete blocks above had sieved out a patina of mineral salts.\n\nBach's rhetoric had made poor Reinhart's head reel, from amusement through indignation to logical vertigo. He repeated the process, this time at greater cost, that he had undergone in Philosophy 100, where the splendid promise of the fall catalogue\u2014\"The major traditions of European thought\"\u2014was blighted by the inevitable petty-Machiavelli of a lecturer with his _cul-de-sacs:_ \"Epimenides, a Cretan, said all Cretans are liars. Was he telling the truth?\" And even if he understood, he was lost, and guilty, guilty.\n\nAt last, in desperation, he said: \"Just let me get hold of this. You want to kill the Jews with kindness?\"\n\nBach made his giggle, and the hairs rose on Reinhart's neck.\n\n\"Leave it to the American to put things without equivocation!\"\n\nReinhart took his advantage to steer into the congenial area of behaviorism. \"But all this is in terms of _feelings_ and _ideas._ What exactly did you _do,_ as a Nazi?\"\n\nBach withdrew the sponge to his own knee, his eyes bagging in disappointment.\n\n\"I should have thought the intellectual history to be the more valuable. Well, then, if you insist, I can produce a few crumbs of physical activity. Humiliating, but perhaps useful as an index to the nightmare from which it took me so long to awaken.\n\n\"I joined the Party in November, 1938. I shan't dwell on the scruples the conquering of which took me an entire decade from the aforementioned events. I placed the button under my lapel a few days before the celebrated _Kristallnacht_ when, in retaliation for the murder by the Polish Jew Grynszpan of an attach\u00e9 at the German Embassy in Paris, the Nazis instituted an action against Jews and Jewish property throughout the Reich. It may sound queer to you that I participated in some of the raids in Berlin. Yes, I the aesthete! My request for a role was most suspiciously received, the storm troops being constituted of the most ungodly scum you can imagine, whose motivation was not a holy passion against Jews but a simple nihilistic lust for destruction. However, a fanatical eye is an effective persuader. I managed to win a position on one of the flying squads that swooped on the Jewish shops in the Kurf\u00fcrstendamm. You cannot understand, nor can I describe the exultation with which I plied my axe, even astonishing the thugs whom I accompanied, so that by the end of the night there was a tacit agreement among these canaille that I was their leader.\n\n\"In a china shop, where we had done a job worthy of your proverbial wild bull and were ready to depart, one of my companions came upon a hidden safe, buried in the rear wall. We had to send out for explosives to open it, it being impervious to the pick, and I was all for abandoning the project for better work elsewhere. But the cupidity of these swine was aroused; they were convinced the Jew had cached his treasure there. The door was eventually burst, revealing an empty chamber save for a single object, a small vase, which on examination I determined to be a piece of thirty-pfennig trash from Woolworth's.\n\n\"Now why the Jew would have placed such a thing in his vault I could not at first explain, and, indeed, was about to pitch it aside, when the thought struck me that the scoundrel had got intelligence of the raid, and, lacking anything better, had employed this means of retaliation, with a sense that Nazis of the common stripe would be certain to think it valuable and demonstrate their idiocy by confiscating it unbroken. A very deep joke, typically Jewish. But I knew, with the penultimate hatred which is, as I now know, stupidity, but which then seemed wisdom, that at last I had in my hands an instrument to enable me to top the Jew at his own game. I led my men in another diligent round of razing. When we had done, the showcases were flinders, the walls demolished to the lath, the woodwork a pile of faggots for the stove, the wiring ripped out\u2014in short, a reduction that could have qualified us journeymen house-wreckers. A tiny table was spared, and placed in the center of the room. On it, I centered the vase, filled to the rim with my ordure.\"\n\nFor all the foliage, thought Reinhart, he is a clown at the core. \"That was sort of childish, wasn't it?\"\n\nBach could not be conned. \"No, with gratitude, if you mean 'and therefore not responsible.' \" And, not seeing Reinhart's grin grow dim, he struggled to his feet without assistance; swaying over him, face contorted, arms rising and falling like a crazy windmill, he screamed in the voice of his giggle, piercing, forceful, but not loud: _\"Oh no, no. Can't you understand? In Auschwitz we of the SS could kill two thousand head in half an hour, but it was burning the bodies that took time.\"_\n\nHe produced a cavernous belch that shook him to the fundament, and toppled backwards, ever so slowly, onto the couch, which recoiled to the floor and recovered. Massively he slept.\n\nLori, too, slept in the chair, but the absence of sound as Reinhart rose and prepared to creep away, awakened her.\n\n\"No, are you leaving?\"\n\nReinhart pointed to the sofa.\n\n\"He is spent, poor man!\"\n\nAt the purity of her look, Reinhart seized her bony shoulders and shook them violently as he might have washed his overcoat with air. When he had exhausted the brutality of his violated virtue and summarized Bach's dissertation, she tossed back her head and laughed extravagantly.\n\n\"Bach in the SS! Pardon my rudeness. Perhaps one must be German to see the joke. The SS had most severe physical requirements.\"\n\n\"Why would he tell such a story?\" asked Reinhart, aloud but to himself, as the chair again received his mass. \"If he concocts this out of the thin air the man is surely mad.\"\n\n\"No, he is not insane. The minds of the insane run in straight lines, not always Euclidean, but always straight. The job there is to find the geometrical system by which to measure them. Here, if you insist, we have something eccentric, twisted but normal. In fact,\" she added, \"normal is twisted.\"\n\n\"But why evil?\" he wailed. \"When people lie they make themselves better, not worse.\"\n\n\"No, you foolish boy!\" She thrust her face up at him. \"No, they first make themselves something, whether good or bad, but something. A man cannot live without a function. Can you understand that, you _American_?\"\n\nHe had never in all his life heard the national adjective pronounced with contempt. _Amerikaner:_ he loathed it for a moment himself, but there was yet one more hateful.\n\n\"You _German_!\" he ranted. \"Can you understand this: I am ashamed to be of German descent! It makes me sick to my stomach. I might lie to make myself worse, as you say, but not to claim I hurt defenseless people. You once asked about my relatives\u2014I hope they were killed in the bombing! And if they weren't, they are dead anyway in their souls. Do you know what you did when you murdered the Jews? You committed suicide, all of you!\" Of course, no sooner was it out than he realized he echoed Bach to the letter, and was ashamed.\n\n\"Don't talk of things you cannot understand.\" She turned her back.\n\nHe reclaimed from the table the pack of cigarettes he had given Bach and made for the door. Lori pursued him. In the dank passageway, in the pale light that reached there from the lamps within, they grappled, she shrilling: \"I must make you understand about Bach. It is simply an overactive anterior pituitary. Not only does this outlaw of a gland produce great size, but it also eliminates the sexual urge!\"\n\n\"I don't care, I don't care.\" Saying which again and again, he nevertheless permitted her to pull him back inside. He knew now of his own impotence: his great moral address had been delivered, every word, in English.\n\nLori drew him to the chair and notwithstanding their differences in size, literally knocked him into it, all that was necessary being one good push in the midsection.\n\n\"Now,\" she cried, standing militantly before him. \"It was you who insisted on coming here. You forced me to bring you against my will. Therefore you will stay until I finish. Bach has done as much for me as one human being can do for another. He has saved my life, my very life!, every single day for three years.\"\n\n\"You were anti-Nazi?\" asked Reinhart in rapturous awe, but she paid him no mind.\n\n\"And it involved more than simply not turning me in to the Gestapo\u2014you perhaps think in your na\u00efve way that that much could be expected of a husband; you have not lived in Germany\u2014and more than concealing me, too, although that at the daily risk of his own life.\"\n\nBeneath the vast, important feelings Reinhart had a little tickle of pride, no less important, at her ceasing to speak so as to favor his imperfect knowledge of the tongue. She spoke swiftly and with the full resources of idiom and construction, and he did not miss a word.\n\n\"The long story of his art collection is pitifully short. He sold it, piece by piece, to pay for day by day of my life.\"\n\n\"The Gestapo then could be bribed.\" The idea made that dread agency less terrible.\n\n\"The money went elsewhere. Who got it does not matter.\"\n\n\"Excuse me, I am so stupid, foolish as you say\u2014if you don't wish to answer you don't have to. Why, when he has this to tell, does Bach pretend to be the reverse?\"\n\n\"Because the meaningful things are never said. Because he is infected with the Berliner's disease, irony and gallows-humor. Because\u2014\" She moved intensely near, and he was afraid she might call him _American_ again, with all that scorn. \"No, _I_ shall not lie to you. ... Because the time when he could do something for me has now passed.\"\n\nHe found that, idiotically, he had replaced the wretched cigarettes on the table.\n\n\"I came here tonight to take pity on you,\" he said. \"I have to ask it instead for myself. Believe me, it is not easy to be a fool. You have to work hard at it.\" He went again to the door, this time unaccompanied, from which distance he looked long at her minor, crumpled figure, and said: \"You are a Jew.\"\n\nBach groaned lightly in his sleep while Lori with careful hands arranged a quilt on his recumbent hulk. Then, extinguishing all the lamps but the one on the central table, she came once more to Reinhart.\n\n\"That saves me, _nicht wahr_? That one-half Jewishness, that mongrel portion which so short a time ago condemned me, is now my salvation. And enlightened people no longer believe in miracles! Yet within oneself, one is always just a person. Even Hitler. Do you know, his favorite meal was corn-on-the-cob and jelly omelet. Think of that: there were moments when his sole concern was to retain a bit of slippery jam on a fork.\"\n\nHe opened the door and stared forlornly into the gloomy passage.\n\n\"Shall I light you out?\"\n\n\"No thanks. I'll try to manage that much on my own. May I come again?\"\n\nBriefly she was against him, her small head in the hollow of his rib cage.\n\n\"You are a fool, a good fool, a kind fool.\"\n\nShe gave his hand the short, one-shot European shake and said no more as he began the tortuous ascent to the mid-world.\n\n# _CHAPTER 11_\n\nONE HAD HIS CHOICE in the officers' liquor ration, but one could not command what was not available. The fifth of gin represented an impressive trial of even Captain St. George's noted patience, not to mention the vermouth.\n\n\"Eleven months, Nate, it took me to assemble the ingredients of a martini, with the olives still to come. And the funny part is that I never eat the olives. Still, a drink looks naked without it, and I think, don't you, that an olive adds a certain essential something. And the ice! There's something, where can a fellow get ice in this stricken city?\"\n\nNo, pickled onions would never do, and although the fashion was passing to lemon peel, St. George had read, he held with the olive.\n\n\"Besides, the question is academic: I haven't seen pearl onions or lemons, either.\"\n\nThe captain was therapeutic, a plump, well-padded bandage. Why the medics did not use him as resident healer in some recuperation camp was beyond Schild's reason.\n\nSunset in the back yard with St. George, an awful thought as recent as two weeks ago, now was Schild's hope. He had fallen into an attendance on the captain's problems as one tormented by the rash might lower himself into a pool of warm oil and, comforted, in debt to the oil, so to speak, take up its study. A new approach for Schild, who hitherto might instead have gone into dermatology. But he had at once lost his strength, not by a slow erosion but at once, as if someone had opened a valve.\n\nLast night, undoing his tie before the mirror\u2014an atypical incident; Schild was so little concerned with his appearance that he rarely stood before the glass to put on his necktie, let alone remove it\u2014standing, then, at the dresser, the room's interior precisely reversed from the real, he was overcome by a quick delight, like some small-flat resident with his persistent discovery in dreams of a door behind the bookshelf that opens into another room no one knew about. Admiring the new figure in the wallpaper, all the fresh textures, the dimensions not yet contemptible by use, his eye swept to Lichenko and arrest. He had not, in the farthest reach of the new landscape, forgotten his guest; indeed, deliberately he had sought him out, as if, since the mirror worked a comprehensive reversal, it would also reverse Lichenko; as if from a novel aspect he would be seen again as he had entered Schild's affairs, the subsequent devious patterns now revealed as a foible of the stale vision.\n\nInstead, on Lichenko's face reigned a supreme and splendid peace, a glutton's on arising from the board, a sadist's on hanging up his whip, a drunkard's on counting his corks. He looked not at all at Schild but into the obesity of the featherbed that collapsed and reasserted itself under his experimental hand as if in breathing. His own serene breaths followed suit. He had got heavier in fourteen days, a fact that his reversed image stated with a kind of hostile assurance not apparent right side front. The German woman did up his clothes: his blouse a thing of smooth planes, his boots another mirror, the trouser crease a lethal edge. His eyes hung heavy, as if he could not bear the weight of the lids. Give him six months and he would be a little fat man, a fat little tradesman, retaining his cheek-furrows but in the discontent of prosperity. The fact was that an agent provocateur satisfied, however that surfeit sat upon his features, was an agent whose mission went well. To watch him was like looking into the mouth of a clogged toilet.\n\nThe violence remained in the glass, as, turning away, he began to measure his position, he, Schild, the man of limited ambitions, commonplace talents, one who served, a rational man, mistaken now by who knew what compound of humanity and history and place for the reverse of these qualities; for although he may have been guilty it was not of the transgression for which he was now under surveillance, could not be, for it was precisely his crime that he was incapable of a crime, and unfortunately no secret police or central committee was yet in search of that kind of deviation.\n\nAs a boy he had developed a feat of controlled consciousness, a triumph over what was initially a disability, almost, he had feared at the time, a madness. Under duress of his parents, who were tyrants for the communal life\u2014at least in theory, at least for the children; when it came to themselves it was another thing: \"when you grow up you got to work don't forget it\"\u2014 expelled from home, he had gone with a children's group, Jewish, always and forever Jewish, to Coney Island for \"fun\"; always and again \"fun,\" a separate and distinct endeavor from one's other pursuits, to be sought only by congress with, in this case, a million other organisms who had not forgotten to leave behind their flesh and sweat glands. Despite the sun's inability to plumb the floor of this forest of skin where he lay, he had, impossibly, got a bad burn. He did not tan and therefore unless forced avoided the sun; once in it by necessity, however, he tested that familiar theory that stern resolution overcomes all, arriving at the invariable and, for one with dark hair and eyes, peculiarly shameful rebuttal of scorched hide. The end of this day found the flames mounting to his head; he was lost for an hour and when found was sick enough to warrant being taken all the way to Manhattan in a taxi\u2014for which when he was well he heard \"somebody had to pay guess who?\"\u2014and, home, was in a half-delirium for three days while his pelt grew leprous.\n\nOnly half a delirium, because he knew what he was about and didn't, simultaneously; or did but suspected he shouldn't; feeling so queer in the head one hadn't the right, so to speak, to be on the same terms with reality as other people. Lying on the sofa whose brown plush marked with patches of psoriasis the points of humanity too often stated\u2014head, hips, and heels\u2014watching his mother drop the wooden egg into the stocking toe, beneath the bridge lamp whose transverse member had long ago been separated from its upright by nervous readjustments and now bore its oiled-paper shade on the frayed cord alone, he felt a dread that she might not look up on schedule and carp. People don't read on the flat of their backs holding the book over them like a sunshade, it blinds them at twenty. He yearned to receive the admonition that in normal times would have driven him out to the library and its public privacy; now to assure himself of actuality, it was a value from the past that he would have given even his assent to establish. His sister, in bed fifteen minutes, failed once to call for water; for once his father, who rarely left the house after dark, was out for cigars, which he rarely smoked. Across the airshaft from the kitchen, the Kaminskys were anaesthetized, for the first time in history they forbore to exchange insults in heavy Polish accents.\n\nIn his three days of partial coma Schild learned what his twelve years of comparative clarity had not laid clear: in the degree of one's need, one's companions and surroundings become negative, fail to comply. One seizes the bathroom in a quiet hour and instantly sets a fashion for the others, who appear at the door in force; one goes to the movies on Monday night and cannot win a seat from the horde of people who will miss work next morning to perform this natural service of denial; one is hungriest the evening the rest of the family, ill, dine on rye and cream cheese and admire each other's lack of appetite. These schemes are seen with the semiconsciousness as colors are more vivid and distances overcome with squinted eyes. In health, we are tormented by reality's presence; sick, by its loss.\n\nWhen well, Schild commanded this partial coma as it had in illness mastered him, for when the prisoner holds the key, a cell changes from a proscription to a defense of liberty. It later became his obsession that experience in the large could be controlled\u2014nay, must be, which had no regard for could\u2014the alternative was fascism. But experience in the small, in the disparate grooves where the larger powers, so to speak, lacked elbow room, what could not be ordered could at least be converted.\n\nIn the present circumstance, Schild looked at Schild from a distance, finding him not small but different, as if in dramatic irony he knew something that his double did not. One Schild was doomed; the other could stand here invisible and invulnerable, if necessary watch from asylum the first go to the noose.\n\nSchatzi had not appeared in ages. Schild had made two fruitless trips to Wannsee on consecutive nights; on the third he had posted a note on a tree in the Fasanenstrasse, in Wilmersdorf, used as a bulletin board by bombed-out persons seeking their families. This schedule, to be put into effect in case of emergency, had been ready for use since his first engagement with Schatzi. The note read: \"Seek whereabouts of Oskar Reichel, formerly of Ludwigkirchstrasse 32. His wife is alive and well. Apply Bauer, Weddingweg 8, Lichterfelde.\"\n\nIn theory, contact having been broken, Schatzi was thus directed to come to Schild, at the former's discretion. In practice, he did not: clearly, because Schild had all at once acquired a bad odor. That Schatzi had himself fallen afoul of one power or another was unlikely, if not impossible; further, it could not be imagined. If for no other reason, fate would keep him free to taunt Schild, whatever the extremity.\n\nSchild felt comfortably like a corpse, with Captain St. George droning on as sole mourner at the wake. The evening lurked in the population of leaves overhead, pandering for nightfall, which in Berlin appeared later than elsewhere and then only after extensive preliminaries, leaving early: at half-past three you could read your watch without a flashlight. St. George's cigar-end periodically bloomed with fire, drooled a thin bouquet. His voice, deficient in resonance, permitted the transmission of noises from small live things rustling in the bush.\n\n\"Even the lizards, or whatever that is, are going, as our British friends say, to Bedfordshire. That's my idea, too. I am so [yawn] sleepy. Must be the [yawn] air. Goo [yawn] night.\"\n\nThe captain rose and snapped-to his folding camp stool, tonight with satisfaction. He liked smooth-snapping things, as being both easy and smart; but his taste was often impeded by the stool, for which he frequently cursed Aberfitch & Crombie: the extra ten dollars they added to every item had no justification when things stuck.\n\nSchild sorely wished him to stay, should have liked to make the brief sound which would have accomplished that, for it was no great or difficult feat to convince St. George his presence was wanted. Yet he could not, as it were, solemnize his conversion to the invertebrate. Assuming Schild was asleep or, more likely, forgetting him simultaneously with his decision to retire, the captain stumbled into the rear door of the house.\n\nThe night chill found Schild's marrow. A bulky insect dropped into the hair of his forearm and was entangled to frenzy. Fool that it was, it interpreted his humane efforts as malicious and died shortly of its false assumption. He sat alone within the limitations of the fence; a small yard, smaller still without St. George; a corral with like squares on either side, extending on to the ends of the block: multiple petty-bourgeois cells. A creeper rose embraced the pickets. He once knew an Eagle Scout who was born and raised five stories above the sidewalk on 191st Street but could identify every plant within a ten-mile radius of the camp at Alpine, New Jersey.\n\nTheir landlady slept on two biscuit mattresses on the floor of the kitchen. The easiest thing in the world, if she had not been German, would be to walk right in and have her. If she had not been German, however, it would not be the easiest thing. He fancied his contempt had some sexual attraction for her. The angles of her face sharpened as he passed, and he sensed furtive movements behind doors when St. George was out of the house. But he had already had his gentile, and of the classic kind, complete with rabbit nose, soap-and-water cheeks, and anti-Semitic Daddy and Mother, and he had no strong sadism even towards Germans.\n\nHe turned his slat chair, property of the house, squealing rustfully in the joints, so that he could not see the kitchen window. A dog whined in the distance; a Southerner or a Negro, passing on the sidewalk out front, described to a mute companion a succession of events that were invariably _mothafuhn;_ the faint odor of pine, which was everywhere at night in the western quarter of Berlin, was superseded by the sudden smell of candy, moreover, a precise candy: Mary Janes, nut-flavored, tallowlike caramel on the outside, peanut butter in the center. Mrs. Grossman gave you one less for a penny than her competitors; Milton, when she took ten minutes off for raspberry soda and plain cake, gave one more. Amazing so shrewd a woman never knew this for fifteen years. It was after Milton had been killed in Spain that she received this knowledge, along with the other things that had to be said, fat and old and bitter, knotting a cord end from the drawer of saved string. \"Better they were poison!\" Although she should have known that her son was his master, and not vice versa. A boy, buying some candy, slipped a nickel underneath a newspaper on the counter, for it was Sabbath and Mrs. Grossman would not touch money until the sun had set. \"Go read your books!\" she shouted to Schild in Yiddish, the language, it struck him suddenly, for many things but, above all, humor; he could feel nothing beyond a terrible impulse to laugh and a sense of how terrible was his impulse. In the doorway, he bumped into the boy, who had been delayed a moment, stripping the wrapper from his bit of sweet; it was a Mary Jane. Schild's teeth clogged in empathy, he could almost taste the peanut butter, it had always been very like putty.\n\nAll this in the second before he knew, like a bat, that a human being stood in the darkness behind his chair. He sat easy, who else could it be but Schatzi?\n\n\"And here we have Herr Schild, _zu Hause_ like any merchant.\"\n\nWhere had he been? was an obvious question, but could not be asked. Schatzi made succulent sounds over his candy, offering some to Schild which when taken was a disappointment not living up to its odor: so much for the memory. He was called back to the present; the atmosphere was less charged at once. There sat Schatzi, renewing the link. He had been a fool to concoct an elaborate, sinister design from meaningless coincidence, for it was through Schatzi that his line of authority led. How could a simple lieutenant in the Red Army be concerned? One must face it that Lichenko was even rather pitiful. It was no disrespect, it took nothing from his honor, was no adverse implication on the triumph of the society that had given him his chance for manliness and heroism, that Lichenko was\u2014he almost thought, was no Milton Grossman; but Lichenko, too, had charged the fascist guns.\n\n\"I suppose you wonder where have I been,\" said Schatzi, careful to keep it low. It was so dark now that he was seen as black on black, improbable but not impossible, which could not have been more appropriate to him. His voice, his rustlings, the thump of his butt-bones to the ground\u2014all expressed an unusual geniality. In his own way, he apparently felt it good to see Schild again. He refused an offer of the chair, although it must have been uncomfortable for an ill man to sit on the cold earth.\n\n\"I saw your note some days ago; although, I was otherwise preoccupied... no, really, I am just pleased, stay where you are sitting. The ground is not unpleasant. Beneath the grass you know is sand, it does not hold the water. Berlin is one single great island of sand on the Brandenburg plain, yet it permits a lush growth of plant life, no? In spite of its architecture, Berlin is a beautiful city, but so few foreigners know it and that is sorrowful.\"\n\nSchild assumed the cynicism of his answer would be _de rigueur:_ \"There is little left to see now.\"\n\n\"So much the worse for all,\" said Schatzi, not shouting but giving the illusion he was and with the kind of conviction that Schild recognized as having originated in higher chancelleries than either of them would ever subordinate. \"It was senseless of the Americans to destroy the city. The most unfortunate way to win the German people away from fascism.\"\n\nLichenko had assured Schild that Russian artillery, particularly that multibarreled weapon known by the Germans as Stalin's Organ, had leveled more of Berlin than the Eighth and Royal Air Forces together, and he had agreed then as he did now, yet neither time in hypocrisy.\n\nSchatzi, making liquid, furry, catlike noises, swabbed his gums with his tongue, and then went with the keen tip of his smallest finger for a molar in the recalcitrant love of caramel. Actually he could not be seen with such precision: his ring flashed in transit, his cuff rustled, and Schild supplied the other details from memory.\n\n\"Not to speak of reconstruction,\" continued Schatzi. \"The Soviet Union has been given the most horrible section of the city.\" To go any farther would be to imply that Stalin had been hoodwinked by Churchill and Roosevelt. Indeed, he had already gone too far. \"You must indulge me in my English. Certainly I did not intend to say 'horrible' except in regard to the bombing there. It is, on one's other hand, the sector most worth for rehabilitation.\"\n\nThey had from the first always spoken English together, although Schild had often sought to turn to German, partly from a masochistic pride in his fluency\u2014and partly from the vicarious nostalgia in which he looked back on the time before his majority: the tongue of the old International had been German. But Schatzi had resisted, not so much from a pride of his own, Schild thought, as from his sixth sense for conspiracy, which told him that obscurity had as great a role as precision in underground technique. In one's second language, facts are never finally established; when blame must be cast, it can thus fall on the vocabulary and not the man, or if the man, then first on him who by birth qualifies for absolute comprehension. There is at any rate a possibility for such miscarriage, and the professional asks for no more, from his own side or the foe.\n\nExploiting, to himself, his ambivalent pleasure with the present confirmation of the hypothesis, he received another notice\u2014as he often did and as often was unarmed against, for it was his constant failure that though he had the imagination of disaster, he had not the mind. His suspicions rose the faster for his inability to believe in them. Not only had Schatzi never before transmitted the \"line\"; he had never been so generally obliging. His manner asked for forbearance, as if, getting that, he would go on to request ten dollars, repayable on demand. He was not, for once, in haste: he had never before sat at an interview; he had never before come to Schild's billet; _he had never before been pleasant._\n\nHe continued to be, despite his theme, which was the occasion for neither grace nor evil but the neutrality of fact. And the first fact laid in Schild's head by Schatzi multiplied within the minute; in the same minute that his heart multiplied its reasons for foreboding, his reason produced offspring, like some woman in Asia, or what-have-you _mise-en-sc\u00e8ne_ for the current classic instance of futile misery, who continues to reproduce like a mink notwithstanding the famine.\n\n\"In the Western zones,\" Schild said, \"all the ex-Nazis are getting jobs with the Military Government.\"\n\nThis cut off Schatzi for a moment of aggrieved silence. Now Schild had perhaps gone too far. His question was put in a voice that suggested this was the first time he had ever been brought to this turn of the road, one nearer the hairpin than was comfortable, and unless Schild could produce Automobile Association sanction he would drag his feet.\n\nThe sudden caution, standard operating procedure for anyone else to be met in Schild's professional circles, was unusual for Schatzi, a piece with the rest of his tonight unique demeanor. But that this was the norm and Schatzi's usual manner the oddity, had no force, for the ordinary Schatzi, who was extraordinary, was precisely what Schild had been prepared to meet in Europe. He had hated him, true, and he had just now begun to like him, but these nervous reactions were beside the point that Schatzi had been absolutely authentic.\n\nOr perhaps so directly to the point that they were invisible, integrated in the drama of hatred and fear and fascination of which Schatzi was a walking pr\u00e9cis. Whatever his temporary odors, to Schild he stank of the concentration camp; he had acquired there a beastliness which but for the final morality could not be separated from that of his captors. Hideous to think so; but only moral realism to know that the difference between saint and devil was frequently never revealed until the last judgment.\n\n\"By the way,\" Schild said at last, when Schatzi's moment of silence had lengthened into an evident volition not to speak at all, \"I saw the 'big lout' and have begun to go through the papers from his office. Only the top two or three cartons have Winterhilfe files. The rest is material from the Bund Deutscher M\u00e4del.\"\n\n\"A female division of the Hitler Youth.\"\n\n\"Yes, I know that.\" Schild was as usual irritated at being told what he already knew. \"At any rate, I have filtered out some things for you.\"\n\nNo answer. The sounds of Schatzi's breathing became quickly like the aspiration of a rubber pillow crushed by a thigh, and died. The crickets sang madly below the fence\u2014or wherever; if you went there to find them, they would instead be at the place you had left, and back there again only to hear their song in the bush. Behind Schild, a casement had its fastenings undone, its halves slithering open in slow provocation, followed swiftly by a broad drift of light that created a visible Schatzi but did not animate him. He wore bicycle cuff-guards resembling money clips. His shoes were swarthy, pebble-grained, and had long Italian points. The sole of one, showing a medallion of chewing gum in the arch, hung directly before Schild; danced to a rhythm that owed more to emaciation and senility than tacit music; the leg within its frayed sheath of woolen underwear was surely bare tibia and fibula and a snarl of ancient sinews. Long underwear in the middle of summer: for his pants cuff had ridden high, one bicycle clip, being sprung, failing; and he lay on his back in the grass, with one leg arched high, the other looped over it. Had he suffered a seizure? Schild rose to see beyond the bridge of legs, saw Schatzi's eyes wide open, bland and insensitive as two bottle caps, paralytic. Dread had just put down his immediate, instinctive disbelief, he had just received the full import of the underwear shroud, when Schatzi belched like a cannon and with a sudden effort of overbearing vitality raised to the sitting position.\n\n\"Queer person who lives in your quarters,\" he said.\n\nSchild turned expecting that the German woman, _d\u00e9shabill\u00e9,_ could be seen framed in the window\u2014not in concupiscence of his own but in amused anticipation of Schatzi's; he was captivated by the sudden transition from imagined death to carnality. Instead he saw Lichenko, in undress rightly enough, but Lichenko! Who, bent at the waist, lips funneled and eyes squinted in bestial ill humor, swung one arm apelike. He was naked. The other arm crooked in menace. In his paw was, again, Schild's .45.\n\nIn the haste to the door Schild yet had attention for the nimble Schatzi, who had sprung up beside him and maintained the pace at his elbow. He saw in his courier's action that which relieved his greater worry: would Schatzi, knowing of Lichenko, show the innocent curiosity of a boy chasing a ladder wagon?\n\nThey symbolically broke into the kitchen, for its door was open and only the oppressive light of the interior barred entry. The German woman lay stiff and still on her mattress in the corner, frozen in contempt, not fear, her handsome face fierce, free, and remote as an eagle's. She had, it was clear, cowed Lichenko with no more than her moral advantage.\n\nLichenko had jumped behind a high cabinet at the first sound of intrusion, where he thrust the pistol, or sought to thrust it, into the space between cabinet and wall. He was apprehended before this was managed. But, as if in that brief moment with himself he had taken a realistic account of his project's miscarriage, seen it, that is, as a mere limited venture gone awry with no permanent blot on the amour propre, he met Schild straight on, handing him the pistol butt-first\u2014to show, by its empty slot, that it was not loaded\u2014and offering his guileless face, open and unafraid.\n\nWas he drunk again? Schild had taken care to keep whiskey from his own room and Lichenko without direction had set a personal off-limits on St. George's quarters; he had in fact developed an unusual delicacy towards the house in general, which Schild found more difficult to excuse than the expected barbarism. Yet here was the return of the barbaric, and he, Schild, had run to brook it, in his reflexes one with the scared calves at Lovett's party.\n\nSchatzi, temporarily forgotten, spoke to the woman\u2014had been speaking to her and was now heard reacting to her consistent silence: _\"Keine Antwort is auch eine Antwort.\"_ No answer is also an answer: for what reason was she working with Schild?\n\nBut Lichenko was not drunk. He began to shiver from the cold and adjusted the cinch in the towel about his waist, for neither was he wholly nude. He was, indeed, suddenly nothing he had been, neither victim nor captor nor na\u00efve nor sinister, and as he prepared to speak from this new person, Schild struck him in the mouth. He had meant to knock him unconscious, so that Schatzi could not hear the Russian accent, but he had never before struck a person with this intent; he had never, since boyhood, struck any person for any reason, even comedy. He now punched too high and tore his third knuckle on Lichenko's teeth.\n\nIt had been as hard a blow as he could summon in cold blood, but with only the free-swinging arm and no body behind it, did no physical damage. Lichenko, however, was whipped, all the more for his initial show of dignity. He grasped again at his towel, grinned in coy brutishness, rolled his head like a fawning dog. And then he whined, in German, and all was lost: \"My friend, this whore tempted me!\"\n\nFrom the other corner Schatzi burst into his aspirant snigger, and an oxlike plodding at the door announced St. George, who, in maroon robe with white piping, slippers with elastic inserts, and pajamas a continuum of pale-blue hounds-teeth, after some deliberation had formulated his amiable comment.\n\n\"This looks like Grand Central Station!\"\n\nThe pistol in his right fist, Schild furiously cut its barrel into Lichenko's cheek and, as he went to the floor, followed him down, hacking him down, not ceasing his awful work until St. George, whose cries had gone unheeded, fell on him and stilled him with his bulk.\n\n# _CHAPTER 12_\n\n\"CAN'T FIND ANY LETTERS of Grandpa's you asked for\u2014stuff all cleaned out from under the porch to provide place for screens years ago,\" wrote Reinhart's father. \"Maybe you even did it yourself\u2014if you were paid for it. If my advice means anything, tho, I'd drop the idea\u2014your just asking for trouble\u2014as soon as you find any German relations they will want to borrow money from you... ,\" etc., typed on a V-mail blank, small as the Lord's Prayer engraved on the head of a pin.\n\nAsk a stupid man, get a stupid answer. When he told Trudchen about it\u2014for, despite her peculiarities, she was still around, still without pay, reporting to the office every morning long before he arrived\u2014she said: \"Ah, vy bozzuh! I will be your relative.\"\n\nThat was all he had told her. He did not seek to expose her pitiful lies; he let stand the assumption that she lived, orphaned, in the little back room in the office building, where indeed she did report at the end of each workday. Above all, he remained silent on the visit to Lori's. What he had learned there was for adults only, and he was not at all certain he could stand to think of it himself.\n\nHe at last understood that the complement to his long self-identification with Germanness had been a resolve never to know the German actuality. Knowledge had exhausted his options; he now had no choice but to seek out, if still they existed, his links to what, a brief half-century after Gottfried Reinhardt took ship for the New World, had disintegrated in murder and betrayal.\n\nHe had not really believed the witness of the Buchenwald photographs; mass exterminations were incredible. Real deaths were your friend Bill, one moment live, the next run down by a drunken driver; Al killed by pneumonia; Roy, his heart full of Jap metal, taking the Iwo Jima bastion and expiring a hero; or someone's brother, well known, electrocuted by the state for the crime of homicide, and his victim; these corpses were believable in sight and mind; despite the mortician's garish art, beyond the mystery of any death, were the concrete memories of impediments of speech, casts of eye, a rolling gait, a red Ford with a two-tone horn, and the only four-button suit in southern Ohio.\n\nSimilarly with the violet shadows under Lori's eyes. Whoever had sold her safety from incineration had seen them upon every payment, must have had the queer guts to imagine their transformation into white ash and his own agency in the burning. And the man who would have fired the oven, dressed in his black SS-suit, with his blond crown and his blue eyes, the model to which every boy aspires, the handsome soldier fearless before the enemy, gentle with women. ... These types were not explained by the simple, pious indignation of: two kinds of man, one good and one bad; we of course are the first; they, the second.\n\nNor by the lack of a democratic tradition: was this what men did when denied the vote? Nor militarism: you mean that the great Frederick mounted his stallion and rode down women and children and unarmed men, and that the old knights of N\u00fcrnberg swung their blades against little ghetto-tailors?\n\nReinhart had been reared in what he assumed to be (since everything else was) the German code; there are two kinds of cowards: one who will not fight a man his own size or larger, and one who will fight only someone weaker; sometimes, but by no means always, the same person. But the validity of this, too, was here outmoded, for the SS man, fresh from his ravages on the helpless, stood fast against the superior enemy; was, to be sure, the fiercest soldier met by the Allied troops.\n\nAs to the anonymous blackmailer, Reinhart insisted that his, too, was a strange, mad kind of courage, for beyond gentleness and humanitarianism and a deficiency of passion, what stays the normal man from murder or even its threat is fear, not of the godly or human law or vengeance or nightmares, but of the suggestion of his own mortality.\n\nHere all the known qualities of humanity had been united with their contradictions. This was what Bach dramatized in his monstrous monologue of truth in falsehood, that guilt could be confessed to only in a lie of the guiltless, that the first loss of the criminals had been in their human imaginations. Where Reinhart had looked in Germany for life, first in dreams of ancient glory and then, after the Nazis, for a vitality at least of evil, he saw only a horror of deadness, of which the literal corpses, the loose skins of Dachau, were but the minor part.\n\nYet more important than this moribund nation were the good people, those \"good Germans\" on whom the sanctimonious propaganda of Our Side did its work of slaughter, the mature ones like Bach who by conscious volition stayed decent and sought no fanfare for it now, and children like Trudchen who willy-nilly were clean. Were his relatives to be counted with them?\n\nEven in his duty of conscience, however, he was balked by the same ineptness which characterized his dealings in the humdrum; when fountain pens were hard to get, people like Marsala had pocketsful; similarly with liquor, broads, and passes; he, Reinhart, so damned special, one of the ought-ought per cent of the American population to go to college, a member of the owning and stable class, could manage nothing.\n\nIt was very well to say loosely, as Lori had, to go to the burgomaster's office. He tried just that, visited the town hall in Sch\u00f6neberg, which he was astonished to see employed as many bureaucratic flunkies as it were an American city untouched by war, who notwithstanding that he was Occupation showed much the same bored insolence and then when pressed claimed a search of the birth records back to 1850 turned up no Gottfried Reinhart. Of course, there was always the Russian Sector, which the eyeglassed clerk recommended snottily-reproachful, as if to say: that's what you get for dividing our city. There was what Reinhart would earlier have identified as certainly a Nazi; now he thought it more likely the man might turn out to be an unsung hero of the anti-Hitler opposition and this job his reward.\n\nHe got aid from an unconsidered quarter. Although when he had first revealed it to Trudchen his project left her cold, she greeted him one morning with sudden interest and suggestion.\n\n\"You must have a _dett_ -ek-tive! And I have just your person. The man who makes some work about here\u2014he with the scarred face. He is called\u2014so silly!\u2014Schatzi, that means 'sweetheart,' did you know? Do you know which I intend?\" She had her own table now, a jittery-jointed piece which swayed like a drunken spider when she assaulted the old Underwood. \"He is very active in the black market. This takes him everywhere and in consequence to that he knows everyone.\"\n\n\"Not the old man in the Wehrmacht cap?\"\n\nA regrettable concomitant of Trudchen's employment was false tint laid on thickly over her natural color, and Reinhart also bore the guilt of that. He had bought her lipstick and rouge from the PX, on her request for the \"raddest of the rad.\"\n\n\"Oh, he has worn it, yes, but also many other costumes. When he sells one thing, he attires himself in another.\"\n\n\"You don't mean that old man who works in Lovett's office?\"\n\n\"Not regularly. He makes much money on the black market\u2014why should he vorry?\"\n\nAnd he had thought the old fellow pitiful; it was a true instance of what one, disinclined to contribute, says of street cripples with their tin cups: they could probably buy and sell any of us poor working stiffs.\n\n\"I don't suppose he was a National Socialist?\" Reinhart could no longer use \"Nazi\"; with the passing of each German day the term became more like the name of a soap powder, some slick and vulgar \"Rinso\" invented by Americans, who eventually reduce everything to that level: \"Nazi,\" the cute name for a pack of buffoons, played always by the same actors, regularly thwarted by some clean-shaven Beverly Hills Boy Scout whom a ruptured eardrum disqualified from the real war.\n\nHowever, he was not wholly serious even in putting it the long way, since in this area Trudchen's unreliability was massive. Perhaps understandably, to her the history of modern times was a catalogue of her own losses and the responsible instrument, fate in general.\n\nShe lifted her little painted clown's-face, the freshness obscured by the rouge but the innocence still there, and said: \"Not he! He was a prisoner in a concentration camp.\"\n\nWhich was a flat lie\u2014although perhaps not hers but the old man's; the surviving martyrs of the camps were hardly thrown into menial jobs and black-marketeering.\n\n_\"Ausgezeichnet! Prima!_ Then he should be just the man to find _die Familie_ Reinhart,\" he said in an irony that she did not receive. \"Of course it isn't likely he'll find anybody. There's a separation of fifty years. Think of that, Trudchen, the last time I was German my father hadn't yet been born.\"\n\n\"Please?\"\n\nInstead of clarifying it, he fell to work with his pencil\u2014which was blunt and unpleasant to use; if she didn't soon return his pen he must come right out and ask her to\u2014on the long-delayed Guide to the Ruins for the sightseeing tour.\n\n> The Olympic Stadium, built for the Olympic Games in 1936, has a seating capacity\u2014\n\nOr was it more graceful to say \"seats\"? Or \"seats\" as a noun: \"stadium, etc., has 124,000 seats.\" \"Capacity\" of course had a more serious tone. This was one of those days when nothing sounded right, which unluckily had begun to outnumber those on which nothing sounded wrong.\n\n\"You do not wish to hire this man?\" asked Trudchen, starting to type the stencil for Page One, which, for Pound had decided on a grandiose project that would impress the colonel, was to stand as title sheet.\n\nHe had to grin. All European girls spoke with an animation at once funny and delightful, an excess of feminine vitality that juiced each word. If this held even in a sadness like Lori's, with Trudchen, who was never less than gay, who was young and unmarred and in a perpetual celebration of ripeness, it was the very model of unalloyed girlship; you never, as sometimes at Home, suspected that you confronted a transvestite boy.\n\n\"Ah,\" she went on, \"how hoppy you will make zem! In these timess to have an American cowsin!\"\n\nIn mock grimness he answered: _\"Our American Cowsin._ I hope for better luck. That's the name of the play Lincoln was watching when he was shot.\"\n\n\"By Chon Vil-kes Boat, yes?\" This in an eagerness which threw a tremble into her physical establishment. \"And the year, 1864, yes? The day I do not know.\"\n\n\"Don't ask me!\" He ambled to the French window to look on as perfect weather as the earth offered, the life-enhancing air of the Brandenburg plain, full of golden light and green smells. \"My family wasn't in the country at the time. They were here.\"\n\nCould Jews have been killed on such a day, or had they waited for rain?\n\nThe great pines stood high in the adjacent grove, and seeing down among their feet he recognized the steel-gray, crosshatched shadows from old German engravings, which were not artist's strategy but the true lay of the land. He could have watched without doubt a delegation of trolls emerge from some root-home and bear away the Nibelungs' lode, but impossible to the mind's eye were the long sallow lines of victims.\n\n\"This man, this good German, how can I get in touch?\"\n\nTrudchen giggled like a spring: \"Tahch\u2014this is very vivid and so clear that no explanation is needed\u2014baht he vill come here some time. I have taken the freedom to ask him that you might... vould... could\u2014oh well, that you want to see him.\"\n\nAlong with the cosmetics she wore a peek-a-boo white blouse disclosing an eyelet-margin slip and, beyond, the rim of a brassiere which carried larger burdens than formerly had hung upon her chest, and the pigtails no longer swung free but were entwined about her head in a yellow cocoon. In the aggregate, this was also a lie: that she was a mature girl.\n\n\"If he was in a camp, then he must be a Jew?\"\n\nAsking which he returned to his desk and fell into the chair with the noise of a beef haunch flung onto a butcher's block.\n\n\"Oh no!\" cried Trudchen with candid enthusiasm. \"You are incorrect when you think only Jews were mistreated. You do not know of the Resistance?\"\n\nSure, the plot to kill Hitler of 20 July 1944. This had already been exposed in his discussion groups as a conspiracy of reactionary generals, scarcely better than der F\u00fchrer himself, whose motives were suspect and results, a failure; and who were eleven years late.\n\nOf course there was that\u2014she took no notice of the negating conditions, perhaps because he lost his nerve while talking to her, who was blameless, and presented them weakly\u2014but what she meant was something of a greater scope and duration, embracing all of the non-Nazi population: a total rejection of Hitler and all of his works, dating back to 1933 and earlier. She as a German could tell him that, even though she took no interest in politics, being young and silly.\n\n\"And what did they do about it?\"\n\n\"Ah, what can anybody do against beasts who are ruthless? The SS and the Gestapo, their first job was to control Germans, not Jews.\"\n\nHe sat upright and brought down his fist upon the desk, not in anger but rather a kind of pleading.\n\n\"That is understood. But it is over now. National Socialism turned out to be nothing. You couldn't find one German today who would say a good word about it. Yet it was a _German_ thing, wasn't it? I don't mean the war, or the Axis, but what went on here: a horrible, dreadful thing that was completely new. Old Genghis Khan and Attila the Hun were saints alongside of this. The whole history of man is disgusting, I grant you, but why would the Germans try to set a new record? But no, I don't even want to ask that. God knows if I had been a German what I would have been. _But why can't someone at least say he is sorry_?\" He looked into space, for he had no wish or reason to make it personal.\n\nHe was an idiot to speak of this to Trudchen, and she was quite right to look calfly insensate and say: \"One cannot be sorry for what one has not done.\"\n\n\"You must pay me no attention,\" she went on, \"because I am not clever, but what I can see is that God makes people suffer.\" Her mouth and eyes went into round wonder, which made her, there behind the crazy lines of lopsided table and old typing machine, a complex of circles: head, eyes, glasses, mouth, breasts, hips. \"At eleven o'clock in the morning of 3 February, this year, I had the fortune to be in the Bayerischer Platz Underground station when your planes came over making a direct strike with an aerial mine that blew a thirty-feet hole out of the bottom of the tube. So suddenly I did not feel anysing, no wownd, and knew only what occurred when this baby in the arms of the vo-man in front of me, now, with the blast, on top of me, this baby stared down and tried to cry at me but instead of the cry this string of blood dripped quietly from its mouth. It was alive, but dead, also; both at the same time\u2014how can I explain this terrible sing that I mean! Your planes had come to kill Nazis, but the bombs cannot tell good from bad. A little chilt of eight months old, it had to suffer. Is it not the same way with God's vengeance for the murder of Jesus Christ?\"\n\nIt was wackily, harmlessly funny, as when the village crank says of the cyclone-torn bungalow: this is what they get for all that drinking. But she was growing into a big girl, and it was time to be set straight\u2014which no one had bothered to do for him when he was on that level.\n\n\"You don't\u2014\" he began, when Lieutenant Pound appeared in the doorway and Trudchen hurriedly flung back into her story.\n\n\"So when this blood began to descend upon me I reached towards my sleeve for the handkerchief but my hand could not go far, being halted by a soft, varm, cling-ging mass such as one's hair after washing it, and I thought: so I have lost an arm, how easier in the fact than in the worry. Limbs, limbs, I have always feared losing them most.\"\n\n\"Don't bullshit, Trudchen,\" said Pound, patiently genial, closing the door which was in his absence never closed, demonstrating his talent for violently hurling it to without its latching: he \"pulled\" it, as one does a punch in a false fight. \"You've got two bigfat white arms today.\"\n\nAlthough his monastery was now neat, this abbot had stayed slovenly; as he went briskly to his desk below the little window, his loose shoelaces clicked, his tie end flapped over his shoulder, his bowlegs like two lips endlessly yawned away from each other and gulped shut.\n\nPerhaps it was Pound's own experience in violence: he never believed anything she said. And by his example, Reinhart, too, invariably lost belief. Although, given her time and place, the tale had been credible enough at the outset, with the introduction of self it became fiction like all the others. She was, he had to face it, the most incredible liar he had ever met.\n\nWith a significant look at Pound, who was too bored to register it, Reinhart said: \"Go on, Trudchen. What happened then?\"\n\n\"Well, it was really an arm, but blown off from someone other and lodged between mine and my ripps, as if it were robbing my pocket.\" She placed a rolled-up stencil in the position described; buff backing to the outside, it was a painfully authentic replica.\n\nHer attention was now directed exclusively towards Pound, and Reinhart, in half-conscious jealousy, went to block her line of vision.\n\n\"You know what? You are a prevaricator!\"\n\nSilently, Trudchen unrolled the third arm in the enormous self-confidence the mythomaniac shares with the artist, while at the same time her round nose sharpened as if in death, as if for a moment she really tested that condition the truthful call life, and rounded again as quickly; she had been there before and did not like it.\n\n\"Stop pissing around with the kid,\" Pound ordered irritably. He was in a rare short mood, probably connected with the miscarriage of certain affairs of money, towards which these days he had developed an obsession. The black market had denuded him of watch, pen, pocket knife, cigarette case, lighter, ring, identification bracelet, all bedding but one blanket, all ties, shirts, drawers, undershirts, socks, and caps beyond one each, towels, writing paper, the leather frame of his wife's picture, and his musette bag. Three days earlier he had received by mail a new pipe and pouch: the latter had already metamorphosed into a paper envelope. Which he rustled in now, spilling much, but onto a page of _Yank,_ which when done he coned to funnel back the overflow, his narrow eyebrows shimmering ever upwards like heat waves fleeing a summer pavement.\n\n\"Haven't you finished that guidebook yet?\" he went on, with querulous twitchings. \"The colonel has a wild hair in his asshole ever since Lovett's Folly. He might put us on cleaning butt cans any minute.\"\n\nBecause he was properly a cigarette man, he smoked a pipe the wrong way, inhaling great mortifying draughts which after a time in his innards came back through every superior aperture, mouth, nose, ears, eyes, suggesting that his head was afire.\n\n\"I'll finish it today,\" Reinhart answered sullenly, not unmindful of Trudchen's spectacular show of industry; she socked so loudly at the typewriter you couldn't hear the clearing of your own throat. No sooner did a third person come than he felt odd man out; his maximum for rapport was one being at a time. Thus it was fine with Pound alone, or alone with Trudchen, but with three people he invariably sensed a conspiracy against him.\n\n\"Oh good,\" said Pound. \"If you are that close to the end, you can put the fucker aside for fifteen minutes and write me a letter to the wife. You know, this and that, etc., and I'm short on dough because we had to buy new winter uniforms this month.\"\n\n\" _You_ short on dough?\"\n\nPound made a sighing descent into his swivel chair. \"Come over here,\" he said confidentially. \"I don't know why I can't tell you, since you know all my other chicken-shit business. The thought of going back to that woman\u2014the one you write for me\u2014is more than I can stomach. You know, when I was wounded I made kind of an agreement with Fate that if I didn't die I would be somebody new. I never told this before to anybody in the service, but I used to be, before I was drafted, a bank teller for thirty-seven fifty a week, a creepy little rectum-kissing rabbit with two snot-nosed kids and a dog with some kinda skin rash that made his hair fall out in pink spots\u2014he also used to sit around on the rug in the evening and fart all the time\u2014and this woman, see. Well, she isn't the worst person in the world, but she is set on making a man a coward. She even wanted to scare me out of using a blowtorch to take off the old paint on the outside of the house\u2014which I was only doing cause who can afford those prick union painters and if you hire scabs the others will come by and bomb your house\u2014you'll start a fire, she said. And by Christ I went ahead and did it anyway, and you guessed it, it did start a fire that burned off one wall. I never missed Bob Hope's radio show on Tuesday nights for five years\u2014Professor Colonna: 'that's what I keep telling them down at the office'; Brenda and Cobina, and the rest of them. Think of that: 259 straight; once they were off because of a special news feature, something about that fucking shitbum Hitler. I tell you I was yellow as they come, but after basic they sent me to OCS where they thought that was just being cautious, I guess, a good quality for a officer. Well, we were pinned down along this hedge row in Normandy and I was dumping in my pants for fear, but still I noticed my top fly button was loose and I fastened it. And then I thought what a dirty little turd I was: with your ass about to be blown off and you button the barn door\u2014do you get the picture? I was more afraid of my dong showing than of the German 88s. So I thought all of a sudden: World, you got twenty-eight years from me, you can keep all the rest and stick them up your giggy, and I jumped up and went across there and took that Kraut platoon, and I don't mean to say I wasn't scared, but anyway for once there was a reason. Shit.\"\n\nHe had puffed so hard on his pipe that already its tobacco was exhausted and the air made noxious.\n\n\"You know what I made so far on the black market? Thirteen thousand, two hundred and twenty-two dollars, and it's all gone back to the States to a bank in L.A., California. That's where my nurse Anne Lightner is from, L.A., where they go in for the beach living. I'm going to get sprung from this woman as soon as I get home, and then I'm going out there and buy a used-car lot. That's the kind of thing they go big for out there, with all that beach living. Everybody drives a car, that's what Anne says.\"\n\nSo was another idea exploded. It was sad, in a way, that nobody, simply nobody was what he seemed. To Reinhart, Pound had been the classic type of swashbuckler. Now he saw the late bank-clerk lines of worry and doubt, faded but still visible, at the corners of mouth and eyes, and he even liked him better for them\u2014for daring has no unusual moral worth if you have lived with it from the cradle\u2014yet there was no discounting the loss of something rare.\n\n\"But I have to play it cool with Alice till I get back and can defend myself,\" said Pound, refilling his pipe. \"So write her nice. I don't have to tell you what to say, you have enough crap to snow anybody.\" This was admiringly put, with the quick wink he must have learned in his new life, but looking sharply Reinhart saw the hint of a quaver in it, as if, in at least the most minor part, there was still a tinge of bluff.\n\nAll the while Trudchen had been typing with fanatic energy\u2014faking madly, for the guidebook manuscript lay on Reinhart's desk.\n\nAs he passed her on the return route, a doorknock sounded, and notwithstanding his shouted \"Enter!\" she leaped up and teetered to the knob\u2014high heels, yet!\n\nIt was a soldier, for Pound. She made him wait while she proceeded to the lieutenant with a formal announcement, working her body in a queer movement which Reinhart first believed was an effort to balance on the high spikes and then recognized as an amateur version of a whore's undulations. Her breasts were hard metallic cones, yet she still wore the thin, little-girl's skirt ending an inch above the knees, and still the owlish, juvenile spectacles. Involuntarily he burst into a loud, barking laugh, which hideous though it was nobody but himself seemed to hear.\n\nLieutenant Schild's judgment had been correct, only a bit premature (as an Intelligence man, of course, he was expected to be one jump ahead of events); if she was not on her way to tartdom, then Reinhart was an orangutan.\n\n\"Dearest Alice,\" he scrawled on the yellow pad, taking in return a warm thrill of fancy that this unseen proxy wife was really his own, that he had entered her in the connubial bed and that she had borne him two small resemblances of himself, albeit snot-nosed.\n\nOn Pound's indifferent grunt Trudchen wobbled back to her table. Reinhart had also purchased the mascara which gave her an appearance of sore, fire-tinged eyes, but the high heels were from another protector, he now had no doubt.\n\nThe soldier had gone. In his stead, in the hall shadows beyond the half-open doorway stood a shrouded representation of a human figure, crepuscular, mysterious. Upon Reinhart's look it slid noiselessly out of range. Sauntering, Pound took Trudchen's typewriter from beneath her very pounding fingers, ripped out and discarded the paper, and saying \"At last I found the Kraut who can fix this old machine,\" left.\n\n\"Darling Alice: Sweetheart, I\u2014\" Reinhart began again.\n\n\"You try alvays to hoomiliate me...\" Trudchen's lips were fashioned into a little red crossbow, through which slid the pink bolt of her tongue, in and out, tasting the lipstick.\n\nHe threw down the pencil in disgust, said malevolently: \"How about returning my pen?\"\n\n\"Vy do you always do this? Because I am only this little German girl?\"\n\nHe strode massively across and bruised his fist on her table: \"Right now, I want that pen!\"\n\n\"Oh, Gee whiz!\"\n\nFind who taught her that and you had the whoremaster: Reinhart had never said \"Gee whiz\" in all his life long. But the tears were her own. He had last seen them when she cursed that poor Jew for telling the truth.\n\n\"Well, Gee, take it beck again, and don't say I vas shtealing it.\" Engulfed by the mixture of water and words, dissolving mascara, smeared rouge, falling hairpins\u2014for in the grief she tore her hair down into the old pigtails\u2014she opened the middle drawer and drew away.\n\nReinhart came round behind her. There it lay, the old black Parker, that gallant, veteran instrument of romance and adventure on two continents, vicarious cannon, sceptre, phallus. He seized it, already feeling the brute, and when her blue eyes peeped sideways at him over their scorched rims and she said \"I _opp_ ologize\"\u2014by this time he had long forgotten what the beef was and took the pen merely so as to return it to her formally, as a permanent gift.\n\n\"So kind,\" she cried, smiling-through-tears. \"Do you care for my shoes? I have yesterday traded them with the chocolate you gave me.\"\n\n_\"Fabelhaft!\"_ He stood behind her, hands lightly riding her narrow shoulders, eyes descending into the sweet crevasse of the pectoral range, very clear through the thin cloud of blouse.\n\n\"And I have somesing for you,\" she said, \"so you will not think so bad of this little Germany.\"\n\nFrom the drawer she withdrew a handbill of cheap European paper, weightless, the color and grain of whole-wheat bread, infamously inked. All he could read from where he stood was a headline: ES LEBE MENSCHLICHKEIT!\n\n\"Proclamation of the Resistance,\" she crooned victoriously. \"I have found it in this very room, in the carton-boxes. Perhaps this selfsame room in which we sit was nothing but head-quarters!\"\n\n_Long Live Humanity!,_ no doubt to be understood in the sense of Hitler's Peace, a peculiar German cruelty. He received her greatest whopper with an enervation so profound as to be almost pity.\n\n\"Trudchen, I can read German...\" he groaned, his hands rising heavily from her shoulders and more heavily returning.\n\n\"Then read!\" she screamed, turning in frenzy, and his left hand traveled into her blouse at the open neck and down the breasts' warm canyon. Her mouth, open throughout the quick transformations of fury, fear, awe, and finally, madness, rose to his neck like the sucker of a great vampire fish surfacing from the depths of the sea, fastening to the elbow of his windpipe, so that, prohibited from breathing he fisted a tail of blonde hair and pulled as if to sever her head from the shoulders. In a moment his large right arm proved stronger than small-girl lips; he had her loose and held her gaping, an interval for bullying mastery, and then turned her, brought her forward and up, the nether hand taking a purchase within her fat furrow, hot beneath cool cloth, and carried her to cover the light snow of tobacco grains on Pound's clean desk.\n\nHe had come so far in what had seemed desperate comedy, as in school when the kids steal your cap and you tolerate their passing it just out of reach until the smallest boy is the bearer and you engulf and batter him to the point at which his incipient grief takes the laugh off you. But Trudchen now had fear least of all, and laughed, herself, as one does whose will is consonant with the world's; the little witch's face in a garish disorder of evil, yet her odor was childlike, of soap.\n\nIn endless pursuit of pride, then, he became fastidious, working his way through the jungle of queer fasteners and ribbons, and the three buttons which at the crucial junction of her parts secured the last guardian triangle of doveskin fabric, beaching finally upon a little round belly incapable of further discovery.\n\nThe key in the devil's lock, _entrez monsieur, enchant\u00e9 de faire votre connaissance,_ excruciating, pain, pain, pleasure\u2014well into that groove of unification where the senses are harnessed towards a single fanatical end, his suddenly lost purpose. Ah, it was all so crazy. A small window broke the wall above Pound's desk, high above\u2014standing at full height Reinhart could just frame his face in it\u2014and absurd, fit only for some lazy postman on stilts to pass a parcel in from the outside, to save a trip through the labyrinth. It was from this glass that he got an immaterial signal into the corner of the eye, and as if to breathe and moisten the throat, he straightened and turned his head, saw close up to the pane the feathered neck of a man who wanted a barber, Pound's; beyond and lower, a face like a contour map of an asteroid, ripped and pitted by hot chips flying off Jupiter; two had by accident embedded collaterally and, still smoking, were eyes: ostensibly directed at Pound, but seeing him, knowing him and what he was at, not caring, not even amused, but knowing. The old German, now named: Sweetheart. In exchange for the typewriter he presented a thick wad of notes. Pound buttoned them in an upper pocket and, one-breasted like an Amazon, vanished.\n\n_\"Mein Tiger!\"_ whispered Trudchen. Looking down, melting, Reinhart felt rather than saw he had unwittingly been a success. He had also forgotten all precautions, and swift through his mind like an Army documentary ran the series of awful upshots.\n\n_\"Ach,\"_ said Trudchen, yet hypersensitive, opposing partition, \"I have taken care...\" Not knowing to what she referred, he accepted her assurance.\n\nCrumpled in her fist, the old handbill, taken in surprise like everything else, was still their partner. He tore it from her and read the first line below the bold title, read it twice as with his unoccupied hand he returned himself to order. It did not change: \"The appeal of Hitlerism is to the eternal _Schweinhund_ in man.\" Of course it was anti-Nazi; no matter by whom or where, it had been produced in honor and conscience and at cost, and its anonymous author, if he had eluded his compatriot enemies, had lived perhaps only to drown in the same foreign flood that swamped them.\n\nHe kissed her, long and exploratory, for the first time, and saying \"Ah, I must be crazy, anyone could have walked in,\" he burst away, she moaning in the sudden isolation. He ran through the French window and around the corner, and saw that Schatzi had not, because of his heavy burden, got farther than the public sidewalk.\n\nSchatzi accepted the inevitable cigarette and slipped it between his ear and the drooping rim of the workman's cap that with neckerchief and soiled jacket and weary trousers formed his present costume, which he would surely have had trouble in selling to a naked man.\n\n\"Do you need some conversation?\" he asked, with a tremble of his nose, \"or is it simply generosity? Excuse my lack of strength.\"\n\nHe placed the typewriter upon the octagonal stones of the sidewalk. No sooner was it done than a woman rode by on the adjacent bicycle path and they felt the slipstream of her passing.\n\n\"Into the mechanism no doubt this blew some sand,\" said Schatzi, his voice like a dumping of gravel. \"So much longer to clean!\" He elevated his hands in a Jewish shrug, and while the right one was up, put out a finger and ran it across his upper lip, making a gargoyle mouth.\n\nSeeing him now in reality and close-up, Reinhart could not doubt his girl friends' tales were true: if Schatzi were not from the concentration camp, then that establishment was illusion. True, he was more than mere skin, but give an unfilled pelt a few months' meals and you would have Schatzi. He lived, but just lived and no more, with not one breath beyond the essential. His face was dreadful, romantically hideous, in the ugliness only supreme virtue permits, perhaps creates, as with the old saints; and though his angles were sharp, his constant tremble blurred and made them remote.\n\nConfronted with this overwhelming authenticity, Reinhart on the instant forgot his purpose and, instead of speaking, sent a grin. He watched Schatzi catch it, warp it with the secret they shared, and send it back.\n\n\"Your breathing is labored,\" he said. \"Exercise shortens the span of life. He lives most long who lies in one place without movement, like a piece of warm bacon, all his life long, _ja_?\"\n\n\"I never thought of that,\" answered Reinhart. It seemed so marvelously reasonable; he put from his mind the obvious reference to the tumble with Trudchen and worried about the years gone in nailing down his coffin with a barbell. He had never before talked with an authority on mortality\u2014who yet, he saw with a happy loss of trepidation, was also a human being, whose smile was only superficially diabolic.\n\nFor a great sweetness was exuded by Schatzi's hard person as he suddenly stared into Reinhart's face and said: \"You wish to send me on a qvest, _ja_? She told me, this little piece of sausage, this Gretchen\u2014\"\n\n\"Trudchen.\"\n\n\"So. You search for your kinfolk\u2014this is correct, 'kinfolk' or simply 'kin'?\"\n\nSo close was he, perhaps by reason of defective hearing, he almost climbed Reinhart's frame. It was disconcerting, especially since Reinhart judged from his clothing that he must stink and drew always away, until on the fifth circle of their patch of walk he envisioned how from a distance their two figures must look in revolution and permitted himself to be captured. He had been quite wrong: Schatzi put forth the distinct odor of eau-de-cologne.\n\n\"Wwwwell,\" said Schatzi, \"you have come to the right potty. Ve vill\"\u2014successful pronunciation of the first _w_ satisfied him in perpetuity\u2014\"simply look for all the Reinharts who are not yet dead and there you are!\" He actually winked, which is to say one eye was swallowed whole by the lids, like a ravenous bird ingesting a black cherry.\n\nImpossible to think the concentration camps had not been serious; therefore what Reinhart saw before him now was the human triumph, a wit which had faced the dreadful and survived, no cloistered humor like his own. He himself was suffering depression, feeling wet and dirty and unusually exposed, and indeed, since Schatzi had taken the initiative he was no longer interested in his own mission.\n\n\"I don't want to remind you of your troubles,\" he said, though of course he did, \"but would you say the concentration camp was the worst thing that could be imagined?\"\n\nIf Schatzi had earlier been ebullient, he now went into a positive delight that Reinhart, because he had no experience of the world, found very grisly.\n\n\"Ah, no, no, not the worst! The worst, my young friend, is to die. Just that simple. Two added to two makes four, always. The living and the dying, and nothing else, makes ray-oll-ity.\"\n\nSo Reinhart, conscious it was asinine but getting no other suggestions, gave him another cigarette. Which went behind the other ear.\n\n\"Now you must tell me an answer,\" Schatzi said. \"Why must you find these relatives? Of course,\" he went on before Reinhart could speak, \"to help them. You Amis are a decent lot. You do not become happy to see anyone starve, let by themselves relations of blood, _ja_? This gives one faith for the future of the world in your hands.\"\n\nHard as Reinhart looked among the rocks which clicked together in Schatzi's voice, he could find no insincerity, therefore he stifled the impulse to say \"Horseshit!\" He had at last, there could be no mistake this time, found the man with a right to say anything and it be valid. Not even Bach and not even Lori, not even when he had learned their truth, had so impressed him.\n\n\"I'd think you would hate the Germans.\"\n\n\"I hate them? My friend, _I am myself a German._ \" Saying which Schatzi bent to the typewriter, on the way down adjusting his cap, the crown of which was dark with oil. Someone had borrowed his tie to hang a felon and returned it with a frozen knot that would never undo; no doubt he had it wired to his collar or to that frail armature on which his pennyworth of skin was hung.\n\nA marvel that he could pick up such a weight. Reinhart moved to aid him but was waved off.\n\n\"But one detail\u2014\"\n\n\"Of course.\" In this regard Reinhart never admitted another as master. He produced his wallet and counted off five hundred-mark notes, fifty dollars, from the wad of five thousand which Marsala had got from a Russian soldier for Reinhart's graduation watch.\n\n\"I didn't mean you to do this for nothing.\"\n\n\"Now,\" said Schatzi, \"you have shamed me with your generosity. Ray-olly, I cannot\u2014\" He drew from his pocket a brilliant blue handkerchief and snorted into it, thin and airy like a fife badly played. He took the money. \"This is not what I purposed to say\u2014which at any pace, I have now forgotten.\"\n\nReinhart watched him go down the walk with his burden. Twenty feet away, he turned and shouted, \"You shall hear of me!\" And then he moved off the pavement into the trees, where he spat fiercely and vanished.\n\nReinhart had neglected to give him his grandfather's name! Hot on the trail he ran, through the patch of forest to the wide prospect of Argentinische Allee, and surveyed the feasible directions. But Schatzi was gone.\n\n# _CHAPTER 13_\n\nSCHILD'S FATHER'S BUSINESS WAS concerned with buttons\u2014well, you know how capitalism works on the petty levels, he neither made them nor used them, but stood in the middle between maker and user, collecting a profit.\n\nLichenko, however, did not know these things, which was why he asked. He was especially interested in the money: were the earnings large from such a trade?\n\n\"He never thought so,\" said Schild, \"But they were considerably better than working-class wages.\" His smile was both bitter and genial\u2014the first towards the distasteful topic; the second for Lichenko, to whose will he was now committed.\n\n\"Oh, but the workers, we will not speak of them,\" Lichenko said contemptuously. \"You surely are of a superior class.\" This was the kind of thing he had been saying, in one way or another, for three days, and Schild could not yet gauge the degree of its subtlety.\n\nLichenko closed his eyes now and breathed profoundly, as if he were falling off. Sometimes he did; sometimes, after the same indications, not. The game hinged on whether or not Schild rose to go: if he did, Lichenko awakened; if he did not, Lichenko slept.\n\nThe bed was a chaos of stale sheets decorated with brown blood and streaks of St. George's iodine salve. Lichenko had not left it since they laid him there on the night of the beating. Not that he had been seriously hurt: his actual wounds\u2014a slash of the cheek, an abrasion of the lower lip\u2014had, after the excitement was done, proved superficial. The rest were bruises, ugly, indigo-and-lavender, but bruises, and had already begun to pale under the application of St. George's paste. And he had been struck only in the face, so that his body was as sound as ever and could have no special need for this perpetual pillowing.\n\nYet there he lay, sometimes straight and stiff as a corpse, suppressing breath; sometimes curled like a foetus, in which position he made bubbly noises; sometimes with limbs wanton and torn mouth wearing a wan, roguish smile, as if he had dropped there exhausted from a saturnalia.\n\nSchild felt towards him a strange, new emotion: not, as in the case of Schatzi, loathing compounded of fear and envy, and certainly not the fierce hatred which was the sudden motive for the beating\u2014indeed, the latter had been transformed in his memory to a distant episode involving two strangers who bore no resemblance to the Lichenko and the self he knew. Rather, this strange new feeling was the sad, sour regret of a father towards an offspring he can neither endure nor discard. He would have liked, in a moment when his own back was turned, to have had him obliterated in some bloodless, painless fashion, with no noise.\n\nHis blows had pierced the mask. He at last faced that issue he had hitherto obscured with romantic moralizing. Lichenko had originally stayed on at the billet to grovel in comfort like a pig in a slough, although admittedly deserved. But the fact of his second breach of peace indicated not all of him had yet gone soft. The fine, progressive elements in his conscience had rebelled against the ease, not with sufficient force to carry him back to duty, but at least enough to generate a protest, which appropriately had been directed towards the German woman. At that point a deft understanding might have restored him to manhood. Instead, Schild had pushed him back again, perhaps forever beyond redemption.\n\nBut in destroying him, he had also cemented Lichenko to himself. If his earlier hosthood, which he recognized as having been too permissive, owed to simple courtesy, it had since the beating become a nurseship, bonded by the obligations of guilt and limited by nothing. He found it ethically impossible even to object when Lichenko, who certainly could walk as well as ever, preferred the bedpan to the bathroom, and that only when transported by Schild\u2014he would not suffer the _Hausfrau_ in the room. Although at other times he showed great facility in bed-positions\u2014the ass mountain, the pretzel, the scissors, the beached fish, the dismembered Osiris, the solipsist ostrich\u2014at mealtime Lichenko would not elevate from absolute supine, so that there was nothing to do but spoon-feed him like an infant. His back itched fiercely every quarter-hour and would admit no cure but the application of Schild's hairbrush, wielded by Schild, to the trough of his spine.\n\nThe problem of washing, which offended Schild most, even more than the bedpan, had been rather more simply resolved: Lichenko left it behind when he took to invalidism. A person, he believed, did not get dirty in bed. With the passing of the days, his decision seemed less fortunate. After three, in a room from which Lichenko also had decided to bar fresh air on the ground that in his weakened condition he might contract a disease of the lungs, Schild had ceased to dread, might even in two more days have come to yearn, the call for soap and water.\n\nNaturally, a man in sickbed needed recreation. Lichenko required an oral reading of each day's _Stars and Stripes,_ first in the original\u2014so that he could \"study English\"\u2014and then in German translation. The comics were to be read with full gesture and if possible in voices simulating the spirit and sex of each character, especially the female ones, like Miss Lace and Daisy Mae, to whom it was impossible to give credence if they spoke in baritone. Furthermore, it was cruelly difficult to understand the narrative without a sense of what had gone before\u2014before, that is, Lichenko had come West\u2014synopses must be furnished, and definitions. For example, who really was Skeezix? A typical American? A character to identify with, or one to hold in _secret_ contempt? He insisted grimly on _secret:_ one was not so stupid as to think you could sneer openly at a feature of an official Army publication.\n\nAfter the reading came the cards\u2014he claimed to be too weak nowadays for chess\u2014which Lichenko scattered across the foul sheets in Russian arrangements, for games that three hours hence Schild would savvy no better than at the outset except to know he was loser and must pay, the fee being invariably fifty marks, arrived at by a computation as exotic as the game.\n\nNursing his patient of course demanded more time than Schild's Army duties would allow, and no one was quicker to see this than St. George, as soon as the morning after the beating.\n\n\"Oh Nate,\" he said, looking away, for he could not have met Schild's eye with anything but reproach, and he was the soul of tolerance, \"Nate, take a few days off to look after the little fellow.\"\n\nConjure with this: a captain of Intelligence, the commanding officer of a unit of the United States Army, a career officer\u2014he still had never inquired why Lichenko was a guest in the first place. One kind of charge placed against the revolutionary by the voices of petrifaction, was arrogance: 'He asks us to believe that he, and he alone, knows the Way, and if we do not admit this, he will not admit that we are fellow human beings.' Schild had read that somewhere long ago, had banned its source from his memory\u2014very likely some renegade, they were always eloquent; of course if he wished he read them, too, he was no Catholic with an Index\u2014but afterwards carried its indictment with him, like a pocket rule, speaking to it on occasion: You talk of arrogance, you, in your arrogant assumption that we suppress all doubt; we at least have the humility to abandon our selves.\n\nHe asked it now: And what of St. George, _l'homme moyen sensual,_ could there be a more ruthless overbearing than that on which his bovine assurance was fixed? In his mood Schild held it outrageous that St. George had not that first morning after Lovett's party turned in Lichenko to the MPs as a deserter from the Red Army. Which was his clear duty, the Yalta Agreement standing as witness. Indeed, St. George could be court-martialed for malfeasance of office, were it known, and reduced to his permanent rank of PFC or whatever was the breath-taking altitude to which he had mounted in the fifteen years before Pearl Harbor.\n\nThus as always, Schild in his deliberations surrendered to irony, the only weapon whose victories were won exclusively from its wielder, the sword with which the Jews, like Samurai, disembowel themselves to spite their enemies. He knew now, in retroactive projection, that he had always known Lichenko was a deserter, even as early as that first rap on Lovett's door, and in full cognizance encouraged him in the defection. He, Schild, was a traitor; he denounced himself in the dock, took himself to the cellar, shot a revolver into the base of his own skull, and did not weep over the loss of one more counterrevolutionary.\n\nWho wept for a Jew? He derived from the question a brutal, hurting pleasure, of the kind one feels as a child, scratching an itch till it bleeds. And whether it was the pain, the pleasure, or the warmth of blood that gave him courage to press on, on he went with sharp nails through the soft flesh and webbed sinews to the nerve core. In twenty-eight years, among the regiments of shadows which had come and gone, wearing whatever badge of unit\u2014no matter whether Star-of-David or even hammer and sickle; no matter whether in love or hatred, sympathy or suspicion\u2014he had met one man alone who did not treat him as a Jew.\n\nWho would weep for a Jew? _Lichenko would not._ Deserter, drunkard, schnorrer, leech, to the undeluded eye he was a compound of the baser failings\u2014indeed he was what Schild's father had always predicted Schild himself would grow up to be\u2014and very likely a liar as well, for when a man is one thing, it is natural to suppose he completes the series, and it seemed appropriate to Schild, perhaps desirable, that Lichenko had not been a valiant warrior, either, but was rather a coward wearing counterfeit or stolen medals. If he would grant him all, he must begin by giving him nothing.\n\nThe final solution will have arrived that day on which one man admits to another that he is a Jew and the second neither laughs nor draws his revolver nor melts in feigned, or more dreadful yet, authentic sympathy, but rather collapses in boredom\u2014as Lichenko at the party indicated he might if Schild said another word on the subject. In Lichenko's egocentric vision he knew now that he had never been more, or less, than a host fat for the parasiting, a mere object, a thing to be used, not comrade nor ally, not even a man\u2014 _and therefore not a Jew._\n\nLichenko was the new man who had sprung, unarmed, from the forehead of the Idea, with no chains, no history, and a concern only for himself, the product of a proposition that worked. Never say that new kinds of creation are impossible; if you can build a bridge, you can make a man with the sensibility of a bridge, without debts, incapable of guilt, and lacking all purpose beyond his immediate function\u2014and therefore neither a Jew nor interested in one. It had been worth the effort, was Schild's thought, and the thought was also new: for not one moment of his service had he sought any manner of payment, any proximate hope.\n\nOne day in August 1939, Ribbentrop's plane descended on Moscow, where the airport building flew the swastika and the band played the Horst Wessel Song, Molotov called fascism a matter of taste, and Stalin signed the pact with Hitler. In New York, Schild straightaway joined the Party. Truth is never literal: he was already a member for some months, and his first response to the Pact was a suicide of all that was not his body.\n\n'If a universal proposition is true, the particular which stands under it is also true; but if the universal is false, the particular may or may not be true.' The merciless clarity of the Greek logic; before it, the Hebraic superstitions were quaintly impotent. If you say A, you must also say B. Those who are not with us are against us. What does it matter, said Lenin, how the chicken is carved, so long as it is finally in pieces?\n\nAlternatives to these were the Munich Agreement; Roosevelt in his wheel chair; the furniture of the Seder\u2014roasted egg, bitter herbs, piece of bone, eye of newt and toe of frog, wool of bat and tongue of dog, presided over by Schild's father, an unbeliever; and millions of weak little Jews chanting the _Kaddish_ for the dead. Now they could pray for the latest corpses, those \"anti-fascists\" who fled this Party and its compact with the devil.\n\nSchild would stay. And he did not simply stay but joined, took that second breath to which all earlier belonging was mere apprenticeship. For a cause, a real cause, a man first forsakes all others to become one; and then, if he has the true vocation, denies the one to become many. First gives up women, if he is a monk, and then gives up the desire for women; if a Nazi, first tolerates the murder of the Jews, and then after that second breath, himself shoots the revolver.\n\nIf a Communist... the only virtue Schild would grant himself was that in his internal dialogues he never lied: that was for the liberals. Certainly the NKVD, like the Gestapo, pays its call without warning, in the small hours; surely \"we\" have our concentration camps, our dictator, our elite, our peculiar truth which denies the witness of the uninstructed eye, and if your m\u00e9tier is opposition to the regime, you did no better to migrate to the Worker's Homeland than had you tried it with Hitler. We wish to hear no exotic points of view; we will not suffer variety; our conscience, too, is corporate. Now we have entered into a pact with what we so much resemble in our means that the cowards and opportunists can cry: all enemies of \"decency\" are together in one basket.\n\nWe do not cavil: it is precisely your \"decency,\" a world in chains, that we would destroy, and if Hitler can hasten its end, he will be used until history is ready to fling him aside. The difference between us and you is that we will do anything to prevail; between us and Hitler, that _we are right._\n\nThus had Schild accepted reality. In the destructive element, immerse! To create that future life in which there will be no separations of one man from another, which is to say that time when no one is a Jew real or symbolic, when all the old rises and falls are planed away and men are simply man and he a stranger to passion, one must first, in the now, act upon the reverse of that vision, be separate\u2014be a Jew, that is, in extremis; if necessary, as it was, ally with an anti-Semite.\n\nSchild's progress had not been easy, or of short duration, and whether the end was serene he did not know, to date not having reached it. In particular, he was corrupted by a special feeling towards the Germans, throughout and in spite of the ideological transformations. With Hitler's invasion of the USSR the pact of course fell from memory. From then until the final victory was apparent, the eye was shifted from sharp focus on fascism-versus-the-Socialist-ideal to the less demanding _Gestalt_ of Germans-against-humanity, the latter represented most crucially by the Russian people, who incidentally had a government which tried new things but was essentially a Slavic branch of that general democracy now menaced by barbarism.\n\nTrue, to the professionals Nazism was still finance capital in the last terrible flush before death, and the Western Powers, temporarily useful, were the same thing not yet so far advanced that they themselves knew it. Nazism was fascism and fascism, capitalism; nowhere was the specific quality of Germanness material. And no sooner did the Red Army take Berlin than it erected its billboards: The Hitlers Come and Go, But the German People Remain.\n\nInsofar as the populace had connived with the Nazis they had seriously erred and must not now resent their rightful punishment by the Soviet troops. But more important, what was past was past and the future stretched out bright and grand, offering that great opportunity which so seldom comes to a people: to start out new, from nothing. Crushed and smoking lay everywhere at foot the best evidence of the failure of all hitherto existing societies. The Germans were wrong, and guilty\u2014guilty of following an extreme reactionary in his mad-dog assault on the Socialist homeland\u2014but were neither fundamentally mad-dog themselves (for peoples can be misguided but are never bad) nor in any way hopeless of reclamation; indeed, by so simple a measure as prompt adherence to the correct ideology they could enter immediate partnership with the Soviet Union itself, as magnanimous in victory as it was invincible in war.\n\nA historical crisis, admittedly, capitalism being done in by its inherent contradictions\u2014yet why Germany? No, excuse me, that is of course understood: the most advanced capitalist country of Europe; inevitably the agony would there have its nucleus. But why the one peculiar feature. Why the Jews?\n\nTo answer the first question is not to need the second: in its desperation, crumbling capitalism will seek a scapegoat on whom to hang its failure. As simple as that, comrade, nothing Dostoyevskian\u2014unless you will admit that Dostoyevsky, too, was a byproduct of the social decay preceding the Revolution\u2014and above all do not quote me Heine: \"It is indeed striking, the deep affinity between these two ethical nations, Jews and old Germans. This affinity has no historical origin... basically the two people are so similar that one might regard the Palestine of the past as an Oriental Germany...\"\n\nWith full respect to all cultures and races, comrade\u2014after all, it was Lenin who with the brilliant collaboration of Stalin, always the foremost of his colleagues, drew up that system by which for the first time in history Russia's many and diverse subnational cultures live today in peace and harmony, each with its own autonomous state, including even the Volga Germans (unfortunately the presence of certain fascist agents provocateurs and counterrevolutionaries concealed among the predominantly loyal mass of the latter made necessary certain rearrangements when the area was threatened by the Hitlerite invasion, and the patriotic Volga Germans themselves requested to be transported elsewhere in the Soviet Union, which plea was granted; a far cry from the concentration camps to which the Nisei were sent in America). With full respect to all cultures, comrade, and to their interesting and colorful traditions each of which symbolizes some old socio-economic thesis or antithesis, it is fruitless and perhaps heretical to stagnate with the past. Not what peoples have been but what they will be, is our sole concern.\n\nHatred of the Germans, therefore, is not valid, and if persisted in might become a dangerous malady. Similarly with the obsession that one is a Jew, which incorrectly puts too much stress on two delusions: (1) that Jews are that important, and (2) that oneself is.\n\nBy the Central Committee in his own skull, then, the first, the last, and the most ruthless of the Party's disciplinary boards, Schild had long before the arrival of Lichenko been granted only one more chance to rectify his errors. Had there been a thousand, he now realized, he would have spoiled them all, because he was not, and could never be, pure, adamant, resolute, unilateral; that is, could not be a Lenin. Lenin was not a Jew.\n\nBut Trotsky\u2014yes, regard that classic example, that bright needle of a Jewish mind and its corrosion from pride, which is a Christian sin. And Milton Grossman, who at twenty-five had collected no excess in his passage through the world, who had seemed only a disembodied conscience and a pair of black eyes fixed on a morning horizon. He was to leave for Spain on a tramp merchantman of which he would say no more than that it sailed soon from Halifax. In his room behind the shop he had packed the knapsack which yet bore the symbol of the Boy Scouts of America. The irony of this had been funny, and Schild laughed, but then seeing that Milton did not, he knew it was no irony, which is the tension between the way things are and the way they are imagined, but rather another marker on Milton's undeviating and dedicated road.\n\nSchild, too, had been a scout, in the same troop. It had of course degenerated by his time\u2014bullying by the patrol leaders, petty thefts in the tents at the Alpine camp, obscene language and practices\u2014Milton, with his thirty-six merit badges, was by then only a distant legend, and it meant nothing to the others that Schild was his friend. Not until years later did Schild come to know that at the arrival of the Miltons, too, the _grosse M\u00e4nner,_ the troop is always in decay\u2014and falls again upon their passing from the scene, because without a constant image of strength before their eyes men, or boys, see nothing.\n\nAt nineteen, Schild was big enough to go to Spain himself, that is, old enough and large enough in size to be in his first year at City College, to sit through purposeless lectures, to sign petitions and stand with a claque at anti-fascist rallies and peace movements and enlist in involved conspiracies to stop the Socialist candidates for student council, to study the terrain of the essential American ground: folk songs, baseball, comic strips\u2014and to report at four o'clock each afternoon to the squalid office which his father kept on Broadway just above the northern boundary of Union Square, there to involve himself for two and a half hours in the commerce of buttons.\n\nBut he was not big enough to go to Spain. It was characteristic of his friend that Milton did not suggest it. What we admire in those who stand above us is their assurance that they do, truly, see over our heads. He had similarly never suggested that Schild join the Young Communist League, never indeed that he so much as become intellectually a Marxist. Milton went towards the truth, the true was the necessary, follow if you will. Of the pre-Marxian thinkers Milton's favorites were the Stoics, whom he had read as a college freshman and shared with Schild, then on the bottom rung of high school and still a simple idolator of athletes and a noisy drinker of cokes at Mrs. Grossman's counter. \"Fate leads the willing and drags the unwilling by the neck. _But they both go_.\"\n\nIt was the first genuine idea that Schild had ever heard, and its function in his _Bildung_ was that upon its movement he had twice passed from adolescence into maturity. The second time\u2014and not a piece with his second breath of commitment to the Party, because it both pre- and post-dated that event, had really no fixed duration, continued still\u2014his second transformation began when he understood its heresy.\n\nMilton Grossman died in Spain, in July 1937. As to the means of his death there could be no question; this was one of the rare times the fact followed from the simple conditions of time, place, character. He had achieved the herohood for which his progress through twenty-five years, from Washington Heights to a Catalan field, had been apprenticeship. And so it was assumed, without the spelling out, for reports were necessarily fragmentary and cryptic, the Lincoln Brigade was outside the law of the country of its origin, and Spain under its cumulus of gunsmoke lay three thousand miles across the sea.\n\nAnother year, and someone was returned, or someone knew someone who had come back, who knew someone in Valencia who had seen Milton in the hospital, felled by tetanus, and since the shortage of serum was notorious. ... Yet the achievement was not diminished; Byron, who had gone to fight for Greek liberty, died of meningitis, and the shorter literary dictionaries, with no space for elaboration, read: \"died, for the freedom of Greece, Missolonghi, 1824.\"\n\n... but what did those rarer reference books on the shelf of some terrible agency tell of Grossman, Milton? \"Found guilty of Trotskyist wrecking. Liquidated.\" \"Executed after investigation uncovered his role in the conspiracy of the Fascist gang known as P.O.U.M.\" \"Agent provocateur in the pay of Franco. Sentence carried out, July 1937.\" Or perhaps only a sparrow-track of cypher. The world had not become more cruel since Byron, but its truths were more devious, less capable of proof, yet, for all that, truer. The real story of Byron, the _concrete_ one\u2014a term of Milton's for a quality he always sought beneath the capitalist veil of lies\u2014might be of another order, the mission to Greece a shabby quest of ego, a Trotskyism of that time, and who knew but what the meningitis were some Aesopian code-name for the 'control of disorderly elements'?\n\nBut surely it was unprecedented that at home a friend dare not speak his name. For Schild naturally had gone with his questions to those who returned. The cause had been lost and they were weary and older than their years, but they were also proud and illuminated with what could only be called the sad joy of men who have wet their comradeship in blood. They sang fierce, exuberant songs, were curt, succinct, yet eloquent in a language which was properly half-alien to the beneficiaries of their sacrifice.\n\nBut for Milton Grossman not even Spanish idiom would serve. There had not, to their memory, ever been such a person, or if there had, no doubt he was overlooked in the terrible struggle against the open fascists on the other side of no-man's-land and the _fifth columnists behind our own lines._\n\nOf course Schild knew of the wreckers, the anarchists, the hirelings of Trotsky, those worst of all enemies because they are one's own kind, who extend a hand as comrades and with the other clasp their dagger. The greatness of a cause can be measured by the decadence of its adversaries; we can be proud of the very rottenness of those we have cast out. For all their mumbo-jumbo, and all matters of clerical fascism aside, the Catholics have a valid principle: he who embraces the incorrect faith in ignorance may be saved; only he who knows the true faith and rejects it is certain to be damned. It could never be said that Milton Grossman was ignorant; like Trotsky he was all mind, his mind all blade, and that all edge, the Jewish edge... and behind it, the abysmal weakness.\n\nTo continue the inquiry was to make oneself suspect. And needlessly\u2014for Schild asked the questions only to test the answers already in his possession. No doubt the flaw had always been there, waiting for the day when the force of concrete, historical events would burst it wide. But it had been the earlier Milton in whom Schild had seen the Way, who had armed him with the weapons. There was ironical justice, but justice, in turning them now against the too-competent teacher. And his oddest feeling was that in so doing he did Milton an honor greater than he deserved; that in the measure of its being undeserved, Milton would be pleased; that, finally, he deserved to be pleased.\n\nIt was then, when he thought of Milton, though dead, though discredited, though renegade, as someone still to be taken into account, that Schild realized his sole defense against insanity was the Party. The acceptance of one's own complicity in the Party's crimes was the only escape from knowing oneself a criminal. Fate leads the willing and drags the unwilling by the neck: ostensibly Greek, but how much closer to the long, moaning servitude of the Jews, with whom in the end Milton chose to identify.\n\nFor he had written Schild one letter from Spain, a strange letter, in the early spring of '37. Strange even for Milton, who was more talker than writer\u2014\"like Sophocles, Jesus of Nazareth, and Hitler,\" as he used to say in his Bren-gun voice and then stop to catch breath before throwing it away again, eyes rising through an atmosphere of mixed slyness and purity, \"all seekers of oral gratification; you will notice none of us smoked. _O vanitas_!\"\u2014and hence never wrote proper letters but rather short scrawls discontinuous in thought and calligraphy, on whatever surface lay at hand and could be mailed, cigarette packages, cereal boxtops, the reverse of one's own note to him; and in Spain, until now, no letters at all.\n\nThis one was pencil, on an unbleached, glazed strip, serrated across the midsection, of\u2014Spanish toilet paper. \"If I should not be at large by next Yom Kippur, read this.\" On the religious holidays in New York, Milton's observance was, dragging Schild along, to go to some lunch counter and stuff himself with pork; his ambition at twenty had been to lay a girl between afternoon and evening prayers on the Day of Atonement; he had never yet done this, he said, because he could not determine which was the greater sin, to screw a Jewish girl or to commit racial shame with a shiksah, for which he used the Nazi term _Rassenschande._ Once on that day, sitting on a bench in the middle island of Broadway, watching the promenaders in their best clothes, he said: \"When at last the Messiah comes, he will be an anti-Semite.\"\n\nThe letter therefore fell within the known context, had besides the familiar mordant-shading-into-mortuary wit, the _Galgenhumorische_ pun like Mercutio's: if I should not be _at large,_ that is, if I should not be a gross _Mann;_ he anticipated his death. Then followed a translated quotation from a Hebrew religious poem of the eleventh century. He had returned to God. Small wonder he could not have made that candid.\n\nBut an old mutual admiration of theirs had been Poe's \"Purloined Letter\" and Dupin's theory of deception, which he explains by a game of puzzles played upon a map. One player requires his opponent to find the name of a certain town. A novice will invariably choose the \"most minutely lettered names; but the adept selects such words as stretch, in large characters, from one end of the chart to the other. These, like the over-largely lettered signs and placards of the street, escape observation by being excessively obvious.\"\n\nIt was a faith that Milton spoke of, but rather one lost than another gained:\n\n> ... thou didst vouchsafe to give me a perfect creed, to believe that thou art the God of Truth and thy prophets are true, and when thou didst not place my portion among those who rise up and rebel against thee; among the foolish people who blaspheme thy name; who deride thy law; chide thy servants, and deny the truth of thy prophets. They assume innocence, but underneath is deceit; they make a show of a pure and clean soul, whilst the bright spots of the leper are concealed underneath... SOLOMON BEN GABIROL, _died Valencia, c. 1057_\n\nLichenko stayed. To keep him was to abet a desertion from the Soviet Union. To turn him in was an admission that the hideous sacrifices which had gone into his making were not finally criminal, but useless. Milton had never been able to forgive a confusion of the two.\n\n# _CHAPTER 14_\n\nLICHENKO STAYED. AND IN that staying Schild ironically discovered a focus for that energy he had ever kept on call against the grand mission. For he was, or had been, a romantic, a man to whom time now and past were ancillary to time's end, and while he saw history as a continuous process and within that process himself as nothing, with the other eye he looked on the personal life as a series of choices culminating in an absolute, a supreme of either victory or martyrdom, a storming of some Winter Palace or a fell day like that in 1933 when the Gestapo was unleashed on the German Communist Party.\n\nInstead, his future had arrived in the form of\u2014Lichenko; and time had stopped. Schatzi, who for all his shrewdness had not known of Lichenko until the beating, for all his eccentricity was a good Communist and had made his report; and what he, for all his hatefulness yet a hero of the camps, thought of the newest traitor did not figure in Schild's reveries so markedly as that Schatzi's long-held, unjust, fantastic suspicions of him had been confirmed and, finally, that, for the first time personally liable for an actual crime, he felt less guilt than serenity and lacked absolutely the sense of being hunted.\n\nAnd most corrupt, his sense of humor had despite his efforts to brook it begun to prevail over the conscience. Lichenko's invalidism had required only his attendance to be supremely ludicrous\u2014to be, in fact, lunatic. Objectively the situation was simply a Russian slob nursed by a nervous Jew; the first was not ill, but the second was; and since each in his present arrangement was necessary to the other in just that condition, both were mad.\n\nOr perhaps only Schild was, for he noticed that Lichenko these days never laughed; indeed, since entering into permanent bed, and despite his abominable appearance, he had developed a dignified gravity which one who knew only the earlier Lichenko would have believed impossible. One lunchtime when, carrying the loaded tray and an under-arm burden of newspapers and magazines, Schild had difficulty at the door, Lichenko sprang from the sheets to his relief, showing not only vigor but incredible strength for so small a man: he took the heavy tray in one hand and the papers in the other and, studying _Life's_ cover tit-girl as he went, walked silently, stately, to the bed as if it were the high altar in St. Basil's and he Patriarch; and immediately upon reclining was again the man so infirm that Schild must needs not only spoon the mashed potatoes into his mouth but also support his head simultaneously. Lunacy, to be sure, but Lichenko's were not so much the doings of a lunatic\u2014Schild realized, as he heard himself laughing without accompaniment from his patient\u2014as those of a sane man who is humoring a lunatic.\n\nSimilarly, Lichenko of an evening had invented a new amusement. He had fallen off his taste for public reading and even for cards. As to the former, he had been disillusioned by the knowledge that Skeezix lived in time, more or less relative to the limited days of actual people, had years ago at the beginning of the story been a baby, was now in his twenties, would grow old. Since fictional persons are a lie to begin with, he said, they are only interesting if they stick to it and do not pretend to have the dull troubles of real people; otherwise you did better to have true stories, which of course are always boring but then don't pretend not to be. Like\u2014he broke off to peer at Schild in a kind of suspicion and remark that it was possible he, Schild, would not agree, and immediately launched an attack on L'il Abner from the opposing ground: nobody could tell him an American peasant acted in that fashion.\n\nAs to the cards, it was immoral to win from a man ignorant of the game; had he known that at the outset he would not have played; he might even return the winnings, as he was not a _gengster,_ unless\u2014again he stopped abruptly as if to give prominence to his expression, which was this time a sneer; one so broad, however, that surely its purpose was rather mock than serious. And again Schild laughed, and again Lichenko's face returned to wood.\n\nConversation appeared as the new entertainment. It was hardly more, being Lichenko's questions and Schild's answers; but it was not less, and since Schild had never known speech could be employed for amusement, at least not by him\u2014he had listened to Milton; in both the Party and the Army the human sound was used only to assent to orders from above and command what lay below; to St. George it was the minimum of small-talk to get rid of him; his parents and sister had been great talkers in disregard of the defenseless tympanum, which was why he was not\u2014since his voice had no resonance in this small room with the peaked ceiling which in the corners joined the wall a scant five feet above the floor, crowded with furniture and now with the warm congestion of dependent humanity; although Lichenko was not ill, it _did_ make a difference to him that Schild was there to serve\u2014these were reasons enough, if still morally inadmissible, why he should enjoy their mutual discourse.\n\nBut more important was the fact that after the initial ten minutes at Lovett's they had never really talked. An ordinary citizen of the Soviet Union, that person who to an American existed only in theory, he had had one under his roof for three weeks and never yet found the propitious moment to ask: what is it like, the experience of that citizenship? Indeed, to place the query was not only an opportunity but, in the present context, an obligation, just as in Party circles in America one was under the reverse imperative _not_ to question the mysterious figures who were manifestly Russian but carried passports bearing names like T. Smith.\n\nBefore the beating, Lichenko had obviously never been in the mood for talk; he had been eating, or sleeping, or washing, or scratching, or hanging over magazines or the chessboard; and that was the answer to the question never asked: there was no question about life in the USSR, it was life with incessant activity and without doubt, and even a deserter from it, one who could not meet its demands, yet carried with him its energy. In his very exploitation of Schild, Lichenko honored his society: a bourgeois gone bad would not have had the guts to go so far.\n\nAs to the other question\u2014why had he deserted?\u2014the science of dialectics admitted no such concern; Schild was not permitted to receive it into his mind; a person was either this or that; if that, he should either be ignored or destroyed; the alternative, if one did neither of these, was to relate it to the fact that oneself was lost. And this Schild had already done.\n\nNow that conversation had finally come, it was appropriately on the theme of, not Lichenko, but Schild; not on the simple deserter but on the more complex; and Lichenko's half of it was so shrewd that Schild briefly considered whether after all he had not been wrong about him.\n\nAccording to Schild's wristwatch\u2014which was strapped to Lichenko's bony arm, having been the stake in one last game of cards before the no-gaming resolution went into effect\u2014the time measured seven in the evening. The tray had been washed and lay gleaming on the dressertop, against next morning's breakfast time when it would vanish briefly to reappear heavy with eggs, melting yellow in the centers, and oatmeal porridge slushed with milk and sugar; in the end compartment, two pieces of white bread, thick as bricks, coated so lavishly with golden butter you could not lift them without smearing your fingers, which was as pleasant a sensation as running your hands over a woman, and though he knew that with this abundance the Americans had developed a culture of eating\u2014it was some old law or another that when there was overproduction on the one hand and a shortage of markets on the other, a society tried to fill the gap with elaborate manners\u2014and while he approved of this whole lovely ensemble of errors, he could not forbear from licking his hands. And Nathan made no objection.\n\nThat, indeed, was Schild's reaction to all of life, so far as Lichenko could see, and he wondered again why a man with such tolerance would join a band of evil thugs whose only difference from the other group just defeated lay in the latter's being German. Although there were German Communists, too, and surely many among them who were but lately Nazis, and wait and see if it was not exactly those who were raised to power in the East Sector. Ah, Nathan, you fool!, you who were rightly so quick to act when Vasya disgraced your house, in the big things you are truly like the silly comic strips you so dearly love to read. Look into the mirror and you will see the living Small Abner.\n\nThough not hurt (and it was an awful strain to continue to pretend he had been; actors justly earned higher wages than a fellow who operated a lathe); although in fantastically better physical condition than he had ever before enjoyed (for the first time he had hopes of one day becoming handsomely stout), the kind it was shameful to have to hide under a mock illness rather than announce with much noise and movement; in spite of the great rewards at hand and the greater ones in promise (if the United States proved but a vain dream, then perhaps merely some sleepy hamlet in the Black Forest and a German woman with a nice round ass and a little craft like decorating Christmas-tree ornaments, and a garden of cabbage and beets\u2014if one lived too high he got only boils and the gout) ...despite every reason for being up and about, for seizing life and making it groan, he had instead chosen to play the sick hog. And it had begun to work.\n\nNathan was a queer fish. For some reason he had buried his humanness so deep that one could bring it to the surface only by outraging him. Yet Lichenko had always known it was there, else he would not have taken the trouble to find it\u2014and it _was_ trouble, and Nathan was very lucky to have him. For now he had, at who could tell what final cost, at last established the conditions for that intimacy in which the truth could be aired.\n\nSeven o'clock, the good air outside the closed window, which he had not had in his nose for weeks, still bright and full of August. But Nathan had turned on the dresser lamp like the indoor man he was, and come to sit by the bed to await his, Vasya's, pleasure. The room which had on first sight looked so grand that he assumed Nathan must share it with a regiment had truly become a home. With use, the very bedsheets, so white and hard when first entered, had softened and lost their harsh odor of bleach. Even Nathan's sloppiness, which until the \"illness\" intervened he had constantly opposed, had worked to the homely purpose, the rug dark with scorchings, the rent in the curtains, the deep scratches of footboard and dresser-front catching the shadows like old scars on the faces of your loved ones. ...\n\nWith a scissor-kick, as if in the water, he shot himself backwards, conking his skull on the headboard, which was not intentional but certainly claimed Nathan's attention. Instantly his friend was up and arranging the pillow.\n\n\"Are you hurt?\"\n\nCould Nathan truly be as pained as he looked, at the possible hurt of another?\n\n\"Ah, no!\" Lichenko tried to joke. \"The bedstead is undamaged!\"\n\nHe had got him there: Nathan fell back laughing. He himself of course did not, it being a kind of vulgarity to laugh at one's own jokes, and instead, with serious mien, fixed the pillow from which Schild had puffed out all the good head-hollows.\n\n_\"Was f\u00fcr Kn\u00f6pfe macht Ihr Vater?\"_ he asked.\n\nNathan could sit in a straight chair for hours without so much as crossing his legs, and he was thin, too, so that this ability owed nothing to the padding on his rump.\n\n\"Oh, he doesn't make the buttons. He buys them from a buttonmaker and sells them to a manufacturer of women's dresses. If that's confusing, don't bother with it. Your country is mercifully free of the middleman.\"\n\nAgain Lichenko shot himself backward, but this time the pillow dulled the thud of his head hitting oak, and this time Schild did not rise, for simultaneously with the action away, Lichenko had shot his hand forward and asked: \"What is that you say, free...?\"\n\n\"From the middleman.\"\n\n_\"So.\"_ The olive-drab undershirt, which with drawers of the same cloth, on loan from Schild, was his costume of illness, had with the movements ridden up and constricted about his narrow chest like a dog harness. \"I should have told you earlier, my dear friend, I hear what is said, but between the words sometimes comes the _swoosh_ of the rockets: 'free'\u2014 _swoosh_ \u2014'from the middleman'\u2014 _swoosh,_ so that what goes into my mind is often different from what has been spoken. For example, I thought just now I heard you say someone was free in the Middle Ages.\"\n\n\"Haha,\" laughed Nathan, but wryly. \"Not being a Jesuit, I could hardly say that.\"\n\n\"Ah, again, another example: what I heard then was something about Jesus Christ! ...You see what I mean.\" He threw his feet about under the bedclothes, which commotion looked as if a small animal were trapped there, and smiled helplessly.\n\nJust the thing to replace Nathan's nervousness with the responsibility of a job; he could never endure being misunderstood. It was a relief to see him break the stiff column of his spine as he leaned forward and said very slowly and with the enunciation of him who speaks into an ear trumpet: \"Je-su-it\u2014a religious order which invented a kind of fascism four hundred years before Mussolini.\"\n\n\"Of course I knew it was something old,\" Lichenko answered. \"But you see a hydraulic engineer does not have time to learn much beyond the principles of his science. I..., my dear friend, should you be angry if I confessed to a dishonesty?\"\n\nBehind Schild's genial facade he saw an emotion begin at the throat and descend\u2014a giraffe would look like that if it swallowed a melon\u2014either hatred or fear, since these were the only feelings a person might find politic not always to reveal, but which of these was here operative Lichenko could not say, there being no apparent reason for either. Wishing no lies to stand between them, he had prepared merely to admit he had not read the American books they discussed at Lovett's party, so long as the truth was out that an engineering student had no spare time.\n\nInstead, he said quickly: \"I borrowed another of your handkerchiefs while you were gone to the dining hall. I shall send you a dozen when I go\u2014\" For a moment he imagined he had heard himself continue with: \"to America,\" for suddenly that was where his fancy had fled, in just that wink of the eye he had seen himself at the handkerchief stall in a store big as a sports arena, had gone back further to park his yellow Ford at the curb outside. He wore a tight blue suit of narrow gray stripes and a black felt hat low over his brow; the woman at the counter believed him a suave but dangerous racketeer, a pearl-handled revolver encased in a silk glove, as he smiled with sharp white teeth and said \"Enchanted,\" or whatever was proper at such a moment, which he would know.\n\n\"\u2014a dozen. Tell me which color do you prefer? Always this olive, or should you like some of blue with narrow gray stripes?\"\n\nThis was what he really said while Nathan loosened, sat back, and finally crossed his legs, one trouser riding up to uncover a pale shin whipped with dark hair.\n\n\"You know you may take anything of mine,\" said Schild, \"and I'll be disturbed only if you try to pay me back.\"\n\nHis incredible generosity! It had, more than any other single thing, been the cause of Lichenko's delay. He understood that far back around the time of Jesus Christ the first Communists worked on that motive and no other, when, that is to say, they were weak and victims rather than victimizers, and it must have been splendid to live then, when good and bad were easy to isolate. Some time since, they had become so mixed that one could no longer take the sayings of one's mother as a serious guide to life. For example, of Schild his mother would first make some old-peasant observation such as that a man with a high bridge to his nose was untrustworthy, or that ears set at that angle caught only evil wisdom. But if he showed his manners she would think him fine as a \"nobleman,\" which in her lexicon took on ever more precious connotations as she grew older and had further to look to see the lovely time of her youth when her father had one hundred per cent more land than her husband had now, since the latter owned none at all, and when the fields were the property of a handsome count who never cursed rather than a gang of rude bullies who stole nine-tenths of every harvest in the name of some swindler they called \"the people.\"\n\nLichenko's mother had been illiterate. She had gone under orders to night school and learned to read and write, but she had still been illiterate\u2014according to his brother, who belonged to the Party and, being very literate, wrote articles on agricultural matters for a newspaper in Kiev, which Lichenko, perhaps because he himself was only moderately literate, could never read beyond the first paragraph: \"The representative liaison committee from the Stalin Collective Farm at Rusovo yesterday presented to the Central Organization of Rural Co-operative Societies a voluntary petition from the Third Link of field workers on the Stalin Collective Farm that it be permitted to raise its quota in regard to the harvest of wheat. Now, what does this mean relative to the development of large-scale socialist production in the sphere of agriculture? This means...\"\n\nOr take his brother\u2014now you would assume he and Schild, being political comrades, would hit it off. But, ah no, his brother had no respect for foreigners, Communists or not, as he had once admitted to Vasya; indeed, he placed little value on any people but the Great Russian and had got so that just before the war he would speak Ukrainian only with the greatest distaste.\n\nNo, to understand Nathan one must regard him with one's own eyes: it was the generosity, not the Communism, that was native to him, and if you said well, the Americans have so much they can afford to give some away, you had only to compare him with another like Captain St. George to see the difference. Nathan lived like a holy man of yore.\n\n\"I suppose your dearest wish is to return to your family now the fighting is over,\" he said, straightening the undershirt. \"Tell me of them. Your sister\u2014is she beautiful? Is she so slender? You have a photograph, of course.\"\n\n\"No\u2014well, I did have,\" Schild spoke in concern, \"but in the area of Metz my belongings were stolen.\"\n\n\"And your mother\u2014can she read and write? No, don't answer. How silly of me to ask! A fine, cultivated noble\u2014gentleman like you! Besides, certainly everybody in the United States is literate.\"\n\nThis seemed to soothe Schild, and his black eyes glowed behind the lenses as he protested happily: \"Not at all. There are about ten or twelve million Americans who cannot read and write. We are not speaking now of the Soviet Union, Vasili Nikolaievitch.\"\n\n\"But then it is not necessary for everyone to read and write,\" said Lichenko, shrugging with his voice. \"All one really needs is something to eat and wear\u2014protection from the _golod_ and _kholod,_ as one says in Russian\u2014girls to love, maybe a drink of spirits now and again, and the policeman not on your tail. I mean, if one belongs to the common people.\"\n\nSchild assented by his silence.\n\n\"The uncommon ones,\" Lichenko went on, \"take care of themselves. Then there are the ones between, who don't know what they want, _nicht wahr?_ Something different, anyway; this is not right and that is not right. Nothing is right for them!\" he exclaimed in a kind of joyful hopelessness, pedaling his legs rapidly as if riding a bicycle. \"But look at a big oak tree: it loves no girls, drinks only water, does not eat at all, lasts longer than the oldest man, and is satisfied throughout.\"\n\n\"And is chopped down by the first fellow who needs wood,\" said Schild, nodding pleasantly. His shirt pocket might be unbuttoned, but his tie and collar were fast and most uncomfortable to see through the heavy, still air. Keeping the windows shut had been a phase of Lichenko's scheme of absolute pressure to the body as well as the spirit, and while no effect could be discerned in Schild, he himself was sweating like a plowhorse.\n\n\"Yet,\" Nathan continued, not so much as a gloss on his steep forehead, \"isn't even that oak better than a worker under capitalism?, who is chopped down when he is _not_ needed.\"\n\n\"Stupid!\"\n\n\"Yes, stupid is a better word for it than evil.\"\n\nStupid Nathan! He saw even a tree politically, and no doubt would be the first to cut down an oak, to make paper for pamphlets to celebrate someone else's sowing of the reclaimed ground, or to denounce them for seeding the wrong thing, whichever would be most bleak and deadly and contradictory of his generous heart. There was a difference of thousands of meters, in more than land and sea, between him and Lichenko's brother, in spite of their similar faiths. His brother had, all to himself, a four-room apartment with a refrigerator and a private bathroom, but what had Schild to gain? He even disapproved of his father's wealth.\n\n\"It would be better, I think, if the window were open.\" Lichenko scrubbed his face with the undershirt tail, which when he pulled it down again was wet as a swimming suit, and since by that time Schild had opened one half of the casement and the evening air made chill entry, his belly was shortly cramped with cold.\n\n\"Good, that is just enough. Now please close it.\"\n\n\"You haven't a fever?\" asked Schild as he came back to his chair softly as a cat.\n\n\"Frankly, I don't know. I feel very strange. Perhaps I should take a bath. ... Of course you have a bathroom in your home in the U.S.A. And with hot water, no? _Sch\u00f6n_!\"\n\n\"But there are many people who have not. My grandparents lived in the working-class quarter of New York City, in unbelievable slums. They had nothing but a cold-water flat, one room for living and sleeping, and the other a combination kitchen-bath. The tub had a wooden cover that served as dining table.\"\n\n_\"Wundervoll!\"_ Lichenko chortled. \"I knew it! They were workers and yet had a private bath, and their son grew up to be a great industrialist of buttons and _his_ son became a fine intellectual.\" He saw a cruel angle develop in the corner of Schild's mouth, at odds with a sad cast of the eye. He, Vasya, had been carried away as usual: fact, fact was wanted and not his opinions, which only irked his friend in the proportion they were genuine.\n\nHe writhed about until his feet hung over one side of the bed and his head, the other. In upside-down vision Schild looked like a baldheaded man with a beard\u2014indeed, somewhat like a Lenin with glasses. He had played this game as a boy: if you frowned, the lines of the forehead resembled a mouth; the real mouth you must ignore, and also that the nose opens in the wrong direction; with the remainder you had a fairly credible face which gave to the expressions what the Moscow radio gave to the truth\u2014an odd twist, both human and not. It was years since he had played it, however, and he had lost his old proficiency in interpretation.\n\n\"What are you doing now?\"\n\nThe mouth in the center of Schild's head answered: \"I'm smiling.\"\n\n\"Forgive me, one gets restless in bed. To entertain myself while you are gone I have remembered certain boyhood amusements.\" He righted himself, all hot above the neck, and sighed. \"When I was sick as a child my mother sang little songs to me. They were always about food. For the life of me I cannot now recall a note, or I should sing one. They only come back when I am hungry.\"\n\nSchild bathed in a pond of jocularity as he said: \"Then we shall have to starve you.\"\n\n\"No,\" Lichenko answered, \"that has already been done, and believe me, my friend, just for the singing it is not worth it.\"\n\nIt was aired, his first open attack on the regime of his country; he felt excellent well for having made it, and he stared fearlessly at Schild, who appropriately cast his eyes aside in deep embarrassment. Which meant he knew, then, of the Kremlin-made famine of 1933, and it meant as well that he was not so corrupt as to try to defend it. Yet if Nathan did know and, regardless of a disapproval however sincere, continued to work for those devils who had not only created the famine but standing on two million corpses denied they were there... Lichenko lost the path as all at once he found he wanted Schild to be both innocent and guilty, for only in that combination could he forgive him.\n\nBut Nathan was neither. So solemnly eloquent he almost cracked one's heart, yet with a peculiar elation that seemed to swell his own, he spoke of Hitler's assault on the USSR and the scorched-earth tactics and withdrawals which, because of the treacherous surprise, had been at first the Soviets' only defense. He spoke well; indeed, so well that Lichenko almost believed the hunger here at issue was rather that of 1941 than 1933. No question that the invasion by the Germans had been worse than living under Stalin: they were foreigners. Yet, although the data was of course suppressed, hundreds of thousands of his compatriots had had another opinion, hung garlands on the invaders and enlisted in General Vlasov's anti-Kremlin army or even in the Wehrmacht. They were wrong. If you must have a tyrant, why not keep your own?\n\nHe could not help it, he still had scruples about disabusing Schild. The Red Army, as Nathan was saying, _had_ done a magnificent job; they _were_ heroes; he, Vasya, was a hero and it was just and proper to hear someone say so. The Soviet Union was the greatest country in the world: there lay no contradiction between believing that and fleeing to America, or the Black Forest, or some southern land where dark-complexioned people drank wine and slept all day in the shade. And it was very probable that the Party elite represented a new and superior kind of man. He even believed Bolshevism would triumph in the long run, everywhere, because he could see in it no weaknesses and knew by experience it would stop at nothing. Even Hitler had a limit: the Germanic \"race,\" by which he measured everything, including his Ukrainian allies, and in the end this folly brought down his house. He was wrong.\n\nThe Communists, however, were right\u2014oh yes, no doubt even the famine was correct from the high point of vantage, the Kremlin had its eye always on the main chance, for there in the grave lay Lichenko's father and mother, who starved, yet there was he, son and heir, fewer than ten years later at the breech of the rocket gun, fighting loyally to save Moscow, and Stalin, from the enemy.\n\nCommunism, Nathan, is never wrong\u2014as you would immediately agree but not understand\u2014because its only principle is success. Just as yours is failure; what you really love is not the Red Army's victories but the sacrifices and agony required to achieve them. How you would have approved of the famine! ...But the point I wish to make is that Stalin and his gang neither liked nor disliked starving two million people. They saw it as necessary to their plan that they requisition more foodstuffs than the peasants produced. If as a result the peasants died, they simply did not care. Communism is never wrong, Nathan, because it has no feelings at all, certainly no good ones, but no bad ones either\u2014none at all. It is difficult to tell you that, because I have and you have, and furthermore I am a man without ambition and thus discredited.\n\nThe unspoken rang so loudly against his frontal bone that Lichenko could hardly believe Schild had not heard it, too; crystalline, cold, and true it was, like the sound of a gong made of glass. And he had never been a great one for thinking, which was his brother's talent.\n\nOnce before the war his brother in a literary phase had read a book called _The Idiot_ by a writer towards whom his brother had mixed feelings\u2014saying on the one hand he did show a consciousness of something, although on the other he was of course hopelessly something and you could not look to him for something else\u2014at any rate, in an unusually amiable mood he quoted to Vasya the very kernel of what in this writer he thoroughly disapproved: this Idiot, who if that were not enough was also a prince, appropriately found everything strange; but one evening in Switzerland, where typical of the decadent Russian nobility having nothing else to do he went to drink sulfur-water or whatnot, he heard the bray of an ass in the marketplace: \"I was immensely struck with the ass, and for some reason extraordinarily pleased with it, and suddenly everything seemed to clear up in my head.\"\n\nFollowing the quotation his brother observed that heavy silence which means such nonsense speaks for itself. To Vasya it had said nothing until this moment more than five years later when, without the ass's aid, he found himself in the princely condition. Everything seemed to clear up. ... He had stayed on not to save Schild but to understand him, not because Schild was good but rather because he was interesting. It was the game of the Communists, who were never wrong, to save people. For an ordinary man, an idiot, it was enough to know how the next fellow used the privilege and obligation of life, which was not the best thing imaginable, but we none of us\u2014his brother, Stalin, Hitler, the Americans, the prince\u2014had anything else.\n\nNaturally, Nathan had not heard. That inner ear through which the rest of humanity hears the most important sounds is confiscated when one joins the Communists. He had often confirmed this by speaking silently to his brother: \"You bastard, the only reason I wouldn't shoot you if I had the chance is that we have the same blood.\" Results always negative, despite his brother's noted gift for smelling out heresy.\n\nHowever, Schild had picked up a subtler noise which Lichenko missed. His voice became furtive as he left the siege of Stalingrad to warn: \"St. George is coming upstairs.\"\n\nAt last Lichenko heard the footsteps, which being both heavy and soft like those of any large animal but the horse, were unmistakable: those shoes which he so coveted, with their fat soles of yellow gum rubber; shod so, a man could run right up a smooth wall. Why Schild should think St. George a menace, however, was far from clear\u2014if at the same time, as Nathan insisted, and Lichenko had to agree, the captain was also a fool. But a good fool, a jovial one, at least wise enough not to try to be clever. He did not even suspect he had a political as second-in-command, and was the happier for it. In a Russian company the most harmless-looking boob was invariably the secret-police informer. The wonderful American invention was a man who looked his role.\n\nHe lay badly in need now of just the neutrality that St. George dispensed. He readied his mouth to call \"Kom een!\" his pronunciation of which the captain never failed to approve; he was already enmired in St. George's warm sludge, that secure, absolute, fool's medium in which all was forever orderly\u2014when, just as the footfalls reached the door, darkness smothered him in its close sheet.\n\nOutside the window night had come unnoticed, but the room was blacker still, for even a night swollen and dim with cloud has its suggestions of distant fire. Damn you, Nathan, for extinguishing the lamp on a friend! Now what had been merely necessary became imperative. He called to St. George and could not hear his own voice; he strove to rise but lost the first fall to inertia, the second to his knotted bedclothes, and won the third only to hear his quarry pad beyond the bend of the hall. Nevertheless he got to the lamp, eerily not meeting Schild on the way, choked the button in its narrow throat, making light\u2014of which he had the conviction it would reveal nothing but a chamber enclosing only himself.\n\nYet there sat Nathan on his hard chair, on his cast-iron behind, and looking not at all guilty, when for once he should have, but rather self-righteous.\n\n\"Yes, it's all right now,\" he said. \"He's gone to his room.\"\n\nIn the interval of darkness the lamp had prepared for a success, developing its weak yellow into a splendid flare\u2014only to lose the contest to Schild's face, which like unpolished bone claimed all the light and gave none back. He had never looked more saintly.\n\n\"But come,\" he said, rising to Lichenko's aid and fading quickly into his old contrition. \"You shouldn't be up\u2014you'll take a chill.\" He offered to support him and, when that was spurned, walked before, as if he were clearing a channel through some invisible marsh between the dresser and bed; alone and unwitting he went, and no one followed.\n\nFor Lichenko had turned to the big clothes cabinet in the corner next the window, turned the key, and peered into its cavern which gave the illusion of a vaster space than the surrounding room. At one end of the rod Schild's uniforms hung unruly, as if rifled by a thief. At the other, his own, which seemed unusually small upon its hanger; and his boots, bow-legged, slumped, wanting straight heels.\n\n\"My cap, I do not see my cap, and I cannot go without it,\" he said, into the depths but to Schild.\n\n\"Oh yes,\" Schild answered, in a strangely strong voice. \"You will want your cap. Isn't it there on the shelf?\"\n\nSurely it was; he had forgotten the single shelf across the top of the cabinet, perhaps because he was too short to use it, but the edge of the cap's shiny visor poked an inch beyond the board, like the nose of a midget peeking down from hiding, and he seized it. Upon his head the cap was tight, since he had not had a real haircut for three weeks, only Nathan's trim-job around the ears with a little sewing scissors. He also got into his boots, balancing badly on one leg at a time\u2014you cannot live abed for more than a day, even faking, and not feel giddy on your feet\u2014and then seeing in the mirror a soldier on tropics-duty, for he wore cap, olive-drab shorts and undershirt, and boots, he groaned at his stupidity and sat upon the floor.\n\nSchild came to him and, bending over, grasped his left heel and toe.\n\n\"I'll pull and you pull, and off it comes. Ready?\" Before he could answer, Nathan did his part unaccompanied; off it came and then the other.\n\n\"Now,\" said Schild, \"we'll just put these back into the cabinet where they can't be scuffed. And the cap, too. You won't want to get it full of lint.\" He plucked it from Lichenko's head and ran his elbow across it twice.\n\n\"Don't crush my cap,\" Lichenko shouted.\n\n\"Ah no, this is how they brush hats in the fine American stores.\"\n\n\"How am I to know that?\"\n\nSeizing his hand, Schild brought him upright.\n\n\"What you do know is that I have no reason to ruin it, _nicht wahr_? Therefore what I do must be to its advantage.\" He looked very scholarly as he replaced the cap on the shelf. At the angle Lichenko saw that his glasses were covered with a film of dust and at least one fingerprint, distinct in oil.\n\n\"Why don't you clean your spectacles?\" he shouted angrily. \"You can't see out of your own head!\"\n\nCarefully, Schild unhooked the temple pieces from behind his ears, and painstakingly shined the lenses with the small end of his straw-colored necktie, which tonight as usual was twisted ahead of the larger.\n\nLichenko turned aside, embarrassed by the naked face, saying: \"You should not have done that to the captain.\"\n\n\"Then come,\" Schild offered, the glasses yet in his fingers, \"we shall go and apologize to him; I mean, we'll go and _I_ will apologize, and you can see his feelings haven't been hurt.\"\n\n\"Oh, I'm sure of that.\" He reached up under the tunic and drew his breeches from the crossbar of the hanger. No matter where he wandered hence he would never find another man so alert to his moods and purposes, but was that not the trouble?\n\n\"Yes,\" Schild reassured, \"he is just a person. ... But whatever are you doing? You are ill, my friend, and must not worry about your uniform. As you can see I have taken good care of it. Look at the blouse\u2014as clean and pressed as new, eh? And the medals\u2014only yesterday I sponged the ribbons with gasoline. How bright their colors are! See the Order of the Red Banner\u2014\"\n\nLichenko sidestepped him and struggled into the breeches. After the fly was fastened he could hardly get a hand into his pocket, so American had been three weeks of meals\u2014and that, too, was the trouble. He withdrew a wad of marks and thrust them at Schild.\n\n\"Here is payment for the underwear and handkerchiefs and whatever else I have taken, and also the winnings from the cards. You see, I cheated in those games\u2014silly, no?, since I could have beaten you anyway, still I could not resist when it was so easy. But there you have it all back again.\" He threw the bills upon the dresser.\n\n\"Yes, the cards!\" Schild said, desperately exuberant. \"We'll have a three-handed game of something and get old St. George\u2014you'll see he isn't hurt in any way\u2014and take his money. He'll like that, he'll do anything for company.\"\n\n\"As to your personal kindness,\" Lichenko continued, reaching for his blouse, \"there is no repaying that, not when one understands what kindness is, a thing which should make the giver feel good or he should not do it.\" He said more as he crumpled the blouse over his head, but could not hear it, himself. He was so sick of himself he feared he might vomit on the very uniform whose smartness he also owed to Schild. He had learned in fifty seconds that cowardice may be a slow disease but is felt as an instant affliction, and comes more violently in rooms than on the fields of battle; at Kursk, when a Tiger tank broke rumbling and malignant through to their artillery position, he had leaped upon the deck and dropped a grenade down its throat; in _gem\u00fctlich_ Zehlendorf he could not even stave off the insulting of a fool, much less tell the cold truth to a friend.\n\n\"Come,\" said Schild, who looked now as if he were drunk or, rather, pretending to be drunk and wild, in the manner of some honor student ostentatiously letting down his hair at the end of term. \"St. George has a bottle...\" He rolled his eyes in what he surely meant as license, but to Lichenko they suggested those of a horse gone mad with fright.\n\nFright? Why should _he_ be afraid, the one who wasn't taking a risk? Or did his odd sympathy even extend to Lichenko's future troubles in the great world outside?, where, after all, most people had had to struggle all their lives without his help. For the first time he was struck by Nathan's incredible arrogance.\n\nHe buckled on the wide dress belt and strung the breast strap through the epaulette on his right shoulder, and reached again for the boots, which Nathan still held.\n\nBut Schild swung them behind his back, like a child, saying: \"First let's have that drink.\"\n\n\"No, Nathan, I am not fooling any more.\" He took the boots from him and this time sat down upon the bed to pull them on. \"I shall say goodbye to the captain but I want no drink.\" He needed only three drops of spirits to fall unconscious; his head already felt like an electric-light bulb, hot, light, empty, fragile, and loose where it screwed onto his neck; a moment somewhere back he had discovered he was ironically and genuinely ill.\n\n\"Goodbye?\" asked Schild, his voice very ugly, so nasty it caught him up a bit, himself, and he pressed it out sweeter for the rest: \"Where can _you_ go?\" He did not wait for a reply\u2014being already in possession of all answers to all questions; indeed, it was mere courtesy that he had put the statement in the interrogative.\n\n\"Almost anywhere but home,\" said Lichenko, grinning weakly, trying to, at any rate, as his head slowly unscrewed and Schild's image kaleidoscoped with the vivid colors of the hair-lotion bottles on the dressertop. Nevertheless his mind stayed clear.\n\n_\"You son of a bitch.\"_\n\nNathan had spoken in English, that flat, nasal language in which nothing sounded either interesting or important; and so far as he could see him through the spinning, his expression followed suit. Lichenko grinned again, hard and acid, but this time within his own heart and on the terms of his own failure. In the end, how he had conducted himself did not matter, that was the funniness of it and also the horror; in the end, the great truths could not pass through the neck of the smallest one: you cannot stir the curiosity of a corpse.\n\nHe would leave in a moment. As soon as he recovered his balance he would get his cap from the cabinet and walk through the door, down the stairs\u2014the German woman, he reflected, handsome if too thin, would continue to go to seed\u2014and stand upon the threshold, facing outward. One could hope the night was not windy; the world seemed larger when the wind blew, especially if the sky was dark and you could see so little that was permanent. Other persons feared lighting bolts, sunstroke, drowning, snakebites\u2014he had always had fantasies of being blown away in a gale.\n\nIn a moment... already he could feel the strength rising from somewhere down about his ankles, which were firm in the good old boots. You couldn't beat boots, which would hold you erect when you were limp with exhaustion. He could not believe that the Americans, in their low shoes, had much endurance.\n\nAfter looking at him a long time in the same blank way, Nathan had suddenly turned towards the dresser lamp, seized the wad of Occupation marks, and begun to count. It would be an impressive sum, for what Lichenko had won in the cards from Schild were just a few negligible leaves around the fat core of the bonus he had been paid on the day of Lovett's party. The regular pay, in rubles, was allegedly deposited at home against one's return; these marks, intended to be spent in Germany, had on some guarantee of the Americans been printed wholesale and cost the Red Army nothing. They also, if he knew his bureaucrats and their ingenious scheme of allotments, were very likely all one would ever get in his hand. For him, of course, the matter was now academic.\n\nHe would face the world with empty pockets and without a plan. This, he realized, in a chill about the kneecaps which was closer to a falling nerve than a rising strength, was absolute freedom.\n\n\"Yes, Nathan, all of it is yours,\" he said faintly, for part of him was in that state of freedom while the rest held tenaciously to the here-and-now, and his voice was not strong enough to sound both places with the same volume. \"Count it, keep it, spend it. Money is a good thing, _especially for a person of your type._ \" He meant: it may not be grand or powerful, but it is human to know the price of beans.\n\nAs if he had arrived at the total, Schild nodded to himself and rerolled the bills.\n\n\"Thank you,\" he said quietly. \"We are quits. And now if you can spare a minute I must get St. George to come and say his _Lebewohl_.\"\n\n_\"Lassen Sie sich Zeit,\"_ Lichenko answered, \"take your own good time.\" He lay back across the bed and closed his eyes; he felt a small object drop upon his chest and separate like a broken egg; he heard Nathan leave the room. He would sleep a minute.\n\n\"Well,\" St. George had said to Schild, \"I did wonder if he had permission to stay this long away from his company. I did think it was funny.\" In his pajamas\u2014his alternate set, of vertical green and white stripes\u2014lipping an unlighted pipe, smelling of mouthwash, he stood sagging near his window just opened over the black-quiet yard. \"But desertion! I hope you're certain about that. Or rather, I hope you are wrong, because he is a nice fellow.\" He anyway had to sleep the night on it.\n\nSchild neither slept nor tried to, nor could have said how he passed the hours of darkness, for they were too grievous small: a turn of the corridor and already the bathroom window was mother-of-pearl; another, and five o'clock had surely come. Silently he crept into St. George's room and took up the wrist-watch from the bedside table, held the cold snake of its expansion bracelet: only four o'clock in Berlin's delusive and too-early light. Nevertheless he woke the captain, who took his warnings with a face like a stale onion roll and at last rose, puffing and aged, to stuff himself into the uniform.\n\n\"Boy oh boy,\" said St. George when he was dressed. \"Here's a time I would give these bars to anyone who would take them. This is a lousy business I have to do, Nate. You should be glad you're out of it.\" He made a pot of his overseas cap and drew it on. \"God knows what they'll do to him. I don't think Russia's much of a place.\"\n\n\"But then you didn't make the regulations, did you?\" asked Schild, as he pressured him, without touching, to the door.\n\n\"I guess that's how to look at it.\" With a foot into the hall, though, he recoiled and, whispering, brushed Schild's ear with his earnest, bulbous nose: \"But does he know yet?\"\n\nSchild answered harsh: \"Now I would hardly tell him.\"\n\nHe ate this thought like a caramel and, swallowing it, grimaced, and then going into a profound melancholy moved with heavy hump of shoulders towards the staircase.\n\nWithin the hour two military policemen\u2014Americans: Schild had somehow believed they would be Russian\u2014came in tall, thin, and bored from the street, mounted the stair with drawn pistols on white lanyards... and soon descended supporting Lichenko between them, for, still in half-sleep, he could not walk erect and would not try to see with his eyes. Yet at the threshold he straightened, jerked his arms from captivity to fix his cap, said _\"Ladno!\"_ the Russian okay, and walked unassisted in the new, barren day.\n\nSt. George had not returned. His mouth metallic with want of rest, Schild mounted to the room which he had not seen since the evening before and in which he had not been alone for three weeks. Scattered across the bed he saw the roll of marks in the pattern in which it had burst when he threw it. He believed that he should burn them straightaway, but as he stooped to the gathering the door downstairs made its sound and he was hailed by a raucous American voice.\n\nThe taller MP stood wide-legged and screamed up the stairwell: \"Lootenant, did that fuckin' Communist steal your wrist-watch? He's wearing a gold Bulova.\"\n\n\"No,\" said Schild, after a moment. \"I sold it to him.\"\n\nHe thought: I will never know how long it might have gone on if he had not made that crack about Jews and money.\n\n# _CHAPTER 15_\n\nCONSIDERED AS A UNIT, REINHART and Very were some twelve feet, three hundred and forty pounds of person, and, as the beast with two backs, would have ranked in the hierarchy of animal size just after the whale, the Indian elephant, and the hippopotamus. Their coupling, however, was apparently not to come\u2014unless it was she who overwhelmed Reinhart\u2014for all day now he ached with the surfeit obtained in another quarter. Discretion ruled out any further sport at the office, but immediately after work each afternoon he had been calling at Trudchen's little room down the hall, to vault between her soft legs in a ferocity which, though it had long left reason behind, never stayed her call for more and worse. Indeed, it had become S.O.P. for her, just before the climax, to scream into his ear: \"You don't hurt me enough!\" and drive her small fangs into the lobe, which, while it is that portion of the human surface with the fewest nerve endings and correspondingly insensitive, still feels pressure and can swell fat and red with mistreatment and make you look odd as you go about your other business.\n\nBut all in all Reinhart felt very natural and right about the arrangement, as one can only when he so adjusts his life as to be dirty on the one hand and clean on the other\u2014a sort of Renaissance ideal\u2014and therefore hypocritical on neither. With Trudchen there was no pretense of love; with Very, very little of sex; although, not being a brute or a pervert, with the former he did not withhold \"love\"\u2014he was very kind to Trudchen\u2014and with Very his imagination was not so barren as to exclude \"sex\"\u2014he after all kissed her rather more than he did Trudchen, if not in so French a style, and who knew what random transport might seize her in some propitious time and place? Meanwhile, it was satisfaction of a kind of lust merely to be with her, to have her seen at his side by resentful others. Though they were not flagrant: in public they never held hands.\n\nAnd usually they were in public: for one, because even in Berlin, with its acres of forests and ruins, even if you could drag a respectable girl through stocking-snagging jungles, people abounded\u2014Germans of course did not count, but Americans were behind each tree and in the hollow of every bomb crater\u2014for another, having no strong need to tumble her, a man had to find public amusements with his woman.\n\nFor example, the Nazi monuments. Pound's and his tour had at last moved from paper to actuality. One Sunday shortly past noon two of the small vehicles termed \"weapons carriers,\" the parallel benches in their roofless beds creaking with packed behinds in olive drab, tooled from Zehlendorf to the now deranged nerve center of Hitler Germany.\n\nVery's turn was like the stately movement of a world-ball on its axis\u2014not a petty soccer-sized globe, mind you, but the grand sphere that dominates some centennial exposition\u2014as she descended from the truck on the same helpful hand that Reinhart, as official guide, had granted the other nurses in the party. Her other difference was that she gave his fingers a pronounced squeeze, which not only brought pain to his knuckles but also impatience to his heart: there they were, in the great chaotic plaza before the ruined Chancellery and she was obviously unmoved. Not to mention that she had given, he had seen\u2014for on general grounds it was a pleasure to watch her\u2014only perfunctory notice to the legend incarnate of the series: Brandenburg Gate, Unter den Linden, entrance to the Wilhelmstrasse, Hotel Adlon, Foreign Office, Propaganda Ministry; had instead touched her cap, flicked her lapel, straightened her skirt, and coughed ladylike behind satiny nails.\n\nNow she nicely picked, with the others in the party of fourteen, across the center island nasty with torn Volkswagens and an Opel, on its side, showing naked steel supports for a roof long gone, and a lamppost twisted and wilting like a licorice whip on end; in her turn presented the long red pass to the inevitable tommygun Russians at the Chancellery door and was, with stupid, mammary ogling, admitted.\n\nReinhart clove to her side, and the others, officers, nurses, and enlisted men, clung to his; shortly they were all lost together in a choppy surf of crushed marble through which black wires squirmed like sea-snakes. And as quickly were again found, in a vast chamber of pale-gray mosaic, where a skylight of ten thousand broken panes still dribbled glass fragments down the golden incline of sun that met the shrapnel-pitted wall. They stood there, the fourteen, in a noisy, echoing silence of rubber heels abrading marble, inhaling the sour white dust which floated on the air like steam in winter, in their awe daring nothing but to take this polluted breath and give it back at the proper intervals. Over the doorway, a mile down a runway of litter fifty feet wide and to the depth of a horse, the Nazi eagle of stone-and-gilded-bronze. Besides themselves, no man.\n\nNaturally, thoughts of a mighty morality spilled into Reinhart's mind, through, as it were, the skylight: if you seek his monument, look around you; Ozymandias, king of kings, etc.; living and dying with and by the sword. And PFC Farnsworth T. Cronin, who had majored in political science, in Massachusetts, and who at this moment subtly wedged himself between Reinhart and Veronica, intoned softly: \"Power corrupts, and absolute power corrupts absolutely.\"\n\nSidestepping, Reinhart eased over to Very. \"Can you imagine him walking down the middle of this vault, his bootheels echoing for ten minutes before you could see him? He must have looked pretty insignificant in his own house.\"\n\n\"Who?\" asked Very, throwing highlights off the undercushion of her scarlet lip. \"Oh you mean Hitler. But did he live right here in the Reichstag? Must have been drafty, haha.\"\n\nIf you were careless you might identify as imbecility that which was rather inattentiveness; before penetrating the Brandenburg Gate, they had swung left up the squalid lane to the old Reichstag ruin, a long, columned cinder surmounted by a dome burned to chicken wire and facing a park of weeds. In his cicerone remarks Reinhart attributed its burns to a fire set by the Nazis in 1933. Cronin corrected in a voice flat with certainty: \"No, it was restored after that. What you see here came from the bombings and the Russian assault this spring\"\u2014he had apparently snooped in all these places before the tour got under way, while the real men in the outfit were out getting tail. Anyway, perhaps it was just as well this all had eluded Veronica, who also probably failed to notice that thereupon Reinhart suppressed the remainder of his own commentary, not only for the Reichstag but the succeeding buildings as well.\n\n\"My fault,\" he said now, manfully. \"This is the Chancellery.\"\n\n\"The What-cellery?\" But he saw in her blue eyes a candid fooling.\n\n\"Of course,\" said Cronin, studying the mosaics with his bland face, \"we are in the New Chancellery which Hitler built circa 1938-39. The Old one, dating from the time of the Hohenzollerns, is next door.\" Cronin never put his eyes on a person; meeting one on the arctic tundra, with nothing else to look at, he no doubt would try to inspect the wind. A tedious creep, yet you could tell by the measure of his tediousness that he did know whereof he spoke; it were destructive vanity not to use him for what he could provide.\n\n\"If you know the place, Farnie, tell us what else is worth seeing.\"\n\n\"Well, the terrace and garden are certainly _there_ ,\" Cronin answered, almost, in his pleasure, giving one a fair shot at his face, but not quite.\n\n\"Then lead on, McSnerd, and make a trail through the swamp!\" said Very, sending her chime like a bowling ball down the marble gallery. And this time Cronin looked full face, demonstrating above it a dun-colored scalp parted dead center, like a statesman of the Harding era, and wondering, Amherst eyes: wondering not only who she was but why.\n\nEventually they crossed a hall of massive pillars, where Russian names, in their queer letters sometimes just eluding comprehension by a hair, were scratched into the bomb-sprayed walls and from a ceiling of bare girders loose power cables swung like thin pythons anxious to drop upon a meal. And, as a thick, sifting carpet, the usual litter of broken stone, plaster powder, splintered wood, and piecemeal metal, in a quantity which if reassembled, by divine act or motion-picture film run backwards, into its original forms would twice exceed them, for no fecundity can match disintegration's.\n\nReinhart thought about this, but it was Very, with her fine intuition, who said: \"Why when things are broken do they seem like more than when they're together?\"\n\n\"Dunno,\" answered Cronin, who had apparently determined her quality and was peculiarly intrigued by it\u2014he was breaking a trail through the trash, as she had asked, and just for her, while the others mushed ankle-deep\u2014\"no doubt the air between the pieces.\"\n\n\"I don't read you.\" She stepped to the French window, of which Cronin opened and held the shutter and then caught her arm: beyond its threshold was a two-foot drop to the terrace floor.\n\nMeanwhile, Reinhart bulled on through and nearly broke both ankles but recovered with the gay veldt-bound of a springbok. Coming back, he raised his hands under Very's elbows and lowered her like a light barbell, effortlessly, then in malice offered the same to less-than-average-size Cronin, who took it!, being indecently beyond that kind of vanity.\n\nAs the others tumbled through each in his own fashion, a nurse named Lieutenant Leek despite support turning her foot, the trio of leaders waded across the terrace and into the junkyard garden of sand, dismembered trees, disjunctive wheels and pipes and tin air ducts, disjected planks; blooming out of these, in the dirty fungus-white of sunless growths, two concrete structures, pocked by shot, seared by flame, sprouting excrescences of scaffold and webbed iron, yet squatted conditionally whole.\n\nOn the left\u2014they had come round to the far side\u2014was Hitler's bunker, according to Cronin, who named the other, a cylinder with conical roof, as a sentry blockhouse manned by the SS until the eleventh hour. In the deep embrasure of the bunker entrance a detached steel door stood angled; next to it at the same degree slouched a Mongol guard, who at their appearance sullenly presented his shoulder blades and a view of trousers-rear seemingly heavy with a load.\n\n\"Slav slob,\" wittily noted Reinhart.\n\n\"Yes,\" said Cronin to a length of corroded pipe lying at his feet, \"he should be wearing a J. Press jacket and white bucks.\" Although his statement was cryptic, his emotion was not: when he looked towards the guard his eyes were filmy with approval. Then, in the self-congratulatory manner of a white man extending common courtesy to a Negro, he plunged across the debris to the doorway, open pack of cigarettes at the ready position, loudly saying: \"Z-DRAHST-voo-ee-tee, ta-VA-reesch, KAHK pa-jee-VA-yee-tee?\" You could hear all the stresses of the little Russian phrasebook distributed a month earlier by Reinhart's department.\n\nThe Mongol revolved instantly and gave him the submachine-gun muzzle big as a megaphone and all perforated with dime-sized air vents, more death-ray than gun, and if a man ever meant to squeeze the trigger, it was he. But Cronin was a stranger to cowardice; with inexorable good will he advanced, and the Mongol, though snarling imprecations in a tongue that sounded nothing like Russian and never lowering his equalizer, gave ground. Reaching the entrance, Cronin pressed the smokes at him as one might a cross upon a devil, engaged him in a going-and-coming, frustrating inquiry, and was at last driven by him into the waste of loose planks before the SS turret, where Reinhart and Very waited.\n\n\"I'm afraid it's forbidden to enter the bunker,\" he said pridefully, stepping up, as if myopic, so near that Reinhart, always uncomfortable in close approach, backed off, caught his heel in the fork of a grounded tree-branch, and freeing it too violently threw away his balance and fell backwards into a shallow trench which till then no one had marked.\n\n\"But that's the next best thing,\" said Cronin, pretending not to see, or perhaps really, in his odd way, not noticing, as Very howled vulgarly and the rest of the party, clattering through the ventilating ducts, joined her in sadistic mirth, \"that's the ditch where they burned the bodies of Hitler and Eva Braun.\"\n\nReinhart's back-skin bubbled in gooseflesh, more historical than personal, as he scrambled slowly upwards: he had felt a distinct and depraved wish to continue lying there for a while.\n\n\"Ostensibly,\" Cronin went on.\n\nOn the bank now, Reinhart saw in the trench's sandy gutter only an ambiguous rubbish of dead leaves, board-ends, and fragments of paper coarsened and grayed by dried rain. Already he had become as reluctant to kneel and rummage in it as he had been, a moment earlier, to leave its placid bed.\n\n\"Here, in this ditch?\" No, it was too much, along with the imperial chaos inside the Chancellery, to believe; was rather lock, stock, and barrel a vast hoax of propaganda and journalism; normal people like himself not only did not make history but did not see its leavings firsthand.\n\n\"I said ostensibly,\" Cronin answered. \"In my opinion it was a not too ingenious device to cover his escape to South America.\"\n\n\"Oh you don't think so?\" asked Veronica, the corners of her mouth yet remembering the laugh on Reinhart, as did her wet eyes, life-blue in this landscape of neutral tones canescing into time past.\n\n\"If so, it worked.\" Said by a newcomer to the area of the three, a stout captain in green trenchcoat, his shirt collar wearing the doctor's bare caduceus, and Lieutenant Leek hobbled up, and in another moment the others, too, lining round the pseudo grave.\n\n\"Unfortunately yes,\" said Cronin, although the captain had not properly addressed the comment to him, \"anything German always succeeds famously with us. Give Hitler a year and we'll welcome him back to defend us against the 'Reds.' \"\n\nReinhart had got interested in watching the captain, whom he did not know, whose face was manifestly German-American, wide-cheeked, beer-florid, piggishly nostriled, stupid and good\u2014what had it to say in defense of that old seed sprung from this ground and carried across the ocean to form it?\n\n\"Do you think the Reds are a real danger now?\" the captain asked in utter innocence, coloring more, for to see Cronin he had to send his eyes across Very's Himalayan front.\n\n\"Only the American Legion and the vigilantes can save us from them. First, the unions must be stamped out...\" Cronin's face became a mask of crafty evil, apparently mimicking a memory of Goebbels'. \"FDR has already been got rid of, thank God.\"\n\nHow much of the sarcasm, which Cronin injected with real ferocity, astonishing Reinhart who had not believed he could show much feeling towards anything, how much of it reached the captain it was difficult to say. Too little, Reinhart feared, and he hastened to spread it abroad that Cronin spoke in jest.\n\n\"Well,\" the captain answered, humorlessly shaking his thick jowls, \"I don't know it's anything to kid about, if these Reds are going to make trouble just as soon as we get rid of this fellow.\" He pointed into the depression. \"If he means the Communists, I don't think in the end they'd be much better than Hitler. Didn't they make a pact with him which gave him a green light to start the war? And then proceeded to divvy up poor old Poland, even though they later became our allies. Killing people is all any of those fellows know, robbing people and killing them, year in and year out, for no reason at all. I've been a physician for seventeen years but I've never been able to figure out what makes fellows like that\u2014because that's what they are, aren't they, just fellows, people like anybody else in the beginning.\"\n\nExcellent fat captain, with your wide, honest, Nordic face: you have come through! Reinhart watched him kneel like a barrage balloon folding, ever threatening to burst upwards again, and poke into the trench with graceful, doctor-sensitive hands that bore not an ounce of the excess flesh he carried elsewhere. Soon he discovered nothing and rose, despite his weight, easily, saying: \"The American Legion stamping out the unions? I have five or six patients at home who belong to both and I also think they were good Roosevelt-Truman men, and so you've got me all confused.\"\n\n\"Truman, ha!\" snorted Cronin and suddenly gave Reinhart a knowing eye; in this matter he was willing to grant that they shared a community, and what was shameful was that Reinhart had no courage to indicate him nay, from a combination of guilt and vanity was yellow to reveal he stood with the doctor, two dense and heavy light-complexioned oafs who saw the mellow where the bright boys detected the sinister. On the other hand, he, Reinhart, would as soon cut his throat as join the American Legion or a union or the Communists or the Republicans or the New Deal, or any other outfit the joining of which prohibited one the next day from being malignantly anti-Legion, anti-union, etc., which alternation, irresponsible as it might be, to him signified, as nothing else, the precious quality of humanness.\n\nThe others by now had lost interest\u2014in the trench; towards Cronin and the doctor they had shown none to start with or end\u2014and broke their ring, meandering into the rubbish towards the Chancellery terrace and the wall through which they had earlier issued, a series of high windows, shutters in all degrees of angle and caries, above each its own _oeil-de-boeuf_ like the dot to an exclamation.\n\n\"We can split up, if you want,\" Reinhart cried before the dispersal had gone absolute. \"Everybody meet in one hour at the truck outside!\" Two persons made a noise of despair. \"All right, forty-five minutes then. There's lots more to see inside: you won't be bored for a moment.\" Nevertheless he again heard the groans.\n\n\"If little Harry Truman's all that will stand in his way, expect Hitler back next month from Argentina,\" said Cronin, \"and back in the saddle.\"\n\n\"No,\" the captain answered, not looking into the ditch now and not with corny, self-conscious moral majesty, but with majesty nonetheless, the placebo-prescription majesty of the American general practitioner, famed source of the basic wisdom. \"No,\" he said, looking directly and honestly at Cronin, the punk kid yet with downy lip, probably still with Onan as his model, \"no, _he must never happen again_.\"\n\nFrom the exodus one figure lingered back, a first lieutenant who held his doffed cap and scratched a graying sideburn with the same hand. He studied something in the litter on which he stood and called, without raising his head: \"Hey Bernstein!\"\n\nCronin's captain was named Bernstein. He joined his friend, who had found a Wehrmacht belt buckle in the sand, translated for him its inscription, _Gott mit uns,_ and with him, two men whose race was half run, walked out of sight beyond the SS tower.\n\n_Bernstein:_ his forebears, like so many Jews, forced by the census takers to assume cognomens, had gone to gems, precious metals, and flowers for their names, had chosen that crystallized juice of ancient trees on the Baltic coast of Prussia, the sherry-golden amber, for theirs, and, fortune's dupes, brought it to America where its sound was more rasping than lovely on the air, if not downright comic, signifying bagels and upthrust hands. But it was another crime to be laid at the German door and not against the Jews, whose old desert tongue contained no word like \"Bernstein\"\u2014or \"Reinhart,\" which in Reinhart's sudden view was scarcely better and only different from the doctor's in that no one owed it apology\u2014or \"Schicklgruber-Hitler,\" the funniest and ugliest of the lot.\n\nWhat could a man called Cronin say to Bernstein, Reinhart & Schicklgruber, attorneys at law, delicatessen owners, or what have you, who fell out over the fratricide practiced by the last-named? Germans, Hitler's first victims were Germans!, for that's what German Jews were, no mistake; else, observing no loyalty but to their own tribe everywhere alien, they would better have defended themselves. Nay, might have taken the offensive, their noted acumen more than compensating for deficiency in numbers, and launched their own Hitler. But no they had been too trusting, too na\u00efve, too German and not Jewish enough. Jews shrewd? They were rather the rubes and boobs of history; after two thousand years they were still fresh from the sticks, assuming booblike that even in the city men were men and life was what you made it.\n\nSuch innocence was almost wicked. Watching Bernstein's shoulders too heavy to be moved by the effort of walking, Bernstein's too-solid flesh which, if some ambitious or perhaps merely desperate forebear had not shipped the Atlantic, would have by his fellow Germans been resolved into a dew, still hearing oxlike Bernstein's simple, hateless statement that Hitler must not happen again\u2014Reinhart himself, pure Teuton, on the margin of this ditch would have condemned German, no, the world's gentiles to eternal fire and thought it too cool\u2014considering Bernstein the good, the innocent, the Jew, obsessed by Bernstein, Reinhart hated him.\n\nJews really were the chosen, the superior people. This had been Bach's final meaning, only put in the queer, inside-out logic with which the truth was approached by Middle-Europeans, who really were sapient and deep and lived on an old ground ever fertilized by fresh gore. Poor cloistered Cronin, poor dear Veronica, they could not understand irony, that means to confront the ideal with the actual and not go mad, that whip which produced the pain that hurts-so-good, so that in the measure to which it hurt it was also funny. Finally, having flogged and laughed yourself to the rim of death's trench, you looked within and saw irony's own irony: the last truth was the first.\n\nPoor Cronin's hitherto mobile mouth fell open, static and silent at the incantatory syllables of \"Bernstein.\" He could be read like a highway poster: 'Can a Jew, vis-\u00e0-vis Hitler's ghost, be wrong?' Far easier to accept that oneself is an ass. When he closed his lips again he wore a smile bespeaking relief; when he returned to the ivy he would switch his major to natural science.\n\n\"Politics,\" said Very, pressing her bosom like an armload of soccer balls against Reinhart's arm\u2014accidentally?: to study that was Reinhart's own relief\u2014\"thank God that's an Irish trait I don't have! Find a politician, find a crook, as the man says.\" Poutingly she flung away from his side, as if he were sure to hold the opposing view, swinging capelike her soft fall of hair which, seining the sun, caught a sudden amber shaming old Prussia with its clarity and fire.\n\nIn the combination of Very and Trudchen, Reinhart's needs were met. Such a thing was thereby proved possible, contrary to the popular wisdom which crepe-hangingly warned that man, the questing beast, was never satisfied, that worse than not achieving your aim was getting it. Indeed, he was living high off the hog in Berlin. He was rich: Marsala had sold all his gadgets in the black market and, each week, the candy ration. He did even less work than before: now that the tour was set it ran itself and Pound was gone off on leave to Switzerland, of course in the company of Nurse Lightner, where he intended to buy and transport to Berlin as personal luggage a footlocker full of wrist-watches.\n\nOrganize your sex life and all else followed, the phallus being the key to the general metropolis of manhood, which most of the grand old civilizations knew but we in America had forgotten. For example, in Ohio carnal knowledge of a sixteen-year-old girl was a prelude to the penitentiary; they could stick their pointed tits like crayon-ends in your face, wag their sloping little behinds, in summer wear shorts to the junction of belly and thigh, but if you rolled an eyeball towards them you were a pervert. He never entered Trudchen without tremors of retroactive revenge.\n\nWith Very, on the other hand, he was getting back at Germany and all its exoticism gone nasty. That was the great thing about women: with one, you had a place in a context. He had begun to think of himself as the kind of fellow who might one day get married; at least he detected the future inclination. Writing to Pound's wife he had felt vicariously that peculiar pleasure of having an attachment one owed to and was owed by. Love as a mutual debt\u2014certainly it was new to him as he grew old.\n\nNo longer did he spring from bed at Marsala's eight-o'clock clarion, but lingered for a second and a third and then the thrust of a hard hand against his head, at which, still unconscious\u2014which was his excuse\u2014he punched out wildly at his disturber, and even though he usually missed, Marsala stayed sullen all day at these thanks. A mature man should not live with another, but with a woman from whose soft lump beside him under the steaming, odorous blankets he can take a motive to rise, the sooner to be off to honest work, the sooner to be home again as evening falls to meet this sweet dependent, now the smiling presence of the succulent table, prepared for two and not five hundred.\n\nYet what honest work? Had the war not come he would now have been for a year and a quarter a Bachelor of\u2014what? A process beginning in Central Europe in 1933 (Carlo had a popgun, wanted an air rifle), or 1924, then: Hitler, having failed to capture Bavaria with his private army of cranks and loafers, sits in the prison of Landsberg am Lech dictating to Hess a lunatic statement of aims which two decades later when they have been realized to the letter are still unbelievable (umbilical cord severed and tied, Doctor slaps Carlo's bare bottom, Carlo wails, he is human and alive), a process whose origins are in the mists of the past, whose products are millions of dead and a continent made garbage\u2014this same process, the blowing of an ill wind, solves for one young man a dilemma, what to do with himself?, but only for the nonce.\n\nInsurance? His father could get him in at Ecumenical Indemnity (Laughter). The campus again?; this time indebted to nobody: \"they\" were going to make it free for veterans, no selling apples this postwar. Which meant either of two: either everybody would go to college, and being mass it would be mean; or none of the ex-servicemen would go, leaving the same old collection of pubescent punks he had got his fill of long before coming to occupy Berlin. Germany itself. Take out papers, if you could find a government to become a national of. Pose as a mustered-out SS man, for which you had the proper appearance, make a living in chocolate bars and Lucky Strikes, pimping for Trudchen. Or merely sit in some congenial ruin and weep away to a skeleton, for what as a German you did, as an American you did not do, and as a man you saw no fit atonement for.\n\nSince his needs were met\u2014women, riches, life of leisure, _gem\u00fctlich_ flat, loyal friend (who else but a true-life Horatio would dodge punches to do one a favor?), his connection with history (American news correspondents staged a spontaneous demonstration of Berlin GIs celebrating the Japanese surrender; photographed it; Reinhart stood upper left dutifully tossing his cap towards the sky)\u2014since all these holdings were verifiable to the senses, euphoria must, by definition, ensue.\n\nYet, within the very seed of comfort he detected an inimical, corrosive juice which like the acid in a hand grenade waited tirelessly on the pulling of a pin to begin incendiary mixture. Satisfaction was his, but so also was a growing conviction it should not be: why should he alone be rewarded when the rest of the world was taxed? Even the other Americans had their troubles, wanted grievously to go home, suffered in what he so grossly enjoyed.\n\nHe began to fear his own compulsions; if he did not hurt Trudchen enough, neither did she him, and it was not because each did not try. Violent as it was, that plunging to explosion only suggested a damage he could imagine but never yet achieve, that catastrophic end the reaching of which he came, in a kind of pride of horror, to believe was his true vocation. Truly, Trudchen was too depraved to defile and too small a mount to ride to victory.\n\nVirtually unused went his murderous-muscled body, the welted hands with one of which he could have lifted Hitler and cracked off that weak neck like a sparrow's, penetrated Goering's breadbasket as a thumb would sink into a rotten pear. Where was the game worth the candle, where now, standing in the empty stadium, too late, alone, a lackey groundskeeper amid discarded programs and ticket stubs, where now to find another contest?\n\nTime had fled. _Berlin bleibt doch Berlin,_ as the natives said, but for the original occupiers\u2014the 82nd Airborne having replaced the 2nd Armored, Reinhart's medics were seniors in service and disenchantment\u2014as September approached, it was a different city from that Newfoundland into which their trucks had rolled on a sun-swept afternoon in July. The aftermath of war had shaded into the onset of peacetime. Regiments of women in kerchiefs and dark stockings labored to clear the bomb-sites and reclaim sound bricks. The Russians freed and dumped into the Allied sectors some thousands of Wehrmacht prisoners, who staggered along the main thoroughfares tattered, hollow-eyed, embarrassing civilians, panhandling American passersby. The black market shrunk from too-flagrant spectacle. The newest currency regulations were difficult to evade: Pound converted his Swiss watches into Occupation marks\u2014and because the going price had fallen with the replacement of Soviet combat troops by a more conservative element, nonrapists, small spenders, of a dour respectability, got only half as much as he would have in July\u2014but could not get them into dollars and home. \"Here I sit,\" he said to Reinhart, once for every hour they spent together, \"with my finger in my ass and one hundred thousand marks.\"\n\nWith the new Russians came fewer explosions from their sector, although incidents, frequently mortal, continued. Earlier they had shot Allies and one another in jest; now the motive had changed to a solemn dislike. Americans were counseled to avoid the eastern quarters of the city, were seduced to remain on home ground by a grandiose Red Cross Club on the Kronprinzenallee, where in the stately dining room a string ensemble in threadbare tuxedoes ingratiatingly whined and the fare was sinkers and coffee in individual silver pots; by the Uncle Tom movie theater on Onkel-Tom-Strasse which led to a structure called Uncle Tom's Hut in the Grunewald Forest, the name German-given, long before VE-Day, for a reason no GI could grasp; by the Berlin Philharmonic, at concerts in the Titania Palast in Steglitz, though soon its conductor, out legally one night after curfew, was misunderstood by an American sentry and shot dead.\n\nPersonnel who numbered their years in the late thirties or more were shipped back to the States as senile. So went Reinhart's friend Ben Pluck, in civil life a lawyer; in the Army, having declined to serve, eternal PFC. Others left on longevity points; thus transported was Tom Riley, from across the hall, saddening everyone whose flat lay adjacent to the stairwell; no more would the iron treads echo his jovial filth.\n\nIn the latrines they predicted the 1209th would go to Osaka, Japan, where the bearded clam ran crosswise, or the Azores, as in the limerick about sores, or as a kind of liaison force to the Turks in Istanbul. On the wards were one hundred twenty complainants of nasopharyngitis, all on the light diet. The colonel ate out the assembled officers and nurses on the subject of fourteen spent contraceptives spiked off the hospital grounds on the lances of his sanitation crew, directing his remarks principally to Chaplain Peggott and Major Clementine Monroe, the superannuated chief nurse.\n\nEverybody in Reinhart's apartment building had a local mistress save two ethereal privates from Supply, who had each other. Don Mestrovicz, technician fourth grade of the EENT clinic, had two in the same family: a mother still young enough, a daughter just old enough, to whom he was the filling in their sandwich. Corporal Toole from the motor pool owned a big round woman with a behind like the belly of a lute. Bruce Freeman, of X-Ray, had an ash-blonde named Mimi Hammerschlag who played bit parts in Ufa pictures; Jack Eberhard, company clerk, a dishwater blonde who like him made strange noises when drunk. Sergeant Deventer's girl could do a take-off on Hitler with a comb for a mustache; Bill Castel's woman, an artist, cut out his silhouette in orange paper. Ernie Wilson's piece was three weeks pregnant; Roy Savery's, one month; five others professed falsely to the condition, three of whom named the same sire, T-3 \"Plumber\" Cobb\u2014he laid a lot of pipe\u2014but were duly unmasked. And Farnsworth Cronin was sometimes seen with a boyish girl whose name was spelled _Irene_ and pronounced _Ee-ray-nuh;_ he, however, called her _Boo._\n\nSupply outfitted everyone with short jackets, like Eisenhower's, calling in the old skirted blouses. All noncommissioned officers in the ETO were granted a liquor and beer ration; in the 1209th these were consumed on the rear balconies, feet on ledge, cigars in jaw, and in the company of the girls, who giggled much and sometimes sang in English. No Werewolves having turned up, the district order that US personnel carry arms when off compound\u2014the medics, their red-cross sleeve bands\u2014was rescinded. Under the authority of the Information and Education Program, Gerald Gest was sent to Paris for a month to study French civilization at the Sore-bone, and a class in basic psychology, meeting once a week in an empty storeroom in headquarters, was offered to qualified enlisted men, which meant everybody; in its chair, PFC Harvey Rappaport, MA from NYU.\n\nA sandy-haired corporal named Gladstone, who worked in the post exchange, blew out his brains there one night after closing, leaving no note. Veronica's neuropsychiatric ward, already so crowded that three patients bunked in a supply room, somehow stuffed in five more beds. Walking past its door you never heard a sound, although by her account half a dozen patients wept all day and another man made squealing noises with a finger against his teeth. A paratrooper, under observation for persistent bed-wetting, was discovered to be a poseur\u2014in the wee hours he did not really wee-wee but soaked his mattress with H20 from the bedside glass\u2014and sent back to his outfit on charges of malingering. A tentatively diagnosed schiz struck Lieutenant Llewellyn, assistant psychiatrist, in the nape, knocking off his glasses, then sought to crush them but couldn't with bare feet. Another patient, a brawny man with the hair of a goat, incessantly planned to become a novice in the Carmelite nuns.\n\nNo doubt it owed to such spectacular persons and events that Veronica by the fourth week of their acquaintance had lost her bloom, or rather that part of it which was rosy towards Reinhart, who suspected that being normal he bored her. And he could not very well divulge the doings of that other self who lodged with Trudchen, the mad one, the one with passions which, being there resolved, freed this one, the front man, to be so smooth and bland. Back there, Himmler did his dreadful work; up here was elegant Ribbentrop, kissing hands.\n\nFor years he had cultivated the art of surrender to women to offset his bulk, which sometimes on its approach caused, particularly small, girls to look for cover. The brute tamed by gentility, the handsome and moral equilibrium of opposites. No, its validity consisted only in the abstract, never in practice. For instance with Very: he cared little about the destination of a date, so long as it was not an official Army entertainment where they must be separated by rank. But Very had for the movies the insatiable hunger with which it was said expectant mothers went to dill pickles\u2014a touch of madness for them, really, Western, gangster, comical, historical, pastoral, pastoral-comical, historical-pastoral, any passage of arc light through celluloid into minuscule glass beads generating counterfeit life, but especially Dramas in which any one of those actresses with big eyes and hard white jaws, dressed in jodhpurs, carrying whips, riding stallions, of course gelded, consummated a union with the scion of a swell family of old Virginia and ate for breakfast grapefruit in a bed of ice, her nostrils flaring.\n\nIn the absence of an enlisted boy friend this taste would have carried Very every evening to the Onkel Tom Kino, to that roped-off centrally situated block of seats exclusive to officers, there for two hours to shuffle off the coil of banal mortality.\n\nNow if this was her pleasure, and as a gentleman his was in seeing she received hers, why now admit obstruction? \"Look, honey, don't worry about me. I'll sit back in the enlisted section and meet you outside somewhere when the show's over.\" \"Now you're sore.\" Of course he was not angry, just piqued at her resistance to civility. With the best intent in the world she went on: \"No, tonight we'll do what you want.\" \"I want to see the movie.\" and usually they did, segregated for two hours and when afterwards they met, Veronica, and not he, looked miffed.\n\nAt other times when there had been no conflict of wishes, when they had taken long night strolls sometimes as far as the walled villas of Dahlem's tree-murmuring walks (almost the only alternative he could offer to the movie-show, which was another reason for his reluctance to prevail), necessarily avoiding society, when they should have formed not two but one, in a sealed capsule of mutual affection, Veronica had lately seemed, not exactly withdrawn, but at least preoccupied. Working with these lunatics all day\u2014apparently her thesis that they got worse in peacetime was daily confirmed\u2014what could you expect? At first he tried to jolly her out of it, but in itself it is a morbid thing to have to cheer a woman, a transposition of the proper roles, she being by nature equipped to bring joy, while man is the rightful brooder.\n\nAnd considering the precise Very, unfortunately her physical design was not for melancholy. When not in the mobile oval of laughter, her mouth formed a horizontal too broad; her chin appeared square and somewhat virile; when not quivering, her nose was a mere cartilaginous organ, not altogether true, for the induction of breath, and one could understand that it might turn crimson with the grippe. Her eyes when solemn were too pale a blue, the little skeins of iris-color patchily breaking unity, and was not the right one a lash-breadth off the zero aim? Not stimulated, her blood declined to flood her cheeks, and once, at the corner of Max-Eyth-Strasse, in the side apron of his flashlight beam he saw her face was ashen.\n\nVaguely desperate\u2014for he _was_ extremely fond of Very; not in love, actually: that was just something he had thought\u2014Reinhart conceived a plan to get her into the fresh daylight air with a view of water and woods, away from minds, anyway, for one afternoon. He organized some hardboiled eggs, canned meat, and other junk from the mess sergeant, even borrowed the still half-full jars of mustard pickle and mayonnaise Bruce Freeman's mother had mailed that gourmet, and one Wednesday, which that week was Very's day off, with her set out for a picnic on the shore of the Havel.\n\nFrom the beginning, from the moment Corporal Toole let them out of his jeep at the woodland corner of Pfaueninselchaussee and Koenigstrasse, everything went right. The better part of an hour went before they gained the shore, but Very's color improved with each brisk step. At intervals Reinhart hopped off the road into the forest, to bring back talismans: a spray of lace fern, pine cones, a root like the trunk of an elf-woman, a stone resembling an eye, and of course, even out there, a clip of rifle cartridges. Excepting the latter, he gave them one by one to Very, who by the fourth presentation complained of loaded hands, twitted him for his idiocy, and, at last, laughed\u2014perhaps only a snicker, but her first in a week. He was rapidly bringing her back.\n\nOn the beach, of which, wandering to the right from the spit pointing towards Peacock Island, they found a length unoccupied by military wreckage, Reinhart brought the goodies from his musette bag. In a messkit bottom Very mashed the eggs with mayo. When Reinhart bit into the first sandwich a fragment of shell cracked between his teeth, just as if he were home. He ate two, and then one of Spam, and then three pairs of saltines enclosing a hard cheese the color and taste of GI soap, and then an orange\u2014for he had brought nothing else for thirst\u2014and Veronica joked about his capacity. The scorings he had lately noticed in her cheeks were but night shadows, already dispersed by the sun.\n\nHe lowered his head against a massive log half-buried in the sand and extended his legs luxuriously, out, out, out, toes towards the lake, taking the pleasure of a prolonged stretch, rather like that of a mild orgasm, grunting, eyes narrowed, arms going back over the log. Five yards away the water munched quietly on the sand. Across against its far margin, the dark horizontal of the Kladow shore, a white sail quivered. On the left, and so near that in his view it seemed not an island but rather the other side of an unbroken bay, lay the Pfaueninsel. A suspicion of autumn, a certain chill filament woven into the otherwise still very warm fabric of sunlight, rather imagined than felt, and as yet too thin to penetrate vegetable nature, was felt by Reinhart, in whom it engendered a sad, sweet deliberation on the coming death of the year; and since the end of anything is peace, his heart, too, like Very's, fell placid.\n\n\"Ah,\" he cried suddenly, sitting up, \"we forgot the mustard pickles!\" He unscrewed the jar and offered it.\n\nVery, while he had unfeelingly stuffed himself, had not eaten a bite, he now noticed retroactively; and the flush in her cheek was nearer the introduction of illness than health returned, as she stared with terrible white eyes into the jar and said, feebly: \"They look like alligators in the mud.\"\n\nShe raised her stare to him, and he saw in it a catastrophe from which he would fain have run, had it not been intermixed with a beautiful weakness towards which his manhood inexorably flowed as all streams to the sea. She had essayed a joke, but tears caught her hard upon the last word. Against his chest he brought her weeping, fragrant head, and told close into her ear the platitudes of comfort.\n\nShe shortly pushed him off in a kind of anger and, with eyes still melting, assigned all guilt to him.\n\n\"If this isn't anything, nothing ever was: I am pregnant.\"\n\nAt the edge of the beach, a fish, or a frog, or some other animate and lonely thing, loudly slapped the water and sank through a necklace of air bubbles.\n\n# _CHAPTER 16_\n\nNEXT CAME THE INSECTAL hum of a far-off engine, in perfect rhythm with the prickling of Reinhart's hide. Unless nocturnal fancies could inseminate, his tremors belonged to another man, for he, Reinhart, had been no closer to Very's reproductive area than the line of her belt. To put down the guilt, he developed a fury: And I, he raged in secret, I have always acted as if she didn't have a \u2014\u2014 (the good old bare word from the honest Anglo-Saxon culture of artisans and farmers, dating from a time before the mincing French crossed the Channel, before the eunuch scholars began to drone in tedious Latin, and eons before small Reinhart belatedly learned from a schoolmate that females are not smooth between their legs and do not produce young by unwinding at the navel).\n\nAnd by extension, the term applied not only to the orifice but also to that woman who made free with hers. In love with a\u2014 but he would not think it again, this short, blunt syllable which in barracks was aired as frequently as exhausted breath: he would not because \u2014\u2014 ness was not here at issue. Suddenly he envied her her achievement, lusted not for her body but for her trouble; wished he could weep for having committed a grand foolishness and be comforted by a big disinterested horse's ass who never took a chance; began himself to grieve for all the errors he never made, all the disasters that all at once he strickenly knew would never ruin him\u2014except that, so far as was apparent to the outside eye, he stayed slick and bland. Control. How detestable it was, control; how uncontrollable. How selfish!\n\nWildly he seized her again, this woman attractively defiled with adventure, for the first time his hand went where the eye's fingers had so often dawdled, to the great hemisphere of her right breast and then to the left, circumnavigating like a Renaissance explorer. Licensed, it was a disappointment; and indeed he knew not why he toyed there, since his purpose was, with lump in throat, self-sacrifice.\n\nHis one hand still mobile and encountering more brass button than pendulous woman\u2014at least, that must be what was cutting him\u2014with his other Reinhart lifted her rinsing face, now of a more poignant beauty, pale, implying the sanctity of a plaster, Hibernian-featured Virgin, so much more moving than must have been the real one, dark and muttering in guttural Hebrew. Deep into her eyes he was careful not to look, as he said: \"Very, I will marry you!\"\n\nWhat did he expect?: at minimum that the rivulets would cease to flow? Rather were they renewed, as like the heat of summer reaching the highest snow, a brilliant flush mounted to her forehead and a greater rush of water came down.\n\n\"How can you!\" she wailed. \"You are not Catholic!\" Repeatedly she struck his chest with her balled fist, no doubt leaving bruises.\n\nJesus Christ. Like a mongoloid he stared expressionlessly at the lake. The hum of the engine had grown to a still-distant roar.\n\n\"Isn't there anything I can do?\" He heard himself say it and was astonished by the mousiness of his tenor.\n\n\"Hold me.\"\n\nHe did, with static hands, and squeezed her, and pushed his nose into her soft hair and breathed relief that he had not really loved her but only thought so for a while.\n\n\"But Him, what about Him?\"\n\nBecause he had clearly pronounced the capital, she germanely asked: \"God?\"\n\n\"Christ sakes, I mean the guy, who certainly wasn't me! The Invisible Man, because I was under the impression I saw you in all your off-time\u2014unless of course it was one of your psychopaths during duty hours. Is that now part of the therapy?\"\n\nIn more abandonment than she ever showed while necking, Veronica snuggled into him. \"Go on,\" she whispered, \"say anything, I deserve it.\"\n\nNo, with just that quantity of censure he was done. Reinhart on the judicial bench would have freed all malefactors who pleaded guilty, for what could subsequent punishment do but incriminate the judge? Besides, he recognized in his coarseness the tedious old suburban lie that the sexual life was to be regulated by a middle-aged housewife's sense of right and wrong. Screw, screw, screw, if you wanted to, he was proud to think was his credo; and that his own girl friend sported on that plan was the sincerest form of tribute.\n\nStill, if that were her taste, why had she to look elsewhere from him? He was not repulsive to women; time past, he had actually spurned unsolicited advances.\n\n\"Who am I to say anything?\" he asked, now looking into her eyes. \"I'm nobody\u2014as you have proved.\" He attempted to loosen their connection, but she had clasped her arms about his waist and locked her fingers, as in that test of strength in which you try to crack the other fellow's spine.\n\n\"You're the best friend I've ever had. Do you think I could tell anyone else?\" Her mouth with its liberal lipstick was crushed against his blousefront; on the journey home he would look as if he had been shotgunned in the chest. In her rich hair, which was no longer his property, was caught a fragment of twig, which, nevertheless, he plucked out. That dear fragrance which in the old days clung to his cheek for hours after leaving her, which during a night of sleep transferred to the hood of his sleeping bag, where he could smell it next bleak morning, now penetrated his nostrils as he supposed a sister's might, stirring mild affection but also thoughts of silly stench.\n\n\"I know, I'm like a brother to you\u2014but God damn it, Very, I never knew that till now. You've made a fool of me.\"\n\nThe chopped-egg sandwich Very had made for herself and not eaten, already slightly wilted, lay upon the green canvas of the musette bag. Still holding her, he took it and began to bite off the valances of squeezed-out filling. He did this theatrically, playing the conscious role of a person who vulgarly stuffs himself at high moments, learned from the motion pictures.\n\n\"Well, now what are your plans?\" he asked. A bit of egg fell, narrowly missing the gold bar on Very's right epaulet, the tracking of which brought his glance to a side view of her cheek and his attention, since her eyes were closed, to the matter of whether or not she had gone to sleep. \"Hey,\" he said, striking her roughly with the blunt of his palm, \"recover! What are you going to do now? Look, first, are you dead sure? You know swimming will delay it, and an illness too, I think. Didn't you have a cold last week?\" Without physical intimacy he yet knew very well the schedule of her menses: the laugh was not so broad in that quartet of days, and she sometimes complained of headaches. It was just, or should have been, over.\n\n\"I've had the Curse enough years to know all its tricks,\" she answered wryly, cocking up a brow that suggested the old, witty Very's\u2014and he would have liked to catch her there, saying That's it, hold it right at that point and nothing is lost, but she was seized sooner by her own voice, which wavered and ended brokenly: \"This time it's for real.\"\n\nAh, Reinhart thought, means business, does it?; isn't kidding around; no joke; on the level; for real. Perhaps he believed that nothing ever happened to him because when it did, its effects were stated in barbarous language. Once in Piccadilly talking to a streetwalker he heard overhead the Model T chatter of a buzz-bomb and thought he might die, there in the thronging black street, while a whore said \"Coo, ain't it a loud one? Four pounds for awnight, I'm no bawgen basement.\" His apprehension proved baseless; the bomb sailed on to detonate in some working-class quarter, where the survivors climbed from the smoking ruins to say \"Gor, that wasn't 'alf close.\" Poets are never bombed and, if women, never knocked up.\n\n\"Well, what am I to do about it, since you so nicely included me in? I don't want in\u2014you might say, I never _got_ in.\"\n\nObviously with Very it had been love; and hardly the kind he talked of to himself in his childish way\u2014never again! Very in love, a victim of the conquistador passion; what would ten minutes earlier have been impossible to accept was now only difficult. At least she displayed one requisite of the authentic state: sorrow.\n\n\"You?\" she answered. \"It isn't your trouble, Carlo. You could just get up and walk away from me\u2014you ought to. I can't ask anything of you.\" She finished crying and sat stolidly in that neutral condition which precedes the return of vanity; unlike Trudchen she looked older without make-up. She _was_ older than Reinhart by three years; his girls always, saving Trudchen, were; one's elders are kinder than his juniors and peers. Maureen Veronica Leary, from a suburb of Milwaukee fittingly named St. Francis, graduate of a grade school, high school, and hospital (on the three-year wartime crash program) each under the rubric of another saint. She had a brother and three sisters, all older, and her father, a retired street-railway motorman, told stories of Galway, where the supernatural was commonplace, although he hailed from a town near Dublin named Blackrock. By the time toys and clothing had come down to Very, stuffing leaked from the dollbabies and the stocking-toes were lumpy with darning; but once when she was twelve her father, drunk, brought home a pair of rollerskates her very own. Her mother stood five-ten and her number two sister, just under six and was unmarried at thirty.\n\nSo much had Reinhart, in the normal course of events, learned. But who was the real, the essential Very?, to the exterior of which he had been attracted by its air of simpleminded jolly Catholic health. Perhaps a pagan. Not only did he usually go for older girls, he also had a weakness for Roman Catholics, who even when Irish remembered the Latin basis of their persuasion and were very feminine, seldom prudes even when they would not submit: to them a man's appetites, being natural, being God's splendid trick to ensure the race's continuance, were never, even when illicit, loathsome. Now he realized he probably could have, with Very; too late he remembered her constant surrender; indeed, she at the outset had chosen him and then waited in vain.\n\n\"You're in love with this guy, is that it? I suppose you don't want to tell me who he is.\" She still sat within the enclosure of his right arm, while his left, propped against the ground, suffered a slow paralysis. The sand worked up under his fingernails and shortly into a small, smarting cut on the first joint of his thumb, on which he had forgotten to put a new Band-Aid after removing the old one that morning. He had damaged himself on the clip of Trudchen's brassiere, which lousy German thing was not a simple hook-and-eye but a pronged buckle with criminal tines. Since in his subsequent lust he had not taken care, if she had VD he with his open wound was a goner. Ah, accept it, we are all submerged in filth up to our heads. Accepting which, he saw the one man who was exempt emerge from the high thicket of marsh grass thirty yards down the beach.\n\nPreceding this, the engine noise he had unregisteringly heard earlier, had grown loud, identifying itself as an outboard motor; had come so thundrous close to their position that Reinhart expected momentarily to be swamped but didn't care; had, just as it must either become visible or explode, shut itself off with two loud farts in the marsh, yet unseen. Within the minute, this person in black beret and bulky coat appeared, stamping down the last few rushes which denied him clearance to the beach and, that done, seeing them\u2014not necessarily looking towards them, but seeing. By the man's use of this unusual faculty Reinhart recognized, despite the altered outline, Schatzi; who surveyed the four points of the world and approached.\n\nFearfully Reinhart promised Very they would return to her business later and ruthlessly withdrew his arm. Not adjusting to the new arrangement, Very stayed numbly huddled, leaning against\u2014nothing, for Reinhart was already on his feet, obstreperous in greeting.\n\n_\"Guten Tag! Wie befinden Sie sich? Wir machen ein_ \u2014 _wie sagt man_ 'picnic'?\"\n\n\"Just so,\" replied Schatzi, ten yards away and apprehensively halting there as if he foresaw an attack. \" _Picknick,_ one and same.\" He winced obsequiously. \"Do I receive your permission to come there?\"\n\n_\"Wo?\"_ Reinhart was still yelling as though his auditor were in Kladow.\n\n\"In the vicinity of you and your lady.\"\n\n_\"Warum nicht?\"_\n\nSchatzi came, still cautious, shoulders thrown high and hands buried in the pockets of the great overcoat, which was a dirty teddy-bear plush and fell to his ankles; scarred face contorted below the beret like a withered acorn in its cap; feet, of which only the neat little brown toes were visible, scuttling forward, one-two, pause, one-two\u2014his overcoat fell past his ankles to brush between his footprints the spoor of a tired fox that drags its tail.\n\n\"Fancy occurring here with you,\" he said when he arrived, gauging on the balances of his eyes a specimen of flesh from both the large lumps before him: the one on the ground and Reinhart.\n\n\"Whatever are you doing here\u2014way out here?\" asked Reinhart, altering to superiority. At the same time his unease grew more severe: he was certain Schatzi thought he had again caught him in a screw, or just after; for a crazy moment he suspected Schatzi trailed him for just that purpose.\n\n\" _Ach,_ business, always business\u2014your gentle lady, she is ill?\" At last Veronica acknowledged his arrival, looking up with forlorn-beagle visage, saying naught. He removed his beret.\n\n\"Just tired,\" said Reinhart. \"We had a long\u2014\" he lost his voice as he watched Schatzi prepare and deliver a massive, obscene, hideous wink. However offensive, it was mesmeric: the lid flattened and then went concave, seeming to close upon a hole rather than a ball. More horrible yet, Reinhart helplessly felt his own eye return the favor.\n\n\"We had a long walk,\" he said quickly.\n\n\"Exercise, ceaseless exercise,\" said Schatzi benignly. \"Well, why not?, as you say. You are yet top young for a _Herzschlag, ja_? _Auf Englisch hei\u00dft das_ 'failure of the heart,' am I correct?\" With fingers like wire-clippers he pinched a bit of jacket, shirt, and skin on Reinhart's forearm. \"Your lady as well, though. Whatever will be her difficulty? Paleness! Ah, right in the pocket I have this brandy which will make the trick.\"\n\nIgnoring Reinhart's weak verbal opposition, he withdrew a silver flask, unscrewed the cap and let it dangle upon its little chain, hitting the body of the vessel _tok-tok,_ and stared down onto Veronica's crown.\n\n\"She doesn't want any,\" said Reinhart, but so as not to offend Schatzi he offered to take a draught himself.\n\n\"Who doesn't?\" Very, who had been playing no heed, now with violent interest seized the same forearm that had been pinched and pulled herself up. Daintily accepting the flask, she arched her neck like an old grad under the stadium and drained off quite a large slug, then paused to take air and would have returned to kill what was left had not Schatzi, deft as a mongoose, leaped into the breach between her movements and reclaimed his property, saying: \"Already better, _ja_?\"\n\n\"Whew!\" whistled Very towards Reinhart. \"That went down like a whole loaf of bread.\" She gulped five times and smoothed the sitting-wrinkles from her skirt; lingeringly, with some evident pleasure in the touch of her own belly and thighs. Schatzi averted his face, as if offended.\n\nIf so, how right he was to be. \"At least thank the man,\" Reinhart muttered low.\n\n\"I don't know Kraut.\"\n\n\"Haven't you just heard him speaking English?\"\n\n\"I'll take your word for it.\" Turning to Schatzi, she asked, naturally very loud: \"Hey, didn't I spot you hanging around in front of Lieutenant Schild's place the other night?\"\n\nSchatzi twisted his neck to favor the left ear. \"Spot? Hanging?\"\n\n\"On the level now, weren't you? Oh, you weren't in that getup. You had on a cap with a beak and you sat on a bike. Well what I mean is, it was you, I know. Come clean, I won't blow the whistle on you for being out after curfew.\"\n\nReinhart made the sound of a bellows. \"Damn it, Veronica, what do you think our friend will be able to understand of that?\"\n\nBy way of answer she simply smirked: drunk, apparently, or pretending to be from the moment her lips had kissed the flask. It was a way out of her difficulties.\n\n\"She thanks you very much,\" said Reinhart to Schatzi, who was confusedly repeating under his breath, 'cap with a beak, sat on a bike.' \"And she thinks she saw you last night in front of the house where\u2014where lives an officer she knows.\"\n\nWhere lived, indeed, to admit to himself the complete data, Lieutenant Schild. _Lieutenant Schild._ Which, admitted to the mind, was instantly transformed to: _that Jew._ Who hath usurped my office twixt the sheets? The Jew, the Jew...\n\n\"Lieutenant Schild,\" repeated Schatzi, wonderingly, pointing his ridged carrot-nose towards the lake, high; meanwhile his eyes went everywhere else. \"Lieutena\u2014wait a moment, I think\u2014no. _Also! A_ great fat beast of a man, with a mustache like a broom, and an implement to his speech, so that when he says something he makes this sound between the words: _shicksh, shicksh._ Now tell me am I right?\"\n\n\"He is thin and dark,\" Reinhart said evenly.\n\n\"Yes, an Italian,\" Schatzi smiled his recognition. \"Yes, I was able to obtain for him\u2014you will pardon me, Madame\u2014some items of which we shall only say they are worn by the ladies and cannot be seen unless one is\u2014please pardon me, Madame\u2014in a relationship of intimacy.\" He laughed quaintly: \"Hahahaheeheehee,\" colored, and said: \"Now I have gone too far.\"\n\n\"That isn't possible in the present company,\" Reinhart answered hatefully.\n\n\"Oh, he speaks English all right, but I don't get a word,\" said Veronica to herself, and then to Reinhart: \"Ask him if I can have another drink of that radiator fluid.\" She threw up her hand. \"I'll pay him for it, don't look so ghoulish.\"\n\n\"Nonsense,\" said Schatzi, already presenting the flask. \"My compliments. You are a friend of Lieutenant Schilda? Please, I do not mean to offend.\" Again he laughed, this time in a very horsy manner with open, serrated mouth. \"Herr Unteroffizier Reinhart, please tell the lady what is the joke.\"\n\n\"I wish I knew it myself,\" Reinhart said sullenly. \"I wish I knew what was so goddamned funny.\"\n\n\" _Also,_ Schilda is the town where the fools live. What is it in the States?\"\n\n\"Reinhartville,\" said its exclusive inhabitant, watching Very swallow the rest of the brandy. With gelid courtesy he accepted the weightless flask and gave it to Schatzi. \"Well,\" he said, turning to her, \"your troubles are solved. Since Schild is Italian, he is also Catholic. He can marry you, and may I say no one would be more appropriate.\"\n\nShe failed to answer. Already her eyes were distorted, as if one saw them under water.\n\n\"You will mah-ree Lieutenant Schild? How lovely,\" crooned Schatzi, moving in upon her, thin jowls tremulous, as an ambitious chihuahua might approach a mastiff bitch. \"I can furnish food and drink for the feast. But you must both soon go back to the U.S. When?\"\n\n\"See what I mean?\" murmured Very. \"If that's English, I'll eat it.\" Now her eyes looked as though a hair were drawn across each retina. By age thirty her figure would be throughout, like a Balkan peasant woman's, the diameter of her chest; her abdomen in permanent pregnancy; thighs, like jodhpurs. The catalogue of Reinhart's malice continued through her parts, which in the here and now were flawless... and the receptacle for a Jew. Evil, evil, evil\u2014with evil he flagellated himself while there was still time. For of course he had this deep feeling about Jews, deeper than any he had had for Very; indeed, he recognized now, in the core of his hatred, that it was love. He loved the dead of the camps, and Bernstein, and half of Lori, and... Schild; and the dearer the possession, the dearer it was to lose it to them; nay, the dearest were not enough. Thus had Schild been in his presence then, he might have killed him as his wedding gift: Jews were too good to live.\n\n\"With all my resources am I trying to be understandable,\" said Schatzi to Reinhart, pathetically. \" _So,_ you tell me please, Herr Reinhart, when is this mar-ee-ahzh?\" He replaced the beret which he whipped off whenever he spoke to Very and drew Reinhart aside. In an undertone he asked: \"And is not this queer?, this little _f\u00eate champ\u00eatre_ without the fianc\u00e9? You rogue! The little Trudl is not sufficient for your capacity. And then the Bach woman, too, I believe, as well. Extraordinary. Soon you will have exceeded the Swiss Ambassador, Herr V\u00f6gli von M\u00f6gli T\u00e4gli.\" As a period to his joke he again whinnied. \"Did you grab it? _V\u00f6gle von moglich t\u00e4glich._ Ah, no matter.\"\n\n\"I had nothing to do with Lori,\" Reinhart stated gravely, \"at least not in that way.\" Nevertheless he was grateful for the accusation. He might have resented another man's combining the disparate ideas of sensuality and Frau Bach and projecting them upon him; but he saw at this juncture that rather than the deed it is the nature of the doer that rules moral judgment. Schatzi, the good German, the gentile, the witness that martyrdom was not exclusively Jewish; was it not a glorious truth of humanity that one virtuous man reclaimed a multitude of sinners? Looking at Schatzi\u2014this twisted, blackened wire, never again to charge chandeliers, to make possible the splendors of filament or the shrewdness of connection; but _wire it still was; honor cannot be annihilated_ \u2014looking at him in homage, Reinhart said: \"Why were you sent to Auschwitz?\"\n\n\"Because I was a criminal,\" Schatzi said mercilessly. \"But now as concerning this present matter: who actually\u2014he switched to German\u2014\"Who is this female lieutenant? Is she really going to marry this Schild? And, if so, when? Pardon my unusual curiosity, but the man owes me a considerable amount of money\u2014enough, let us say, to give me an interest in any major activity of his. I suspect he's a slippery customer. You know these Italians.\"\n\nHow unfeeling of Reinhart to have stimulated these unpleasant memories! With an agitation painful to see, Schatzi babbled on in rapid and incomprehensible German, blinking, panting, wiping his nose.\n\n\"My friend,\" said Reinhart, placing his big hand on Schatzi's shoulder cap, encountering nothing there but bunched teddy-bear plush, withdrawing it lest the weight fell the poor ill person, \"my friend, I did not mean to disturb you. I just want to say: is it not tragic that in our time it came to pass that a man had to be a criminal to remain decent?\"\n\n\"No, please, I'm not\u2014\"\n\n\"No,\" said Reinhart, \"I won't say anything more about it, I promise.\" He sat down on the log he had earlier used as head-stop. \"Here, have a cigarette with me.\" He took one himself and pressed the remainder of the pack upon Schatzi, who, still upset, struck it away. \"Go on, you can keep them, I mean it,\" Reinhart said and with sweet exasperation looked to Very for support, and saw her ambling drunkenly up the trail off the beach.\n\nSchatzi marked her too and in a kind of fear choked: \"She leaves!\"\n\n\"Yes,\" Reinhart answered dully. \"And I don't think she knows the way back.\" Aware of his responsibility, he nevertheless took his own good time in mounting a pursuit, so that when at last he arose she had for some moments been out of vision, beyond a bristling turn of bush. And then the essential sadness struck him like an instant fever: a woman abandoned, unloved, stumbling off alone. In this matter he could be of some use, all the more because of the late harm done his vanity: for once put aside your goddamned self!\n\nPelting round the bush, squashing pine cones, whipped by green streamers, he spied her moving particularly, whoopsily up a bank of firs ten yards from the path where stood motionless a substantial animal showing the outline of a wolf, as well as its immediate difference: a tiny twig between its monster jaws. Seeing Reinhart, the dog spat out and as soon recaptured the twig, danced, made as if at him then away, and suddenly losing guts and idea, dropped the stick and with lifted leg discharged a high stream of urine against a sapling.\n\n\"Come back, Veronica,\" Reinhart called. \"The dog is harmless.\"\n\nBut first to respond was the animal. Kicking back a spray of sand and leaves, it advanced on him sportively, threw great paws upon his blouse, and sought to lave his face with a tongue big as a towel.\n\n\"Down, boy!\" By a mistake of tactics he was drawn into the game of shove-return; the more forcefully he flung the heavy body back, the more joyfully did it thrust in again, with salivary grin and mock-ferocious tusks. From her place among the firs Very peeped through the hairy branches and screamed.\n\n\"Cut it out!\" Reinhart yelled. \"I told you he was harmless. Down, you fool! Get down, damn you. Oh, damn you. _Heraus_!\"\n\nBut nothing served till Schatzi, coming up silently behind, barked: _\"Pfui!\"_ Midway in its spring, the dog at once closed in upon itself like a jackknife and folded to the ground.\n\n\"What we call a German shepherd,\" said Reinhart, brushing himself clean. \"Does he belong to you?\" The dog looked from Schatzi to him in the quick, simple changes of canine emotion, from a loyal shame to a disloyal expectation, and slunk its great head forward in a neutral direction.\n\n\"Oh my goodness gracious!\" Schatzi said in exasperation. \"It follows me about\u2014but swiftly now before she returns back...\"\n\nIt appeared he had taken as an expression of fact Reinhart's wry remark that this Schild should marry Veronica; was concerned about the money Schild owed him: \"married men have spare marks\" were his words. \"But if they marry they must leave soon for the States, _ja_? Married couples are not permitted by the military laws to exist while giving service into the American Army\u2014do I make this clear?\"\n\nReinhart backed away a step: in the high emotion of his interest Schatzi had begun to spray a mist of spit. Curious fellow; but then if Schild, whom it seemed everybody had a case against, was in his debt, no wonder. Owing money to an alumnus of Auschwitz was a good deal rottener than any sexual transgression. He decided it was impeccable to detest Schild, and since that detestation had no intercourse with anti-Semitism, it was generative of power.\n\n\"Look,\" he said in a strong, new voice. \"I will get your money back. _I_ will. Just don't you worry. You shall have it.\" He seized the man's birdlike right hand and crushed it in pledge. Then seeing Schatzi's emotion rise rather than fall and not wishing the embarrassment of maudlin thank-you's, he slipped away to fetch Very, who while they talked had gingerly emerged from her green shelter and reached the trail.\n\n_\"Pfui teufel!\"_ said Schatzi, behind him, and the dog, who had presumably offered to be out of order, whined like the slow splitting of a board.\n\nPicking the briars from Very's uniform, brushing her with disinterested, whisked hands, he counseled her not to brood upon and surrender to misfortune; for his promise to retrieve Schatzi's money had been but a prefatory resolution to the main, to the one with which he assumed the obligation of her rescue.\n\n\"Don't tell me what to do,\" said Very, as a drunk does, _de haut en bas._ \"And watch your hands.\" Since he was at that moment in the region of her shoulder blades and had not gone lower, this could hardly be the complaint of modesty outraged.\n\nSo he laughed and smacked her full on the bum and repeated: \"Don't worry!\"\n\n\"You're vulgar,\" she said with dignity and marched on to the log, and sat, and coolly went a-fishing in her bag.\n\nReinhart threw up his hands in light despair, for the benefit of Schatzi, who was looking the very devil. The dog leaped to its feet; Schatzi cried: _\"Pfui!\"_ It subsided.\n\n\"Why does he keep making that hideous sound?\" asked Very, pinching her face into a tiny looking glass while her other hand screwed a scarlet bullet of lipstick from its golden shell.\n\n\"Madame,\" he answered, instantly restored, definitely bowing. \"This ahneemal is an undisciplined rahscal without a code of ethical manners. One feels that one must give apologies.\"\n\n\"I think,\" said Reinhart as he saw her face sour, \"that she wants to know why you say 'Fooey.' Is that the dog's name?\"\n\n\"Ah! Ohhohoho, _jetzt verstehe ich._ But no, this is how in German we speak to docks. What must you say? We say _Pfui!_ This means 'stop what you do!' 'dezist!' and so forth.\"\n\n\"It seems to work very well,\" said Reinhart. \"I've never seen a dog trained so well.\"\n\n\"Why not?\" Very said to her mirror in weary disgust. \"That's the way the people are here, except that instead of 'Fooey' it was Der Fooey. Heil, Der Fooey!\" She fascist-armed her lipstick.\n\n\"Knock it off, Veronica. You don't know what you're saying.\"\n\n\"Heil Reinhart,\" she cried, playing on him the sun's little spotlight off the mirror.\n\n\"Ignore her,\" he told Schatzi, only to see the man vastly amused and himself raise a flat palm and say: \"Heil Reinhart!\" and laugh with stained teeth.\n\n\"Excuse me,\" said Schatzi, repeating the salute but this time only mouthing the address. \"However, it is very funny to see Americans do this.\" He clapped himself upon the skull. \"Of course! I am forgetting! Soon I may find your relatives, dear boy.\"\n\nReinhart counterfeited an excitement he did not feel: \"You don't mean it.\"\n\n\"Most surely I do.\" Schatzi shrugged in his coat, cast an ominous glance upon the dog, and grimaced at the lapping margin of the water unclean with minor driftwood. \"I am on the tracks, it is as much as to say.\" He inspected Reinhart to see what he had aroused, put a finger in the aperture of his own ear, and said: \"Ah well, perhaps I am interfering with your afternoon.\"\n\n\"Not at all! Sit down on this log and tell me about it. What could be more important!\" Or more inconvenient? He sat down, himself, a weariness having caught him in the reins. He envisioned his kin as tattered, hungry, and cellar-dwelling, that much responsibility added to his present chores. Arrange an abortion for a Catholic, retrieve money from a Jew, accept as family a tribe of Germans, go and catch a falling star, get with child a mandrake root\u2014here at last were things to do, God wot. The dog, he noticed, was inching towards him on its belly, great gray lout of a thing, beseeching.\n\n\"Well,\" said Schatzi, continuing to stand. \"I have my look upon a certain family right there in Zehlendorf, who I know had had some great-uncle go to America many years ago.\"\n\n\"But is their name Reinhart?\"\n\n\"That is simply the whole point. No. But could not have your grandfather a sister?\u2014who would quite naturally change her name when she married a husband?\"\n\nIn relief, Reinhart said: \"Now you're joking.\" Behind Schatzi's back the dog had crept forward two feet; now it paused and slavered amiably. \"No doubt thousands of Germans have relatives in America, and none of them named Reinhart. But it's my fault. I never gave you my grandfather's first name and date of birth.\"\n\n_\"Also,\"_ Schatzi reacted. \"You had better do that, so that we can put to shame the false persons who will try to claim your blood.\" Jamming his fists deep into his pockets, he shuddered.\n\n\"Ill write it down,\" said Reinhart, \"\u2014are you cold in the sunlight?\"\n\n\"Mere _Angst,_ \" Schatzi smiled. \"Freedom is difficult to endure. But you must use my pen.\" He brought forth one of those American fountain pens that profess to last a lifetime\u2014Reinhart wondered if he had owned it in Auschwitz: \"Mr. Schatzi of Berlin, Germany, used this Superba Everlasting Masterwriter for three years in the living death of a concentration camp. Yet when he was liberated _it still wrote good as new_!\" He also produced a writing surface: a matchbook cover, also Yankee, on the outside a riot of yellow and red exhortation; within, a cooler plea terminating in a tiny coupon one could, if his name were no longer than Li Po's, mail in with ten cents for a sample of accessories to shaving.\n\nUnder the salutation provided by the advertiser\u2014 _Dear Allah Shavecream Folks: Yes, I want to take advantage of your generous offer. Please rush sample kit to:_ \u2014Reinhart had no alternative but to write:\n\n> Gottfr. Reinhart, b. Aug 14, '61.\n\n\"Thus!\" said Schatzi, reading the script close to his face. \"An old man.\"\n\n\"He died more than ten years ago.\"\n\n\"Therefore one can die in America just as anywhere else, _ja_? This is sometimes doubted in Europe, and then it is too suggested you stuff your dead as hunting trophies and mount them round the parlor, but I am sure this is peculiar to Kah-lee-for-nia, if there.\"\n\nQuick to catch his mood of levity, Reinhart jokingly commiserated: \"Too bad, I spoiled your coupon.\"\n\nSchatzi reclaimed his pen so quickly that Reinhart's fingers felt as if struck by the beak of a carnivorous bird. \"Whatever do you mean?\" he cried, reading the matchbook, then slyly cocked his head: \"This is a swindle, _ja_? The persons at this postal box will still keep your ten cents and send you nothing, _ja_? Hahaha...\"\n\nNo doubt it lay very deep, but Reinhart was never hindered by such a concern when it would be mean and ill-mannered to withhold a reply in kind. He made laughter, too, and as Schatzi's increased in volume his own increased in racket, sobbing for breath, and was joined in the second chorus by Very's golden instrument\u2014how healthy it was to hear her!\n\nScreaming with laughter as one does when he finds the joke is that there is none, Reinhart watched the dog worm in under the clamorous cover and, taking from the general amusement a fool's license, roll upon its spine and wave great ludicrous paws.\n\nExpecting Schatzi to begin laughing all over again, he saw him instead hide the matchbook in a fastness of his coat and, stooping, attempt to take the dog unawares with a hook of fingers to its upside-down head. To scratch was apparently his intent; but the dog held to the first appearance, rolled upright, and fell back snarling into the fence of Reinhart's legs.\n\n\"I offer to this thing love,\" Schatzi said, \"and receive back only ill humor. _Was kann man tun?_ Worse than a human woman.\" He stared at Very. \"I must be about to my business, now. What did you say Madame's name is?\"\n\nSince in her present state Very would no doubt take unkindly an oral answer; since her head was at the moment turned away, Reinhart picked up a stick and scratched VERONICA LEARY in the sand, feeling somehow, against his better judgment, as if he were selling her to a white-slaver; and in atonement to Schatzi\u2014for how wickedly misguided was a heart which was queasy towards _him_ \u2014offered another five hundred marks to finance his assignment.\n\n\"You must not at all times be so ready with your purse,\"\n\nSchatzi adjured. \"What have I done for you as yet? Besides, do you know, there could be only a single payment if I give you satisfaction. Namely, that when you return back to the Oo Ess Ah you find my kinsfolk there.\"\n\n\" _You_ have American relatives?\" Reinhart wished instantly he had not sounded incredulous.\n\n\"That is my only trouble. But I should accept some, nonetheless, and they could be gangsters or anything, I would not care.\"\n\nLittle, wistful man, he shook goodbye with Reinhart and then with Very\u2014yes, she too put out her hand\u2014and ambled up the trail. With no more clowning, with frequent backward faces of reproach, the dog followed.\n\n# _CHAPTER 17_\n\nIT WAS A FALLACY to confuse animals with human beings. Schatzi thought for a moment, as if he were counting seconds on his fingers, then gave the dog another taste of the stick. He had a technique of whipping refined to maximum sting, minimum bruise. The dog was his property and to disable it were no sense. Simultaneously with the blow, he said soberly and with no great volume:\n\n\"Guard the boat.\"\n\nThe beast cried out, as was to be expected, and, as Schatzi knew, far in excess of what the pain would require, for it was not without a limited intelligence. Its chief want was constancy: a singular defect in one of a breed noted for just that virtue. But then, in justice to the dog, it had come into his possession no longer than a fortnight ago, and there was reason to believe its primary loyalty was still fastened to the former owner, a fellow countryman who had reciprocated to the extent that he recoiled from an offer of two packs of cigarettes but sold him for three.\n\nHe, Schatzi, had fed it well, had made obvious a capacity for return affection relative to what the beast showed him, had shown tolerance to the first few miscarriages of the dog's assignments, was now nearing the margin of estrangement. When the disobedience could be interpreted as willful, he understood, even approved: the finest organisms are those with a recalcitrant substance which when tamed by its master does not dissolve but compounds with his own. Thus Russian cavalrymen he had seen who were one with their horses, not so much riders as centaurs. This in fact was the timeless sense of the ancient myth. But he had begun to think otherwise of the dog, to see in it a fundamental baseness which said not: \"I refuse to guard your cursed boat until you associate it with my being.\" But rather, \"What boat? I chase hares and sport in the sand, and you beat me for your pleasure.\"\n\nThe latter it was saying now, with the voice of its large craven eyes, its great back hunched against the forward seat; and with the repugnant knowledge that it had duped him, that he had given it what it most wished and so confirmed its appraisal of him, he in fury threw the stick far across the water. The dog went over the side and into the surf with a sudden displacement of weight that put the deck awash, and before Schatzi could work with the bilge can, was back and rearing its wet snout to the gunwale, the dripping stick between its jaws. Yes, it was not without intelligence, he admitted, reluctantly amused, but see what it could make of this! He spun the flywheel and the motor caught, and gunned away full throttle. Looking behind, he saw the dog strike out valiantly in pursuit, in a violent battle with the water, which as the distance grew between them it slowly lost but would not admit. Halfway across the Havel and far enough, he assumed, to make his point\u2014he could no longer see its commotion\u2014Schatzi bent back towards the Tiefehorn, the apex of the Wannsee peninsula.\n\nTwo hundred yards from shore he stilled the motor and rowed in, an eye on the woods. Which after a time satisfied him that they were deserted, and he beached and concealed the craft. Ten minutes' walk through the forest brought him to a compound of four brick buildings around a garden: a peacetime tuberculosis hospital and during the war a school for air-raid wardens. In the garden were half a dozen Russian graves with their red stars of wood.\n\nHis goal was the great radio-transmitter building a hundred meters beyond the compound proper. Built of pallid concrete diseased with green-and-black camouflage splashes, the structure bulked four floors tall, was as long as high, as deep as long, and had no windows. To a median groove in its rear face rose a pile of rusting Wehrmacht helmets, taken off German heads by Russian hands. Also in the environs were: cartridges and shells, both unexploded and used, all calibers; hand grenades, both as loose eggs and, with the wooden handles attached, potato mashers; bayonets; _Panzerfaust_ bazookas; elements of the imitation Luger called P-38; corrugated gas-mask canisters; gray-green tunics with a thread of red decoration through a middle buttonhole\u2014the rusted and patinaed and mildewed and rotten, already forgotten, material particularities of an obliterated army. Which meant nothing to Schatzi\u2014he remained.\n\nAs he entered, Schatzi took a noseful of the unique odor of the interior, a blend of urine, feces, damp, fire, and electrical effluvium from a transmitter that through it all\u2014last stand, Russian plunderers, American snoopers\u2014retained a deep, visceral stream of life. Its inexorable hum, issuing from the second floor but audible throughout, with the odor and, where the bulbs remained, the dim lights still burning in the halls from which humanity had fled and yet remained in the characteristic carpet of litter and excrement, had spent its force on Schatzi. Once inside he passed into a calm, and picking his way down a concrete stairway clogged with junk, which two steps before its bottom connection surrendered and itself melted into waste, he descended to the basement. Where, since he had earlier extinguished the ceiling lamps and smashed their sockets, he worked his passage with the hand torch that had once disturbed Schild.\n\nAlready he thought of Schild in the past tense, no feat for him who had but lately served in that enclosure where the present was so difficult to establish and all Jews looked alike. There had in fact been a uniform diminution of indentities as one went down through the categories of prisoners, from the green breast-triangle of the professional criminals to the yellow and black superimposed to form the Star of David. On his morning work gang the faces were the same for three years, yet a good five thousand individuals, by the record, had come into that lineup and shortly gone, without distinguishing themselves in transit. ... It was most unlikely that Schild was a fairy; to be a Jew was enough, and a Communist to boot. (In Auschwitz his breast patch would have been superimposed yellow and red, to show his double affiliation.) Therefore all the less was his keeping the Russian understandable. After Schild and the preposterous Sankt George had carried the Russian, all bloody, upstairs, a piece of chocolate oiled the woman's tongue: the fellow was a deserter, of course.\n\nThe Red Army had dismantled the dynamos and shipped them off to the Soviet Union\u2014this made all the more mysterious the live transmitter on the floor above; its power supply was gone\u2014but in their great haste to complete the job before the Americans took over the sector, they built huge crates that couldn't clear the basement door, then had to take them down and start again. The detritus from their work\u2014boards, tarpaper, peels of metal housing\u2014Schatzi had assembled wantonly to fill a shallow corridor off the end of the main cellar-hall. Which barred the nosey without teasing them to burrow through it, and also caused Schatzi himself some trouble in his arrivals and departures. For this reason he placed a rigid limitation on the latter, and returned now, breaking his own rules, only to fetch some Meissen china for the last deal with Lieutenant Lovett. That worthy, who had been as the Americans said \"framed,\" was flying out of Tempelhof tomorrow in the direction of the U.S.A. and wanted a souvenir for his mother.\n\nIt took both time and care to pass through the barrier, since one had to close in the tunnel behind, and before he could draw after him the last length of coat tail, above the noise of his entrance he heard quick paw-sounds on the stairway and in the hall and, unseen but heard, his dog announced itself without the blind. Nothing to do but grasp rearward to its collar and pull it in, and forestall in oneself the impulse towards congratulation, which was what, with idiot tongue and rolling eyes, it sought and getting would store up as merit against future failures.\n\nBack of the debris, a door unlocked directly into Schatzi's quarters. For earlier tenants it had served as storeroom; its walls were continuous metal shelves from floor to ceiling. They now were heavy with stores of another nature, the materials of Schatzi's major trade: cigarettes, confections, cosmetics, and the mechanical instruments of utility-pleasure: fountain pens, watches, lighters. And also: china from Meissen; Black Forest cuckoo clocks; unique beer steins, hand-crafted and -colored, each with a history; Hitleriana: signatures of the Man, photos of same with notable associates, counterfeit currycomb scrapings of his dog Blondi's coat, and two books from his personal library: a sob-sister romance by Hedwig Courts-Mahler and one volume of Ranke's _History of the Popes,_ the latter with marginal annotations in the F\u00fchrer's hand, often simply _Scheisse_!: souvenirs from a broader range of Nazidom; and finally a sheaf of small paintings on cardboard by an old man who lived under a heap of rubble in the Soviet Sector, whose wife had been killed in the bombings, whose daughter was raped and VDed by the Russians, and whose pictures\u2014calendar landscapes painted in saccharine and molasses\u2014were moving slowly even with Ami soldiers.\n\nSchatzi took some teacups and saucers and wrapped them in pages of the Red Army paper _T\u00e4gliche Rundschau._ Although his collection held twenty-four, he had chosen only five sets and, moreover, had in a sharp, glancing blow against the edge of a shelf chipped the rim of one saucer. It was just those persons who claimed sophistication in _objets d'art,_ like Lovett, who were the easiest marks, who could be relied on to call it \"Dresden\" and be suspicious only of the price.\n\nWarehouse, yes, but the place was also home; there was a cot for Schatzi and a length of chain for the dog (where, having enough foolishness for the day, he now secured it), and a little iron stove whose pipe issued through a chink in the wall, emerging outside beneath the cairn of helmets. Even so, he did not dare to keep a fire in the daytime\u2014giving precedence of mind over body, for he was always cold notwithstanding summer. Cold always, a feeling to which one never adjusts, the history of which is the history of the person and in his case almost a history of the times.\n\nThe first, the only, personal comment the man had ever made him, and he could not recall it without its full complement: 1919, seven idealists in the private room of a cheap caf\u00e9 in M\u00fcnchen. The sour and insidious stench of beer, not only in the air, one's own mouth, and the breath of the others, but in clothing dropped on the foot of the flophouse bed and donned again the next day (one could not go naked while they were washed), and doubtless also in Harrer's briefcase, which along with the cigar box for funds made up the Party office.\n\nHarrer was president; had he remained so, it must be admitted that events would have been less interesting. For one thing, Schatzi's clothes would likely have stunk of beer to this very day! He enjoyed such reflections, trifling with times past and irrefrangible; they were the only feasible control\u2014which surely even that other early member, he who drank no beer, would admit now, granting for the moment that he could be assembled from the ashpit in the _Kanzleigarten._\n\nBut the cold. ... This fellow, about thirty, voice roughened by poison gas in the war, clothes neat but knot of tie off center, capable of incredible fury in abstract argument, but when the _Ober_ splashed beer (which he would not suffer in his mouth) on the green fedora upon light raincoat on the adjacent chair, unruffled and gracious. In the discussion he moved that invitations to meetings be printed on the gelatine-duplicating machine and, further, that the cigar box be opened to buy three rubber stamps. On this matter Schatzi cautiously stood with the majority, thinking it over till next week; he had understood the group's aim was to put a little money in his pocket, rather than take it out\u2014the latter, however, being only academic at the time, for he was a month in arrears in dues and on the point of ejection from the \"Home for Men\" for nonpayment of rent. No, it wasn't true that he had joined to make his fortune in the narrow sense\u2014unless one is a German bourgeois or an American of any class, money is an obsession only when one is poor\u2014but a country is putrid and needs airing when it gives no justice to him who still carries enemy shrapnel in the meat of his thigh.\n\nHe, Schatzi, seldom spoke at meetings. He was never strong on ideology, and for that reason his associates treated him with a certain condescension. But earlier in the year when the premier of Bavaria, the Red Jew Eisner, was shot in the street and the ensuing proletarian revolution caught Schatzi's friends of the Thule Society momentarily planless, he had got a chance to show his talent. The Reds hung a picture of Eisner on the wall against which he fell and mounted a guard nearby to force passersby to salute. Schatzi bought a sack of flour, soaked it in the urine of a bitch in rut, accidentally dropped it while passing the portrait. The bag burst, and the stuff powdered the base of the wall: soon all the male dogs in Munich were congregated there to whine and sprinkle their eulogy.\n\nIn crushing the revolution there was some loss of blood. The Thule Society\u2014a different order from that of the seven caf\u00e9-gatherers, though with like sympathies; the fellow of the rubber stamps, for one, had been elsewhere\u2014fought as underground shock troops within the city, while the Whites besieged it from without, and in a matter of weeks the revolutionary forces had dwindled to a rabble of left-wing soldiers in the 19th Infantry barracks, of whom the Whites executed every tenth man, and a swinish lot of prisoners in the courtyard of the Munich slaughterhouse, some hundreds of whom were formally shot and the rest battered, pierced, crushed, mutilated, and otherwise coaxed to enter the land of the shadows. Having won some merit in this action, Schatzi came to the attention of Captain Ernst R\u00f6hm, who was always on the lookout for young men\u2014for more purposes than one, as it turned out\u2014and was recruited for one after another of R\u00f6hm's private armies, some disbanded the day they were formed, by the Jew-Socialist traitors in the government, the same that had betrayed Germany in the last days of the war. Schatzi had been very young in that time, twenty-two and three, and a prisoner of the feverish passions of the callow: for example, when he thought of the government he saw a single face, wan, spectacled, hooknosed, showing sly sanctimony that broke quickly into womanish fear as a good fist smashed into it.\n\nBut the cold. ... After this meeting, when the cigar box had been replaced in the briefcase and the briefcase snapped and the reckoning paid, R\u00f6hm paying Schatzi's, the seven rose to leave. Even as he buttoned his poor outer clothing\u2014he had no overcoat\u2014Schatzi trembled before the thought of the late-fall wind in the street; and the man beside him, getting into the raincoat, stared from the deepset eyes since famous.\n\n\"I don't know why, I am always cold,\" Schatzi apologized, and didn't know why he did that, either, for it was honest enough, but the man without opening his mouth seemed to demand it.\n\nIn answer Adolf Hitler said: \"You no doubt eat meat, which oxidizes too fast in the stomach and the warmth is dissipated. The German nation as a whole consumes meat in the manner of a pack of hogs at their swill, and can never be strong until all that is at an end\u2014not to mention that, as Schopenhauer observed, it smokes instead of thinks. I oppose all that.\" He pulled the hat very low over his brow and left the caf\u00e9 with quick steps as R\u00f6hm, smiling with his mutilated nose, took Schatzi's arm.\n\nIt was a tablecloth of many colors, handwoven, fringed, and according to Lovett, who folded it briskly and placed it in the wooden crate, an article of Holland. Although the old lady of the house swore that she had bought it once on holiday in that country, he had pronounced it contraband of war, first for her and now for himself. And now, in the incredibly solipsist way that only Americans can do well, he related the details to Schatzi, as if expecting congratulations.\n\nAfter a cursory inspection of the china, he drew five hundred Occupation marks from a fat wallet and thrust them at Schatzi, for all the world as if he, Lovett, had got the better. For who feels he has got it, has it\u2014added to which, by the look of the billfold, if when Lovett arrived in the States his purchase was exposed, the expenditure had been small and the swindle might even give him an aura of adventure. Standing there before him, Schatzi could conjure up a little narrative two months hence in which his own image would appear as a quaint, Old World rascal. And its force was sufficient to alter, for a moment, the long, straight direction of his life.\n\n\"No, no,\" he said, returning to Lovett half the sheaf of bills. \"The price that we agreed upon was two hundred and fifty marks. You are so careless of your money!\"\n\nIn Lovett delight and dismay contested, with the latter ultimately victorious. For, while he took the money, he now for the first time studied Schatzi and then applied the same inspection to the china.\n\n\"This chip,\" he said. \"Oh! It isn't old at all\u2014\"\n\n\"But,\" Schatzi broke in happily, \"it is not the age of the chip that must trouble one, but instead the age of the china. As it does happen, I know the late history of these pieces. They were on the estate of the Graf von Halsbach zu Willmark in East Prussia for decades of many years. Unfortunately for him, the count remained until the last hour in the face of the Russian advance, and is it necessary to relate further of his outcome? His daughter alone escaped, with means of certain compromises\u2014\" He slowed down, watching Lovett's doubt metamorphose into a sexless, vicarious lust\u2014whether fastened to the count, the Russians, the daughter, the china, or the unspecified violence, he could not say\u2014and continued: \"But one can never be for long uncertain in these cases.\" He turned over the saucer in question, and pointed to the moldmark of a factory in southeast Berlin: \"You see, unmistakable. Every piece of genuine Dresden ware carries that age-old stamp.\"\n\n\"Yes,\" said Lovett, \"unmistakable. I hope I didn't offend you, but the price, well frankly it's so modest. You see\u2014\" laughing girlishly\u2014\"I'm not one to usually complain about something costing too little, but some things you just _know_ you have to put out a good price for, or they're no good and there's no use in puttin' out your money...\"\n\nLooking through the living-room curtains, Schatzi saw Nader, whom he feared, on the other side of the street and about to cross.\n\n\"The price,\" he said hurriedly, \"is set at that level because I cannot in all decency take a commission on this selling. The count's daughter is in a bad state of life, ill and needs the money for drugs and food.\"\n\n\"You must take the rest of this.\" Lovett, who had also seen his roommate, thrust the bills into his hand, and they had disappeared into Schatzi's shaggy pocket before Nader entered.\n\nNader scraped about dispiritedly in the hall for some moments\u2014time enough for Lovett to conceal his purchase beneath the tablecloth in the box\u2014before he came into the room with a sad look for his friend and a hard one for Schatzi, who prepared to leave.\n\n\"It's no dice, Dewey. The Old Man's had it in for you for a long time. He told me frankly that he has been looking for an excuse to ride you out ever since you joined the outfit. And he also said he always thought\u2014he said\u2014I don't want to hurt your feelings, Dewey, but he said, 'Nader, I soldiered with you for ten years. I'd hate to think you turned queer when you got your commission.' \"\n\n\"Well, Wally, you tried, and I am very grateful,\" said Lovett. He flipped away like a doffed glove and began to stuff the crate with his enormous stock of extra underwear. \"I told you before that I'm quite actually happy to be going. By the time I get back to the States I'll be up for discharge, and I'm so anxious to get out of this horrid uniform and back to the shop. Mother's been going it alone there for three years and just hasn't been able to cope. The _qui vive_ is what one must always be on in antiques.\"\n\n\"That prick!\" said Nader. \"His trouble is he just hates culture. You know his idea of fun? Throwing down glass after glass of booze and telling stories about toilets. Hour after hour. I used to have to listen to all that trash without opening my mouth in the old days when I was top for the station-hospital company at Bliss. One time I signed up for a correspondence course on how to improve my English. When he saw it he said: 'Now, Nader, you can't make a silk purse out of a piece of sowbelly.' How I used to ache to get that dirty muff diver in an alley and slam the poison outen him\u2014why can't a man improve himself?\"\n\nNader's body took on the temper of the grievance; the trapezius muscle at the base of his neck threatened to burst from the shirt.\n\nLovett fussed the rough top onto the crate. \"It's all right, Wally,\" he said. \"One can't right all the world's wrongs\u2014Ouch!\" He had got a splinter in his pinkie.\n\n\"The point is,\" answered Nader, taking over the job, nailing down the top with sixteen nails, precisely one hammerblow for each, and without a break in rhythm getting after a nose-itch with his left hand, \"the point is, a guy does all he can for a friend.\" He manhandled the great carton to his shoulder and fought it to the porch, being at the door the recipient of Schatzi's courtesy.\n\nRid of his burden, and having no gratitude, he blocked Schatzi's exit. \"What the hell are you doing here?\"\n\nSchatzi's arms flew up to guard his face.\n\n\"You know why I don't like you?\" Nader continued, glaring. \"You always look like you want somebody to kick your ass.\"\n\n\"But I have authority to come now to this house,\" said Schatzi \"The Lieutenant\u2014\"\n\n\"Well, if you're finished, screw.\"\n\nSchatzi glanced up and down the street and moved closer. \"My dear Captain\"\u2014his upgrading Nader had a gross purpose for what he assumed to be a gross person\u2014\"I have been told that the Lieutenant Lofatt's difficulty can be traced to a Russian officer, is it true, and perhaps if this Russian can be discovered, your friend will not suffer for it.\"\n\nNader was not attracted. \"I said blow.\" He offered Schatzi assistance in negotiating the stair.\n\nAt the same moment, however, and before Schatzi had begun to move\u2014looking at Nader with an odd smile that the lieutenant did not understand was admiration\u2014he saw the old housekeeper issue from the door and hail him with her fingers.\n\n\"The blond officer has stolen my tablecloth and I don't know what to do,\" she cried. \"You are their friend? Then you can help me.\"\n\nShe was breathless, fat, and wheezing, and what was left of her reason and passion obviously had its locus in the thick and tasteless furnishings of her home. It was precisely this kind of person that the movement in its early days had been pledged to get rid of; Hitler had instead purged R\u00f6hm and dispensed with the Strassers, and Goebbels, degenerate, maimed opportunist that he was, had submitted to the policies under which the bourgeoisie flourished.\n\n\"You are a widow, no?\" he asked, noticing that on her second sentence Nader went within.\n\n\"My husband was office manager of a fine company, small but fine. It was a direct hit. Afterwards we couldn't even find his body. Please, I have no one to help!\"\n\n\"My good lady\u2014\" he drew back as she clutched at his sleeve. Anybody with a brain in his head would have anticipated Lovett by offering to sell the cloth before he had ever touched it. \"\u2014the Americans are honest enough. There has no doubt been a misunderstanding. You must speak with him again.\"\n\nHe was already on the bottom step, but the woman followed him down and, unless he broke away immediately, would surely weep, and that he must be spared.\n\n\"With their parties they already have destroyed everything else,\" she wailed. \"Did you see, the living room is empty, and I have not yet been paid. The ceiling\u2014the ceiling was shot away for no reason.\"\n\nNow that it was called to his attention, he remembered a certain damage in the room\u2014yet still not enough for his tastes; they would have had to burn off the roof and knock out at least one wall for it to seem anything like a home to him.\n\n\"But of course, this is why the officer is being sent away. You do not go unrevenged.\"\n\nThe silly bitch listened to nothing he said. \"Please speak to him,\" she cried. \"I have no English.\"\n\n\"Ah, my good lady, neither have I, you see.\"\n\nHe had left his bicycle in a clump of bushes around the corner\u2014not from fear of theft, for in spite of all it was still an honest land, but out of caution; avoiding the neighbor Schild, who might have seen an unconcealed vehicle.\n\nOn the long trip to the Soviet Sector, Schatzi had to show a different combination of papers at each checkpoint, American, British, and Russian, and there was always the possibility that some illiterate of the last type might shoot him. Sergeyev would of course spring him from an arrest, but, in his own words, could \"grant no immunity from a bullet.\" However, he once again without incident went through the waste of Potsdamer Platz and the barricade on its east side, and although the crowds delayed him\u2014where did they all come from, and why?\u2014it was far better than to chance a remote and less-peopled entrance, with guards accordingly more primitive.\n\nFrom here on he found it more politic to walk much of the way, wheeling the bike beside him: it was unwisdom in this area to distinguish oneself on a wheeled possession. Even so, he was stopped once by a Russian private, not a guard but one of the many roaming at large, who would have confiscated the vehicle had not Schatzi thrust in his face the pass from Sergeyev that read: \"The bearer, L. K. Burmeister, German national, registration number 2XL-1897340-C, is on special business for the Army of the Union of Soviet Socialist Republics. \u2014V. Sobko, 10th Section, Hdqrs., Red Army.\" At which the fool saluted as smartly as a Russian could, and went on.\n\nArriving before a relatively sound four-story building off Alexander Plata, Schatzi parked his bike in the iron rack, and this time snapped a small lock around two spokes and an upright of the frame, and with still another pass issued him by Sergeyev, with data as false as the other, persuaded the soldier on door-duty to lower his machine pistol, and entered under the long red banner that said: \"The unity of all Antifascists is the guarantee for the construction of a democratic Germany.\"\n\n\"Yes, do that,\" Sergeyev was saying into the telephone as Schatzi entered the smallest room, at the farthest end, on the last floor. \"Show him no more mercy than you would a fly that had fallen into your soup, and at the same time deal with care, just as you would with the fly, for if you crushed him then and there you might have to empty the entire bowl.\"\n\nTo one who on first meeting Hitler had seen an eccentric small-town sissy, there had come in ensuing years a disbelief in anything but the unlikely. However, it must be faced that Sergeyev differed from the commissar of legend only in his wearing mufti rather than the high, tight collar that was wanted to set off his bullet head. But then, even the civilian clothes were regulation for the type: the paradoxical jacket, both too tight and too baggy; dark-green tie and blue-striped shirt, both clean but looking dirty; and on a folding chair in the corner, a black felt hat with a little pond of light dust in its crown-dent and the brim lowered all the way round.\n\nReplacing the instrument in its cradle and without giving Schatzi any sign that he was received, Sergeyev revolved his squat weight, the ancient swivel chair croaking like a frog, to a low wooden shelf on the wall behind the desk, where, as usual, the articles from his pocket were scattered: crushed packet of Russian cigarettes, cheap brass lighter that took forever to catch, mean collection of zinc small money, and a nail file in a mock-leather case frayed here and there to its subcutaneous paper. On his own initiative\u2014for he wished to give Sergeyev no more than he already had, and the best strategy to that end was no unrequested sound\u2014Schatzi had assumed this foible owed to a stout man's difficulty in getting to his pockets while seated. As to the drawers of the desk: Sergeyev had no more considerable paunch than a keg, which is to say from shoulders to thighs he was one thick swell with no protuberance, but he sat so tight against the furniture before him as to join it to his person. Thus the shelf. Facing which he now stayed and, to it, said in German: \"This is not your day.\"\n\nThe diameter of his cropped skull widened as head gave way invisibly to neck, and both head and neck, and face, as he now made his return revolution, and the thick, hairless hands that grasped the cigarette and smashed at the lighter's wheel, were crimson as an angry baby. Sergeyev, however, was never angry. If anyone threatened to make him so, he had him destroyed. As, anyway, he had once told Schatzi, who was disinclined to demand proof.\n\n\"You have no answer to that? Ah well, in the east country you'll have years to talk all you wish to the ice and snow, unless a guard puts you out of your madman's misery with a rifle butt.\"\n\nSchatzi waited through the inevitable joke about Siberia, as one does for the amenities. \"Yes, quite true, it's not my regular time, but I have something you should want to know.\"\n\n\"And you've come here last of all, not having been able to sell it elsewhere. You think you can fool me, you piece of filth? You still do not believe that I can fling you down the stairs at my pleasure?\"\n\nSergeyev arose and pounded to the door, opened it and thrust half of himself into the hall. \"Yes, that stair down there, the one you came up,\" this part of his speech itself being flung in that direction and thus scarcely audible to Schatzi. Who nevertheless had heard the threat clearly enough in the past to know it was habitually delivered in a voice devoid of all emotion; but not that he believed it empty\u2014somehow one knew without evidence that Sergeyev was the type to say it a hundred times and do it on the hundred and first, or the thousand and twelfth, or not at all, for he had no rhythm and no limit and, indeed, beyond the pocket articles, no discernible self. These on the return trip he cleared from the shelf with one hand as sweep and one as scoop and buried in his clothing, as if in anachronistic worry that Schatzi might swipe them while his head was out of the room.\n\n_\"Also!\"_ He threw himself into the chair and grasped either end of the desk. \"Proceed!\"\n\n\"Lieutenant Schild\u2014\"\n\n_\"Are you insane?\"_ shrieked Sergeyev. He sprang up again, went again to the door, looked out, came back on a circuitous route of examination\u2014his office was small as a private washroom, with no window, the streaked beige walls marred by no ornament, and no furniture beyond the desk and the lone extra chair that Schatzi occupied\u2014and disengaged the telephone's handpiece from its berth.\n\n\"Do you think me so na\u00efve that you can inform to American Intelligence before my face?\" he screamed, still with no emotion, stamping out his cigarette in a little glass bowl evil with tobacco tar.\n\n\"Fritz, then,\" said Schatzi. \"A _Russian deserter is living at Fritz's billet._ \" He stirred in his chair, smiling ill in fright and pride. \"Also: Fritz is going to marry an American nurse.\"\n\nHe was met with an open mouth of short teeth, which appeared to be a smile. \"Tell me,\" said Sergeyev, his voice liquid with unction, \"confess to me\u2014you were Ernst R\u00f6hm's very favorite fairy-boy of all, _nicht wahr_? This is the sole reason why you were present on that famous 30 June 1933 when your lover and his faction were purged. We know all this already, so I can tell you it is useless to continue your mad resistance!\"\n\nA half year before, in the middle of January, when the Russian forces were rolling through Poland, the SS closed the Auschwitz camp and herded the dangerous prisoners\u2014mainly such Jews as were left, and politicals\u2014on a long death march to the enclosure at Mauthausen, in Germany. Schatzi was permitted to escape. Right off, he was almost murdered by Polish vigilantes who came in to fill the vacuum. For the uniform he had continued to wear as protection against just such a hazard, snipping the green triangle off the breast, was precisely what identified him to a Polish tradesman who had made deliveries to the camp and seen Schatzi in his privileged role as \"professional criminal\" leading work gangs to dig their own mass graves. This Pole, until two weeks before a collaborator, was now applying the same industry to preserve Number One in the new arrangements; in which he was as unsuccessful as a man can be: the guerillas shortly knocked _him_ off, but saved Schatzi for the oncoming Soviet authorities. Who in turn not long after arrival dispensed with the vigilantes themselves, so neatly that no trace of the bodies was found by three Swiss Red Cross delegates searching for eighteen days, _but saved Schatzi._\n\nIn neither case were the Russians wanton: the Polish guerillas, having shown enterprise once, would likely have proved troublesome in the Soviet occupation, and Schatzi, being officially an unperson and by personal history an advocate of no live cause, a friend of no man, totally dependent upon his captors and nicely shaped by years of captivity\u2014it would be almost indecent to get rid of a man who could be used, and for no payment, beyond not taking that which had no absolute value: his life.\n\nHe was taken to Berlin and assigned to Sergeyev, who notwithstanding the mufti, was apparently an officer in an Intelligence section of the Red Army: _apparently,_ because this was never mentioned, Sergeyev's office being this shabby, airless cube in a building tenanted otherwise by the German Communist Party.\n\n\"And we know, believe me, that you make daily reports to American Espionage,\" Sergeyev continued in his genial way. \"Must I remind you once more that you are no safer in that sector than this one? How much sufferance would the Americans show if we informed them of your past, _Misterrrr_ 'Burmeister,' _sirrr_.\" On the English words he did a humorous imitation of the American _r,_ which at the same time was very accurate.\n\n\"The only American agent I deal with is Fritz.\"\n\n\"Never mind about that!\" Nevertheless, Schatzi saw him write FRITZ on the back of a used envelope\u2014which he pulled from a wastebasket; there was nothing on the desktop but the glass bowl for ashes and a pile of paperclips artfully arranged to appear loose but really joined into a two-foot chain, as he had discovered on an earlier visit when Sergeyev suddenly hurled it at him\u2014FRITZ, he wrote it a second time and began to elaborate its lines with the pencil as he started again on R\u00f6hm.\n\nR\u00f6hm, R\u00f6hm! From Sergeyev's badgering at every visit, each time with a different angle of attack\u2014the last time, of all things, he had been accused of being a spy in R\u00f6hm's camp _for Hitler_ \u2014one could see that beneath the surface foolishness they knew everything already. And if they knew everything, they must surely know he had not been with R\u00f6hm's personal party on the terrible night of June 30, 1933, when Hitler and company burst into the Bavarian hideaway and carted them off to the slaughter. And, to boot, Sergeyev had once asked him for an account of the executions at the Lichterfelde Cadet School in Berlin. But surely they knew that if he had been with R\u00f6hm he would have been taken to Munich, if not killed on the spot, as some were, in the sanatorium at Wiessee.\n\nAs to his erotic associations with R\u00f6hm\u2014it was impossible to explain to anyone who had never known him the dynamism of the man, the virility which made denying him his pleasure almost shameful. Schatzi had not been given to the practice before he met him, and did not continue it extensively after the purge\u2014indeed, although he had tried most of them, he had yet to find a kind of sex that was not tedious.\n\nHis not having been with R\u00f6hm's party on that historical night was a piece of the strange kind of luck that blessed him his life long\u2014or plagued him, for with his leader's death perished a purity that he had found neither before nor since in the walks of men, a hard, clean, uncompromising resolution, honor, and bravery that the foul little Austrian upstart had betrayed to a moral leper like Goering, a weak-minded fanatic like Himmler, the antediluvian cowards of the Reichswehr, and the reactionaries of the Ruhr who had given niggardly money to the Party with the sole aim of getting more in return.\n\nWhat was there to tell? Schatzi stayed in Berlin at headquarters, keeping a finger on developments, while R\u00f6hm and the other SA leaders conferred in the Bavarian retreat. Aware that they were incessantly calumniated by the evil voices at Hitler's ear, sensing that they, the private army of the National Socialist revolution, the oldest fighters, the idealists, the conscience of the movement, had already been made superfluous in the general corruption, they were yet unprepared for the ferocity of their blood-brothers. R\u00f6hm was expecting a visit from Hitler on July 1, at which he intended to plead again to his old comrade-in-arms the case for the SA. He had a touching little gift for the F\u00fchrer, a handsome bookplate. He waited in trust, with no guards; he was after all the only man in the Party who called Hitler by his first name, not to mention that he had been a Nazi even before Adolf. But when Hitler arrived, it was with a band of thugs and in the dead of night.\n\nSimultaneous with the raid in Bavaria, Himmler and Goering took the headquarters in Berlin, capturing a hundred and fifty officers, whom they imprisoned in the Cadet School coal cellar in Lichterfelde and shot in quartets throughout the next twenty-four hours. The condemned men kept precise count of the executions; guessing whose turn came next was insurance against despair. They sang the song named for Horst Wessel. And, in innocent trust, heiled Hitler and went to their deaths faithful to his memory, for they supposed him also to have been a victim of the reactionary plot to crush the revolution.\n\nIn the twenty-seventh group-of-four Schatzi's name was called\u2014not, of course, \"Schatzi,\" but \"Ernst, Friedrich Paul, _Ober-sturmbannf\u00fchrer_ ,\" and even at that moment he thrilled to the crisp drumroll of his title: he had been a poor lance-corporal in the army for three years of the war, owing to the petty jealousy of a sergeant who consistently blocked his promotion. As he was marched with three others out into the mild morning and across the yard to the execution-wall, he saw some of the faces of his remaining comrades pressed against the cellar window, those old veterans of the Putsch, of a thousand caf\u00e9 and street fights, of the Freikorps, and, before that, spotted here and there in the army of the Western Front. They had been fighting somewhere for almost twenty years, against impossible odds, for much of it ill fed and ill clothed, and always betrayed. Not one had broken down in the cellar. That was pretty good for the \"pack of fairies\" that so revolted Goering.\n\nThe wall was a dripping stucco of human flesh; fired from six yards away, the bullets blew the heart through a man's back. An SS guard opened their clothing at the breast. Having difficulty with Schatzi's woolen undershirt, he parted it with the ceremonial dagger from his belt and, inadvertently nicking the skin, excused himself. On Schatzi's right hand was Appel, whom he had never liked. He caught his eye now as the guard went down the line drawing charcoal target-circles around their left nipples, and said softly, \"Ahoy!\" the old Freikorps greeting. Appel had been one of R\u00f6hm's especial favorites; he smiled now over the gravity of his girlish face.\n\n\"By order of the F\u00fchrer, FIRE!\" The four prisoners stiff-armed the salute to Hitler and cried his name so loud they did not hear the order, and their chests were blasted through their backs. Or rather, three died not hearing\u2014or if they did, were in a second beyond knowledge. Schatzi, falling with the others, heard, and knew that R\u00f6hm was dead, that Hitler had betrayed them, and that from then on he would give credence and fealty to no movement but that of his own pulse\u2014which he heard now in the wrist crumpled beneath his ear, for he was not dead, had not indeed been hit, but rather was pulled down by the unity with his fellows. Lying with slit-eye at the level of the concrete, he saw the approach of the sole of a boot, was turned over and tested by it. A pistol slug fractured the pavement near his nose, the sharp chips whipping his face, already bloody from the liquid of Appel's heart.\n\nSchatzi preferred later, with his last ration of sentimentality, to believe that the officer had missed on purpose\u2014it was said the executioners' squad had to be changed frequently because of nerve failure\u2014but he dared not see who it was. Shortly the disposal wagon, borrowed from a local butcher, returned from its last trip, and he along with the lifeless others was sacked into its tin bed. The rear doors were secured. The deliberate horse wheeled it creaking to the gate, which, opening, had its own sound. Fortunately, he had been thrown on top of the pile and was not crushed by the other bodies. Giving fate five minutes, as near as he could estimate, he tried the doors and found his hands too weak to manipulate the catch. Treading back, the wagon swaying, Appel and two more soft underfoot, he hurled himself forward. The wagon stopped\u2014he had been conscious of the awful silence only as something to flee, but of course his movement broke it for the guards up front. The blond face of a horrified SS private was a circle in the bursting doors. Gory and wild\u2014he had come so far since that he could smile at the remembered terror of that young calf\u2014Schatzi flung out, felling the boy. They were on a deserted side street near the Stich Canal. He knew the area well, and escaped unpursued.\n\n\"I can only repeat what I have told you before,\" he said to Sergeyev's smile, which was turning more grisly. \"My associations with the Nazis ceased on June 30, 1933, except that for the next twelve years I was their victim like so many others. What we in the early SA wanted was much the same as the Communists; we were even called 'brown on the outside, red on the inside.' \"\n\n\"Don't insult me with your filthy comparisons between the international workers' movement and a reactionary-mystico-homosexual cult,\" Sergeyev shouted. \"That was the only intelligent thing that Hitler ever did, to crush that foulness without mercy. What I want from you is the truth about those intervening years. In reality, you all the time were working with the Hitlerites as underground agent, _nicht wahr_? Or were you even that early taking American money?\"\n\nSchatzi patiently went through it all once more: after his escape he had lived for two years under a variety of aliases, outside both civil and Nazi law, until discovered by the Gestapo; after which he was kept in places of confinement for ten years.\n\n\"Excellent, excellent,\" said Sergeyev. \"Go right ahead with your resistance. But when you collapse into a quivering, boneless mound, remember it was your own doing....\" He put down the pencil and, with the difficulty Schatzi had foreseen, dug into his pocket and found the nail file, put it to work with minute attention on the fingers of the right hand. One by one; it seemed hours before he finished and started on the left. Finally, though, it was done, and he brushed off the fall of nail dust\u2014only to go into his breast pocket for a toothpick and clean around the little pegs which served him for teeth.\n\nSchatzi ever so slightly changed his position in the chair, which made a loud, splitting, flatulent sound. He was genuinely embarrassed. Sergeyev bit through the toothpick, chewed it up, in fact, and blanched.\n\n_\"Did you\"_ he said, for once not acting, and thus showing that everything heretofore had been dramatics, and in a voice so mad with anguish that it seemed afraid, and Sergeyev afraid was so fearsome that in another moment Schatzi might have flung himself from the window, had there been one, _\"did you have the audacity to fart?\"_\n\nPerhaps because this time he had really been moved, he accepted the explanation, took up his pencil again, and twitched it in dismissal.\n\n\"Report on your regular day.\"\n\n# _CHAPTER 18_\n\nNOW TO THE SAVING of Veronica. Of all women for fertilization of the egg, a nurse; of all for illicit impregnation, a Catholic. Finally, a professional worker in the branch of healing to which problems of love were fundamental, herself love's dupe.\n\nSince on her own terms her infraction was inexcusable, his job would not be simple. It was even possible she would resist being saved\u2014as she had refused that first, hysterical offer of marriage\u2014and absolutely certain she would not admit the mode he had determined on. To a Catholic the mere use of a Trojan, he understood, was the denial to a new soul of its right to incarnate, reach puberty, and disapprove of contraception. Either you suppressed lust at its first tingling or, embracing it, you were obliged to stay for the d\u00e9nouement. Abortion, of course, was downright murder.\n\nTherefore would his guile be summoned to sally forth from the imaginary fields where it had so often bested Machiavelli. And his ingenuity: not even in a military hospital with a hundred doctors could one hope easily to recruit an abortionist, another nurse was unthinkable, and although he could name as many unscrupulous enlisted technicians as there were wards he had little faith in their Army-learned craft.\n\nIn the last he was terribly confirmed by a story of Marsala's. Roy Savery, an enlisted assistant in the operating room, had just yesterday performed an abortion on his German girl friend and she bled to death.\n\n\"His trouble was,\" said Marsala in high disgust, \"oh my aching back!, he loved her. If he didn't of, she would still be alive and he wouldn't be up for court-martial. Any girls I knock up I do them a favor and don't see them again.\" He chuckled and screwed his gangster's face around the stump of cigar on which his large incisors were clamped, smoke and speech intermingling from the side alleys of his mouth: \"Why not? I never raped anybody long as I lived. Am I right?\"\n\nThey sat _en famille_ in their living room, at the round table beneath a chandelier of five dead bulbs and one live. Marsala took off his undershirt, revealing a natural vest of hair, from deep in the tangles of which glinted a silver religious medal as might a fragment of broken airplane within the jungles of the Mato Grosso. He had too extravagantly stoked the corner stove an hour before, and the air was at that temperature in which the skin weeps and philosophy proliferates.\n\n\"Poor girl.\" Reinhart groaned, in part because he was miserable with perspiration.\n\n\"Yeah, he held a gun on her to make her haul his ashes,\" Marsala growled disingenuously, suspending from his index fingers the dancing, ghostlike undershirt, which he inspected for cleanliness and finding insufficient balled and cast under the sideboard. \"He should of done it, see? Then he woona owed her nothing at all, if you get my meaning.\"\n\n\"It's burning in here. I'd better open the window.\"\n\n\"No, whadduh yuh crazy? I take pneumonia with no shirt on, you dumb dong.... So get yaself a American girl like you got, huh you big dummy Carlo? Knows how to take care of her humping self, huh? Now don't tell your old buddy you don\u2014\"\n\n\"You got any extra money, buddy?\"\n\nMarsala snatched from a back pocket and propelled across the table his old brown billfold fat as a squab and said, while drawing on the stogie: \"Take whadduhyuh want.\"\n\nReinhart chose a sheaf of one thousand marks from a store of twice that much. \"Can I have this?\" He fanned the bills so Marsala could count them.\n\n\" _What_ is this?\" his friend answered, outraged, and bending over, seized the wallet's remaining notes and threw them in his face. \" _What_ is this, fuck-your-buddy week? _La putana Maria!_ You won't take my money, I give you a shot inna head.\"\n\n\"I can probably pay you back next month\u2014\"\n\n\"Okay, say one more word and I go rub shit in your sack,\" shouted Marsala, dilating his hirsute nostrils. \"Don't hump me with them college insults, Carlo Kraut. My cash's not good enough for you, okay, okay, OKAY!\" He paced furiously around the room, having his great noisy pleasure.\n\nIn a moment he marched into the hall, flung wide the outer portal, and bellowed Riley's old call up the stairwell, hearing which Jack Eberhard came out upon the top-floor landing and cried in riposte: \"You like cake? Take this, it's raisin.\" Then more doors opened and some of the other good old boys popped out shouting all the grand old irreverences on the genito-urinary tract, the oestrous cycle, the gastro-intestinal system, and their heresies, and when someone mock-flatulated with a hand in bare armpit, someone else whooped: \"Kiss me again, sweet lips!\"\n\n\"Where's Reinhart?\" called the guys from the third floor, and the cry was taken up by throats on all levels to the roof: \"Rein-hart! Reinhart!\" Inside, Reinhart listened, a kind of warm cramp in his stomach, and then rose, went into the hall, and looked up through the spiral of shining comrade-faces whom one day it would be a death to leave.\n\n\"Short arm!\" he shouted. \"Marsala, get the flashlight!\" And everywhere sounded the cheers and catcalls and boisterous generosity, and the third-floor guys fetched a pitcher of water and poured it down in a great quivering sheet, really funny because they really aimed to hit them and only narrowly failed. Marsala got angry and had to be held back by real force from climbing up and kicking the bowels out of the whole bunch. To soothe him Reinhart recited everybody's favorite poem:\n\n> When the nights are hot and sultry\n> \n> Is no time to commit adultery.\n> \n> But when the frost is on the punkin,\n> \n> That's the time for Peter Duncan.\n\nA society grounded on common inconvenience, where friendship was innocent of opportunism and tolerance flourished without manifesto: no crime could outlaw you from this company; no merit beyond the grossest went recognized; where sensitivity was soon reduced to coarseness and ambition stifled; where lethargy was rewarded and disenchantment celebrated; this cul-de-sac off the superhighway to the glorious Houyhnhnm of the future where a chicken would stew in every pot and each man be his own poet, unarmed, owing allegiance to one world\u2014this splendid, dear, degrading society, here as nowhere else Reinhart felt at home and loved.\n\nAn invitation from an _ad hoc_ party headed for the noncoms' club, there to swallow strong German beer, cuss, spit, smoke, and perhaps, about closing time, to plunge into a sharp dispute on a subject of no permanent importance (such as Marrying a Virgin) and nearly come to fracas, poignantly tempted him\u2014as in college when a gang formed in the recreation room, he had never been. At the moment, having a role, he saw his mission to save Veronica as only arbitrary, but manhood's job could be defined as that which replaced the known and comfortable with the difficult and unpleasant.\n\nBeing a man, he went inside to the bathroom and spread his available money in series along the washstand lip, which being European did not seek to stint on marble and extended flat and wide for ten inches on either side of the basin. Last week, unsuspecting next week's extremity, he had mailed home a money order for his maximum allowance, corporal's pay plus ten per cent, roughly eighty bucks. Remaining were three thousand marks, to which were now added Marsala's twenty-two hundred, totaling the equivalent of five hundred twenty American dollars. Vis-\u00e0-vis such a sum, a German physician of the present day could ill afford to stand upon his ethics. How Reinhart would lure Veronica to a foreign operating table, unsuspecting, he had not as yet studied. But the means by which the doctor would be gained were as close as belowstairs in Very's very billet.\n\nLori Bach\u2014Lori and Bach, who in their combination, in their-cellar, in his conscience, localized a grief which, unable to admit, he for a month had pretended was not there. Also manly was his resolve to go, on the strength of a concrete purpose, and look it in the eye.\n\n\"Ah!\" said Bach from the sofa. \"So kind of you to bring a friend, Mr. Corporal Reinhart, and if I am not deceived by my failing vision\u2014although the cooked carrots brought almost nightly by my good wife from the American mess, if indeed stewing does not destroy their sight-giving properties, are restoring it\u2014he is an officer; and where but among you excellent Yanks could be possible such a friendship: corporal and lieutenant, splendid, splendid.\"\n\nFalling from Reinhart's hand, his cow-teat fingers in a feat of levitation floated to the lieutenant. \"Bach. So good to know you.\"\n\n\"Schild,\" answered the officer who bore that name. _\"Es freut mich.\"_ And then his eyes, pained, confused, bugged at Reinhart and seemed to ask approval for himself.\n\nInstead, Reinhart recommended Bach. \"He is a good man, Lieutenant, he is a better man than I can say. I am very proud to know him.\"\n\nSchild stared dully, said plaintively: \"Yes.\" Without waiting for the invitation Bach already prepared upon soundless, moving lips, he fell into the nearest chair and put a grim surveillance on his own feet.\n\n\"My wife,\" said Bach, beaming on Schild but speaking to Reinhart, \"has not yet returned with him you require. Let us then, over three of the cigarettes you so kindly sent along to me, commingle our thoughts. The packet is just there upon the table. Please serve Mr. Lieutenant Schild\u2014which of course means 'shield'; and one is happy to see, ha!, that he has come _with_ rather than _upon_ it; every American, how singular!, seems to be of German descent\u2014and yourself, and then I shall be so bold as to ask one.\"\n\nAnd there was all of it again, like the landscape of a recurrent nightmare: the concrete tomb, the sweet smell of garbage, the white monster; all awful and yet familiar, like Xmas with the relatives, or for that matter, life, simply life in general, from whose calculated ills we do not fly to seek others known not of but surely worse, because unchosen.\n\nChoice: make this one and you must also make the next, and once begun you have the habit. A mere hour ago he had sought out Lori as she came from the mess tent, given her, right there on the plain thronged with her colleagues making for the trucks, his problem, bald and coarse; and so forthright was his temper that he left uncorrected the implication Veronica was his mistress.\n\nCertainly she knew a German doctor, and her wise-weary eyes took no stock of him at all, seeing him as end, not means, yet were fond in recognition, attended on him specially and without demand. Yes, that very evening, if he liked, she could bring the physician to her cellar for a meeting, Bach's and her cellar on N\u00fcrnberger Strasse, which since he could never have found it again she placed in relation to the Kurf\u00fcrstendamm and the ruin of the Kaiser Wilhelm Church. She would see him there at eight o'clock, as simple as that. He shook her fine-boned hand, her small, dynamic hand, and saw her hair again could use a soaping, that her beret was frayed, that her stockings of rough brown cotton sagged at the ankle and the gray coat wanted its central button; and each deficiency was another focus for his sudden love.\n\nHaving chosen action, then, having chosen love, clothed in the warmth of his volitions he had wandered through the slowly chilling late-afternoon light, in the time of day for gentle melancholy, the hour when perhaps even devil and saint are briefly, postprandially imperfect; when colors, which had been subdued by its noontime flare, spring defiantly at the sun in its decline, radiantly false as Kodachromes; when Reinhart in his earlier self had been wont to dream of being ruthless Tamerlaine, or Don Giovanni severing a maidenhead, or a poet with flashing eyes and floating hair.\n\nNow, however, in the realization that he had, in the only sense harsh actuality permits, done these, been these, or didn't wish to be, he forgave himself and plunged into the palpable present. Schild. He would go upon this moment to Lieutenant Schild and squeeze from him Schatzi's money. Moreover, since morally speaking it was beside the point and tactically an obstacle, he dispensed with the identification of Schild as Jew, thin, dark, sharp, arrogant, and deceitful as the man incontestably was. To dispense with it he had first to make it; and then must congratulate himself on its not making a difference, and then say a thanks to fate for at last coughing up a Jew who had trespassed against gentiles.\n\nBut the first-lieutenant's bar was quite another thing. To beard an officer, a corporal armed only with right's might was ill weaponed, and the technique of obsequious insolence which in three years' service Reinhart had made his own was a device rather more for survival than dominance.\n\nHe moved along the street of officers' billets, a short block of the little toy houses of Zehlendorf with terracotta-tiled tentroofs, tight fences, and playing-card lawns. How queer it must be for Schild to live in such a house and look out upon a provincial street through white curtains; whereas Reinhart himself had done it for years; how contemptible to Schild's keen senses. How could Schild forgive the neat-meshing casements and the correct dun stones in the walk? A spreading evergreen bush flanked his stoop, from the lintel above his door sprouted a night light like a globed mushroom. Had a Jew ever lived in such a house, and had he been ripped screaming from it by pink-and-blond young men?\n\nAs, asking, he lingered at the gate, the answer opened the door and stood uncertainly upon the threshold, _ecco homo,_ Lieutenant Schild, and the response of Reinhart's heart, in the same vocabulary lately used for loving Lori, said: even had he raped Veronica and murdered Schatzi, I could never raise my hand against him.\n\nMan, man, one cannot live without pity. What Reinhart proposed to feel was the general emotion, but as he watched Schild come pitiably down the walk in his forlorn movements and crummy uniform, wiry hair bushing his cap, opaque spectacles, blousefront a home for lint, splay-shoed, wrinkle-pocketed, choking on a necktie with a dirty knot, insignia corroded and awry, haddock-faced\u2014as he made these sorrowful entries in the ledger, Reinhart's sympathies became particular. Whatever pity Schild deserved for simply being a Jew, he required more for merely being Schild. The decent thing to do was leave.\n\nBut before sluggish Reinhart could get under way, Schild had reached the gate and, with its faded pales between them, said stoically, for all the world as if he knew of the mission which Reinhart had just abandoned: \"Yes, Corporal, you came for me?\"\n\n\"I was taking a walk,\" Reinhart answered shamefully. \"And I saw this house and remembered the crazy Russian we took upstairs last month\u2014\" he broke off and in concern came back: \"Did you get all the files from the office?\"\n\n\"You did me a kind service that night,\" said Schild, cloudily, fingering the gate's catch; but though it was a simple rod and slot he could not work it, stopped trying and capped his hands on the picket-points. \"I wish I could do something about repayment, but you see I am not in your company.\"\n\nTo Reinhart, too, it seemed a tragedy; he felt his cheeks lose their blood and fall in, to match Schild's; like Schild's his voice sounded as if it crossed a body of water: \"I'm sorry, very sorry. ... That German kid hasn't bothered you any more, has she, when I'm not there? Dirty little whore, she makes me sick.\"\n\nWithout trying the exterior handle, without hands he applied his hip against the gate and pressed inexorably in: the hardware ground, bent, was sprung free, shooting its several parts and screws tinkling to the walk; and Schild came through to the pavement, unheeding what had been necessary for his egress\u2014which, done, struck Reinhart as regrettable and clarified his mind. He gathered the fragments of the lock and after a quick determination that they could never be reassembled, at least left them available on the cap of the gatepost.\n\n\"Since I can't repay your favor,\" said Schild, perhaps, in the public air, a breath or two less mad\u2014for mad is what he was, or had just been; as clear a, as well as the only, case of depressive mania Reinhart had ever seen and which, now thank God it had begun to pass away, he was able to identify and reflect that he had answered it correctly\u2014\"since I can't repay your favor, may I ask another one?\"\n\nA formidable non sequitur, yet suggesting an idea not at all lunatic; irony, rather, and one had only to look at Schild, in whatever condition, to understand the authority with which he manipulated that instrument. Half-dead from some despondent cancer, he yet in one short question, in a failing voice, exposed the skeleton of charity: he who takes a favor returns it by asking another; he who gives one is repaid by the commission to do a second; and the score is even throughout, unless, indeed, the giver has the better.\n\n\"Of course,\" granted Reinhart, foreseeing the little drama without passion in which he would deliver to Very a billet-doux from Schild, foretasting his own humiliation and perversely enjoying its savor.\n\n\"May I come along with you on your walk?\"\n\nSo. Again he had persuaded another to play him for a fool, for, make no mistake, people use us as we ask them to: this is life's fundamental, and often the only, justice. If he understood that, on the other hand he saw that to Schild it was not a mocking, ass-making request. The lieutenant actually waited on his approval, head down, his cap points echoing the general wilt of his body.\n\nDid his grief owe to Veronica's, of which he had been agent? Surely no man, whatever his responsibility and whatever the upshot, would lose his nerve by this. It was rather Schatzi's money; but again, would a bad debt to a _German,_ even a good one, so resound in the sane conscience?\n\n\"Would you like to borrow some money?\" asked Reinhart, without a warning to himself. \"I have an awful lot.\" He drew his wallet as if it were a gat and with one finger triggered it open. \"See, over five hundred.\"\n\nInterminably Schild stared into the note-clogged leather breech, and so near Reinhart could have snapped it to and clipped off the end of his nose. When at last his eyes lifted, their fright was giving way to the old, cold certainty that they, and no one else's, owned all truth and virtue.\n\nSuperiorly turning his head towards the house, he said to the yard: \"Now I know how a whore feels. Everybody offers me money.\"\n\nOh, he was a fellow who could be rubbed the wrong way, and certainly he had his reasons; society had slipped him the shaft, he had doubtless been diddled by the dangling digit of destiny; there was some extenuation for his own failings, but none for those who trespassed against him\u2014and for once to all this Reinhart, rebuffed, said _balls,_ and with as much offensive familiarity as he could summon from dead start, clapped him smartly on the shoulder and announced:\n\n\"Why sure, come along. I'm going to see a man about an abortion. A broad I know, as they say, has bread in the oven. How do you like the size of this wad? If that won't buy the job, nothing will.\"\n\nNot waiting for Schild's reaction, he businesslike stored the wallet and marched down the sidewalk. At the corner he was pleased to hear the hurrying footsteps behind, but still he gave no quarter, and who knew how far his calves might have propelled him unaccompanied\u2014for in contrast to Schild's they were muscled as an oak root, tireless as pistons, and at the moment the body they supported was, inflated with purpose, a lighter-than-air craft\u2014in reality, he was detained at the curb by the passing trucks of Lori's caravan.\n\nReaching him, Schild spoke breathlessly above the roar: \"You can't be serious! That's against the law; besides, it's dangerous. You could be tried for murder.\"\n\nHis concern, if innocent, was madly out of proportion to their acquaintance; if disingenuous, nonsensical\u2014if he knew Very was the object of the plan, why should he, who already had fled from his own responsibility, complain? Anyway, God damn the man for his officiousness.\n\n\"But you see,\" said Reinhart. \"I'm not doing the job myself. I'm going to hire a German doctor.\"\n\n\"So.\" Schild gave him a face of regretful sadism\u2014a smile of malice taking pleasure in itself Reinhart had seen, but never a _frown._ \"So, the little blonde got to you even though you were warned.\"\n\nNow here, where Reinhart should have felt anger, he did not. His reply was simple sullenness: \"You're not even an officer in my company.\"\n\nHard upon the tailgate of the last truck he stepped into the street, into a cloud of blue exhaust, choking. Thus, with his eyes closed, he did not see the jeep which turned the corner and, also blinded by oil smoke and carbon monoxide, might have injured him, or he it, had not his persistent saviour this time succeeded. Schild's thin fingers, he felt with smarting arm, were strong.\n\n\"Nate!\" shouted the man behind the wheel, a fattening captain who wore a knitted OD tie, \"I thought I might _run_ into you, a-ha-ho, mpf, mpf! Give you a ride?\"\n\nHand still hooked into Reinhart's swelling forearm, and applying a force whose aim was the other side of the street, Schild answered curtly: \"I have some private business with this corporal.\"\n\n\"So be it,\" spoke the captain, reaching for the gearshift, gathering in at the mouth the drawstrings of his barracks-bag face. \"Nowadays you're always arresting someone.\"\n\n\"If you can't use that ride, I can,\" Reinhart told Schild, shaking him off. \"Going towards the Ku-damm, Captain?\"\n\n\"Could be, if you'll tell me where it is, unless that's in the Russky sector. Brr, I wouldn't chance it there, and do you know, Nate, I still can't get that poor devil out of my\u2014\"\n\nSchild interrupted: \"We've changed our minds.\" He produced the kind of smile, with much evidence of teeth, that one shows when his underwear is torturing his privates. \"I'll confess to you, St. George, if you won't tell my CO., the corporal and I have something cooking on the black market.\" He lowered the back of the front seat so Reinhart could hop in back.\n\n\"I know your commanding officer\u2014a real son of a bitch,\" replied St. George, going into uproarious mirth. \"A dirty son of a bitch! Corporal,\" he said, gagging on the _r's,_ \"in case you didn't know, I'm cussing out myself. You got that kind of C.O.?\"\n\nReinhart grunted icily at the silly slob. Tyrannical officers, who were candid about their power, were preferable to jovial ones in love with their own decency. As to Lieutenant Schild, whose head snapped back on his fragile neck as St. George jerked the car into forward movement, he defied classification: who was doing what for whom and how was one to feel about it?\n\nSo started they towards the enormous cairn of rubble underneath which lay N\u00fcrnberger Strasse, in whose name Reinhart for the first time recognized a memorial to his old city of legend and determined to lay the symbolism before Bach, the specialist in things undreamt of by other philosophers.\n\nHowever, now that he faced Bach, with Schild in the adjacent chair, Reinhart could worry over nothing but that Bach would begin where they had last left off, on the Jews; or, before an audience half of which was virgin to his dramaturgy, repeat the farce so successful at its opening, while Reinhart sat paralyzed by the ethics of entertainment: _please do not tell your friends the surprise ending._ Hastily he began to collect the differences between this visit and his last, as the man lying down to rest adds up and tries to cherish the details which differentiate this night from last, the nightmare-ridden: tonight I am lying on my other side, the pillow slip is fresh, the moonlight does not shine upon the window\u2014oh, but God, I have the same head and I am scared.\n\nFirst he noted an increase in illumination. The oil lamps were in their old positions but unfired. From the center of the stained ceiling, the nucleus of a web of hairline fissures, hung a hot electric bulb. Augmenting whose glare Bach's reflecting, porcelain head irradiated his immediate area. His sofa, at the principal surfaces worn to the bare hemp of warp and woof, in the hitherto obscure corners shone now in a pattern of emerald, turquoise, white, and scarlet: a scene, a world, the edge of some equatorial swamp profuse with hot flowers and curving flamingos and reed-green water, and, on the lip of the depression behind Bach's shoulder, the great throat-cup, here in ruby, of the bird whose beak can hold more than his bellican.\n\nBach himself wore a green suit, a moss-colored huntsman's suit with oval bone buttons and odd straps and trimmed in gray beading; in the lapel slot, a spray of edelweiss, fake, showing its wire stem. His trousers were cuffless, bell-bottomed, seam-striped like a uniform, and between them and the floor lay ankle-high shoes of reversed leather, pine-cone brown, fastened with tasselled cords threading through a series of bright chromium clips.\n\n\"You are feeling better now,\" said Reinhart.\n\n\"Oh thank you, thank you,\" Bach replied, the inside of his mouth red as the flesh of a blood-orange, here and there the yellow seeds of teeth. \"But the clothing produces an illusion at odds with reality. In truth, I believe that I am dying\"\u2014he threw his hands at Reinhart to dispose of a reaction which had not come\u2014\"please do not grieve: 'by my troth, I care not; a man can die but once; we owe God a death and let it go which way it will he that dies this year is quit for the next.' \" He looked slyly towards Schild and returned, fingering the blossoms in his lapel. \"This flower, by the way, is quite false.\"\n\n\"It is very nice, anyway,\" Reinhart replied.\n\n\"You are always kind,\" said Bach, coyly raising his right trouserleg to reveal an inch of brace, as a Victorian coquette might have exposed her ankle, \"but the chiefest consideration will always be: where could a man with my infirmity get the real thing? Mountains, my good Corporal, one must climb the highest peaks to reach this noble plant, which is as difficult to come by as an honest man.\" Having exhausted his air on the speech, Bach took more through the tube of his cigarette, in a long and intense suction which burned back an inch of ash. \"The same characterization that applies to me does as well for the so-called building under which we sit at this moment\"\u2014swinging his head over the sofa arm, he spat the smoke at the floor, as if it were a mouthful of milk\u2014\"despite its apparent improvement\u2014the laying on of electricity\u2014it is quite likely, I am led by all my senses to believe, to collapse without warning.\"\n\nReinhart, who would never again be taken in, said in swaggering irony: \"Not while I am here, at any rate; because I have a charmed life.\"\n\n\" _Is_ that true!\" exclaimed Bach, fanatically interested, seeking to rise unaided, in the violence of his attempt giving the illusion that he had almost made it and lost by a hair; whereas in fact he had not moved a centimeter.\n\n\"Indeed it is. May I sit down?\"\n\n\"Ohhhh\u2014\" Bach began a long gasp at his own poor manners, not waiting for the completion of which Reinhart fell beside him at the end of the couch and ground out a space with his hips, at Bach's yielding expense.\n\nHe plucked at the threads of upholstery on the sofa arm. \"Handsome, very tasteful.\"\n\n\"Gobelin,\" said Bach, with difficulty twisting his neck, upon a static body, to face him.\n\n\"I certainly know his name,\" Reinhart replied, crossing his legs and inadvertently fetching Schild, whose chair was a good four feet away, a kick in the shins, smiling absolution for himself for that, smiling then at Bach in self-admiration which quickly shaded into joke as he saw upon the great grapefruit a polite confusion that told him he had guessed wrong. \"Don't mind me,\" he said rakishly. \"I told a Catholic friend last week that I had never read Father Douai's translation of the Bible.\"\n\n\"Yes,\" Bach answered, still perplexed. \"May I ask, however, of the charm upon your life?\"\n\n\"Oh of course.\" He glanced covertly at Schild, who had, as late as a Stanley Laurel, just begun to rub his injured shin. \"Well, I think I felt it first when we were pinned down along a hedgerow in Normandy. There was the enemy a bare hundred yards away in the next hedge, laying down a withering machine-gun fire. Well, they were bottling up the whole American advance; somebody had to do something. And I must confess, our leaders had failed us completely. The company commander, the platoon lieutenants, the NCOs, they all proved to be perfect cowards. You see, this was our baptism of fire\u2014\"\n\n\"You were infantry?\" asked Bach, a hand against his left cheek, as if he restrained his head from swinging back to the frontal position. Despite the evidence of a similar, internal attempt to control his eyeballs, they were their own masters and veered continually towards Schild, until at last they fixed in that direction as a lecher's will upon a maiden.\n\n\"Glider infantry,\" Reinhart corrected, \"a unit in the 101st Airborne Division, later to become the so-called 'Battling Bastards of Bastogne.' \"\n\n\"How terrible!\" interjected Bach.\n\n\"And I don't mean to say that at first I wasn't scared myself. But then, crouching there, staring across that new field of rye through the hedge, towards that line of green blooming like roses with gun flashes, I suddenly looked down and saw my trousers were open. I put down my submachine gun to button them\u2014and then I thought: 'What a wretched little swine I am to care about this when I might be killed in two minutes!' And then, just as quickly, I _knew_ I would not be killed, got this absolute certainty that I could stand up and walk slowly across the field and never be hit. So I did just that, climbed up over the top and began to walk slowly towards the German line. After I had got about ten meters out, slugs whizzing all around me but never hitting, the Krauts stopped firing! Stopped cold. I think now they thought I was coming to surrender; and it is true that the end of a white handkerchief was showing from the breast pocket of my field jacket. Anyhow, when they stopped I gave a big holler and discharging my Thompson advanced on them as fast as I could run. Behind me the rest of the company came whooping forward, not shooting, though, because I was in their line of fire. And do you know\u2014\" he slapped his hand upon Bach's green knee and felt, rather than the expected quivering of aspic, a hard and sharp junction of almost naked bone and metal brace\u2014\"do you know, those Germans sat paralyzed behind their guns and did not shoot once more, and when I looked over the hedge, down into their trench, all fifty-three of them threw up their hands and yelled _'Kamerad'!_ And of all things they turned out to be a crack unit of the SS, you know, the SS, fiercest fighters of all, who never surrender.\"\n\n\"Oh yes,\" Bach answered, lowering his hand; his head, as promised, instantly swung away like some half-door between a kitchen and dinette. \"I surely know of the SS and can only say that the fact must have been as you suggest, that they anticipated the surrender would be vice versa. For to them fear meant as little as does memory to an ingrate. In the Warsaw Ghetto the SS fought on until the last schoolboy put down his penknife and the last little housewife dropped her paving brick.\"\n\nSo of course there it was, Schild raised his eyes, the curve of Bach's fat cheek glistened with triumphant sweat, and Reinhart's big feet began to punish each other for the humiliating failure. \"Ghetto,\" that beastly ugly word the pronunciation of which began in the deepest throat and worked forward like a piece of phlegm\u2014he had heard nothing else. The loathsome Germans and the damnable Jews: the plague that had befallen both their houses was kind beside the one he now wished upon them. He also wished for nerve to direct Schild to the booby hatch and for courage to tell Bach he intended to carry off his wife, with whom he was in earnest love.\n\nYes, spiting all his wishes, he forced himself to say: \"Were you in the SS at that time?\"\n\nBach again pushed round his head, but before he made a word Schild rose and spoke ferociously to Reinhart: \"I'm not going to let you do it, you understand? If anything goes wrong they'll put you in Leavenworth for twenty years. According to your stupid middle-class morals, I suppose, better to take a chance on ruin rather than beget a child out of wedlock. You are an idiot!\"\n\nThere was no longer a question that he had gone nutty as a fruitcake: with hard steps he strode to the end of the cellar and leaned against the wall and gravely examined its waterstains.\n\nBach began to speak in a low, grating, regular tone, like an electric drill needing oil: \"The SS? My friend, I\u2014\"\n\n\"What business is it of yours what I do?\" Reinhart screamed at Schild, notwithstanding the poor fellow was mad. \"I can get through life without your help!\" And notwithstanding that Bach, poor chap, was an invalid, he turned on him viciously: \"For Christ's sake can't you talk of something other than the Jews?\"\n\n\"Curious,\" said Bach, smiling mildly, \"the manner in which a member of the other ranks may speak to an officer, in the American Army.\"\n\n\"He's not in my unit,\" Reinhart answered, lowering his voice. In the corner of his eye he saw Schild return.\n\nBut the words were kind; the face, gentle: \"Because I am your friend. Isn't that reason enough?\"\n\n\"Sure it is, sure it is.\" Reinhart swallowed. \"I suppose it is the only good one for doing anything in the world.\" He dared not admit to himself how deeply he was touched, how much sense lay in madness, how heroic was decency's response to brutality's negation. For this he could repay Schild only with candor.\n\n\"Things have got all complex,\" he said, \"simply because I let them slide.\" Schild, standing, hovered before him blankly, nervously. Beside him Bach breathed with a slight moan. Perhaps, after all, now that truth was having its day, he _was_ about to die. The winding stain which Schild had traced on the wall was not, he could see now, a decoration of seeping water but rather a weakening division in the concrete which seemed to widen as he looked and perhaps _would_ bring down the house\u2014there had been sense in that, to him, lunatic action as well.\n\n\"I should have told you before. But maybe it wasn't eccentric to think you might know. Veronica Leary is pregnant.\"\n\n\"That big nurse?\" Schild shrugged, splayed his hands in impatient despair.\n\n\"Why put it that way?\" Reinhart was angry all over again and himself despaired that relations with his newly found friend could ever be on the unswerving line of constant respect. \"Can't you even call her by her name?\"\n\nBach snorted as if he, too, had never witnessed an outrage of that magnitude, but turning to him in alliance one saw him chatteringly blow his snout into an aquamarine handkerchief.\n\nSchild's feet, too, were splayed, and his head forward and depressed below the level of his shoulders; sitting before him Reinhart could look down the back of his head to where the collar, too large, yawned out from the hairy neck.\n\n\"So,\" said Schild, \"that's worse yet than the German girl, isn't it? How could you get in such a predicament?\" Fierce yet charged with loving concern, like that sonorous old actor who always played the father of an East Side boy torn between the life of the spirit and the life of matter, when that theme was \u00e0 la mode.\n\n\"Ah God!\" sighed Reinhart. \"Finally, I see. I didn't knock her up, if that's what you mean. I'm just trying to help Veronica out of it.\"\n\n\"Why?\" Schild again chose his chair.\n\n\"On the basis of friendship. She was never my girl. She didn't 'betray' me. But I might do the same if she had. Common humanity is more important than sex. What matters is, she's in trouble\u2014just as, a moment ago, you thought I was. I'd rather aid than be aided any day, just like you.\"\n\n\"Then I am out of order,\" Schild replied, \"and there's no help for that.\" After the briefest illness, his face lay down and died.\n\nBut why take so hard a simple error that in the end had done no harm? In his statement was implied a personal doom, unpeopled, glacial, bone-white, so much more terrible than Bach's presages of a technicolor disaster. Was he serious? Reinhart looked at Bach, the absurd man, the absolutely useless man, who even if he were restored to health, if he had ever been there, would only stand and gawk at Oriental art, crap like that, and rant foolishly. But was he frivolous? And finally, did it matter?\n\nHe asked the last question only to make sense of his ready answer\u2014for that was truth: first the answer and then the question, so that while we wonder we can continue to live\u2014did it matter?, oh hell yes, for all we have in this great ruined Berlin of existence, this damp cellar of life, this constant damage in need of repair, is single, lonely, absurd-and-serious selves; and the only villainy is to let them pass beyond earshot.\n\n\"Do you know what we could use right now?\" he said unwaveringly to Bach.\n\nThat huge fellow swung round his enormous head, his pale eyebrows climbing in inquiry, his second chin reluctantly altering its seat in his collar, which was white and overlaid with peasant embroidery in red thread.\n\n\"A good laugh. Say something funny.\"\n\n\"Very well.\" And Bach was as good as his word in that at least he tried. He told a story of two friends, Palmstr\u00f6m and Korf. Who, finding a mouse in their house, built a cage of latticework, into which Palmstr\u00f6m climbed at twilight and began to play the violin. As night fell, the mouse was lured in by the music. Palmstr\u00f6m went to sleep, then so did the mouse. In the morning Korf put the cage into a furniture wagon and hauled it out to the country. The mouse was there released. He loved his new home. Korf and Palmstr\u00f6m, delighted, returned to town.\n\n\"That's the end?\" asked Reinhart.\n\n\"Of course,\" said Bach, wincing in amusement, suffused with rose color. \"What more could we wish? Consummate art, which I can assert only because it is certainly not of my own creation\u2014needless to say, for what is?\"\n\nFor Christ's sake what a story. Then he heard Schild snicker, and saw him laugh with a na\u00efve mouth of which the upper lip flattened and glistened tightly midway across his upper teeth, and his ears protruded like a schoolboy's.\n\nThrough water-brimming eyes\u2014his spectacles were tiny fish-bowls\u2014Schild finally looked at Bach.\n\n\"That is Christian Morgenstern.\"\n\n\"Exactly,\" answered Bach. \"How exciting that you also know his work!\"\n\n\"Do you remember this one?\" Eagerly he moved to the edge of his chair and rapidly, in an accent which to Reinhart sounded perfect, quoted in a German of which Reinhart understood nothing.\n\n\"All right,\" said Reinhart testily, watching them howl at each other, \"what does that mean?\"\n\nBach began: \"This gentleman named Korf\u2014\"\n\nBut Schild, impatient in his high levity, broke in: \"He has invented a kind of joke, you see, that works by delayed action. The people he tells it to are horribly bored. But later that night, when they are in bed, they suddenly wake up and laugh like babies.\"\n\nAll very German and although remote from Reinhart's old medieval visions, somehow not alien to them. At least he was gratified by the alliance of Schild and Bach, Jew and German, in a common cause.\n\nAt this point he heard a distant, cavernous sound, as one in the bottom of a sewer would hear a person scratching at the manhole. Lori approached through the passageway.\n\n# _CHAPTER 19_\n\nBY THE SLEEVE, LORI ushered in a man wearing dark glasses and carrying a cane, a meager man concealed within an enormous overcoat. This doctor, if such he was, would be splendid for the job. He was blind.\n\nReinhart heard and felt the slow removal of Bach's weight from the couch and, staring up the rising underbelly of the green Zeppelin, towards the gondola, discerned that respect drew him up. Schild, too, had risen, was already, being nearest the door, in an introduction.\n\n\"Sir,\" said Lori in her to Reinhart always lucid German, \"I am Frau Bach. I should like to have you meet my brother, Dr. Otto Knebel.\"\n\n_\"Herr Doktor, es freut mich,\"_ said Schild, shaking the hand which groped for his, showing an unsuspected command of the gracious forms, even slightly bowing. \"Oberleutnant Schild. _Ich bin ein Amerikaner_.\"\n\n_\"Ich bin dessen gewiss.\"_ The reply was in a high, aspirant voice, not ugly or unpleasant but strangely lingering within the innermost channel of the ear, as if a bug had crawled in there to die and, caught, changed its mind. \"I am certain of that.\"\n\nFor the second time in his life Reinhart had heard \"certainly\" as answer to an American's self-definition. It no longer seemed strange, but because he had already got his he did not wish another. Therefore when the doctor was moved to meet him, he, mimicking Schild's handshake and suspicion of a bow, rumbled low and uvular, authentically, _\"Sehr angenehm!\"_\n\n\"This surely,\" said the doctor to Lori, \"is your Ami corporal.\"\n\nCompared to his, Schatzi's hand had been full-fleshed, hamlike; one thought not of bare bones: one held tendons and a complex of thin vessels through which slow and miserly came corpuscles one by one. Behind the glasses, in front of the tall back collar of the coat, was a real head: small, stark, but real, and so marked with life, so marking life, that the memory of other faces was rank on rank of dummies. The lenses were too black to see through, in compensation for which they themselves were animate. Finely amused now, they dramatized the implications of the breathy voice which rendered stout German as if it were the tongue of dragonflies.\n\n\"Yes,\" said the doctor. \"But you should have seen me six months ago!\" Bach made a giddy noise. \"What, Bach, my good fellow! You have held captive these Americans? Then there is still a chance that we may win the war! Very well, my dear Lenore. Now that I have located Bach I can manage alone.\"\n\n\"Ah Doctor, you come right to me and take this seat, _my_ seat, _bitte, bitte._ May I help you? Please, please.\"\n\nIn the strength of his schoolgirl agitation Bach took two quavering steps and grasped for the doctor's arms, which that gentleman, moving efficiently behind a probing cane, ignored with a blind man's insouciance. On his left sleeve he wore a yellow armband carrying the rubric, three black balls, of a vicious, violent, antidemocratic cause. (Reinhart remembered his colleague Cronin's description of such an insigne, such a movement, the week before on Cronin's boarding an airplane which would fly him back to France as a case of chronic athlete's foot. \"Open your eyes,\" Cronin said, upon no provocation whatever, \"the same old thing's starting up all over again.\" The boring ass; why had one come along on the truck to say goodbye? But then Cronin hit him lightly on the shoulder and said, \"So long, Reinhart. You're the only one I could ever talk to.\" Very simple: one had come along because one, all in all, had liked and would miss him.)\n\nSitting down in Bach's corner of the sofa, the doctor said:\n\n\"Lenore, have you some of those excellent American pastilles? The anticipation of talking dries my throat.\"\n\n\"Oh, here,\" said Reinhart, who happened to be carrying a cylinder of Lifesavers. \"Take these... and keep them.\"\n\nThe eyeglasses widened their circles. _\"Vielen dank_ \u2014 _sprechen Sie Deutsch?_\n\n\"A little. _Ich verstehe besser ah ich spreche_.\" He grinned in self-deprecation, though his auditor could not see it.\n\n\"Your accent is very good.\" The doctor's mouth was a pale pink cave, toothless; moreover, showing no evidence that teeth had ever been.\n\n\"Not good enough to fool you.\"\n\n\"Why you should wish that, especially nowadays...\" A Life-saver tumbled over the doctor's tongue, glinting orangely. \"But I knew you from your hand, not your speech. ... Now Bach, are you still standing there with your misplaced courtesy? Kindly be seated. And Lenore and the Lieutenant, and you, Corporal, please. As to the Lieutenant, now, I should think that though he has been in the U.S.A. some years, he was born in Germany, no?\"\n\nSince seeing the armband Reinhart had been occupied with nothing but worry for Schild. From the data of his first visit to the cellar he could hardly suppose Bach and Lori were the doctor's fellows in a neo-Nazi faction. Who then was the doctor but the blackmailer that had preyed on them during the Hitler years and still today somehow retained his evil power? And how compelling he was: Reinhart had brought forth the Lifesavers like an automaton. Schild, the eternal do-gooder, was already captured by the man's infirmity; Schild, the Intelligence officer, did not see the armband; Schild, the Jew, already was impaled on the doctor's fascist needle.\n\nSchild, the innocent fool, looked sadly pleased. \"Is my accent so good?\" He sat down, as he had been ordered to. \"I am a native American, doctor. I am one of the lucky Jews.\"\n\n\"I too am lucky, but I have not been able to decide whether my luck owes to my Aryan mother or my Jewish father,\" said the doctor. \"This is the kind of thing which confuses everybody but the Nazis.\" He closed on his candy, swallowed it, and took another from the pack. \"Why do your countrymen waste so much paper, Mr. Corporal? Really, these fruit drops would not grow stale exposed to the air. Really, what are they but crystallized sugar-water? But won't you, all of you, join me? Bach, you must! I prescribe sweets as a substitute for that abominable ersatz-schnapps with which you are destroying your liver.\"\n\n\"Doctor, I have sincerely tried to stop drinking,\" Bach said, his face a quivering sack of shame as he lowered himself onto a folding camp chair which he overhung in every dimension. \"I will conquer it, I will, you shall see.\"\n\n\"May your reformation not wait upon my seeing,\" replied the doctor, lightly. And Bach's despair was as if a truck passed overhead.\n\nOf course, if the doctor was Lori's brother he was but half a gentile, had but half the aptitude for corruption. Of course, Reinhart had not forgotten that so much as ignored it in his quest for a villain to save someone from. Yet why the brazen badge?\n\n\"Now Corporal, I think you and I have a private matter to discuss,\" said the doctor, placing his cane on the floor and in so doing offering a view of his full profile in the various perspectives of slow movement. His right eye, seen in the harsh knife of light which, as he bent, thrust in from the side, behind the dark glasses\u2014my God, an eye? A navel, rather, a belly-button of the head, baby-new and pink within the old foxed leather which bound the skull.\n\nOne's own eyes indrew behind the barrier of cheekbones, hid in scarlet darkness, as nevertheless one's more courageous mouth asked: \"Doctor, what is the meaning of your armband?\"\n\n\"It means\"\u2014the black circles swung round and established order\u2014\"that if you drive an automobile French fashion, use it, that is to say, as a projectile with which to aim at pedestrians, I am your perfect target. I cannot see you come.\"\n\n_\"Wie bitte?\"_\n\n\" _Es tut mir leid._ I was having a bit of a joke, most unfairly. The sleeveband is of course the sign of the disabled person. Unfortunately I do not have Bach's gift for foreign languages. Bach, could you perhaps\u2014\"\n\n\"No, it is not necessary,\" said Reinhart. \"I understand. It is an excellent thing\u2014\"\n\n\"They do not have it in America,\" Bach cried eagerly. \"Never, nowhere have I seen it.\"\n\nLori, still standing, chided: \"Now Bach, if you do not permit Otto to have some privacy, he will not talk with you later.\"\n\n\"Quite so, quite so,\" Bach mumbled, turned laboriously, and to Schild instituted a speech which began: \"However\u2014\"\n\n\"Lenore,\" the doctor said, \"There is no reason why you should not sit here and assist us with your good sense. Also, working for the Americans you should have learned some English by now, unless Father's old claim was true, that we were the champion dunces of Dahlem.\"\n\nAlthough, because of the difference between the doctor's and Bach's girths, there was now a good seat and a half to the left of Reinhart's port hip, Lori sat down so close against him that, for the comfort of both, he had to lay his arm along the back ridge of the sofa. His love for her was just in the degree to which it remained intactile. Introduce desire and you would soon have the same old two-backed animal scuffling in the dirt, into which he and Trudchen transformed themselves daily, destructive, nightmarish, impermanent, having nothing to recommend it but necessity. With Lori he mixed spirits, was embarrassed by the flesh... but she rested, almost lay, within his arm-hollow, her hard, thin bones piquing him, the shoulder of her thick old prickly-wool sweater, carrying a scent of spice, touching his cheek. And he, who involuntarily rose at a woman's smell\u2014as a sleeping cat erects its ears at every sound\u2014almost any woman, any smell, sometimes, in the street, at pure cloud of odor, the woman having long gone by, was shortly, or longly, risen.\n\n\"Now,\" said the doctor, to see whom Reinhart had to clasp Lori more closely in looking round her blondeswept head, \"this young woman you have got in trouble\u2014\"\n\n\"Ah no, Otto, it was not he,\" Lori broke in far too eagerly for the pride of the fellow she had made her cave.\n\n\"How do you know that?\" asked Reinhart, arrested in his drawing away by the sofa arm in the small of his back; because of this his irritation became briefly paranoid: how dare he be boxed in?\n\n\"Because maids, like concierges, know everything,\" said Lori, mock-mysteriously, without trying to turn. \"The Gestapo of belowstairs...\"\n\nThe doctor disintegrated another Lifesaver and swallowed its rubble. He chose a third, perhaps a fourth, since the pack appeared to stand currently at three-quarter size. His thin lips, opaque glasses, and traces of eyebrow expressed satisfaction. His hair was a thick bush, one finally noticed as one continued to creep so tightly against Lori that when she spoke he heard the vibrations in his own chest. Bach, remote in a spirited monologue to Schild, Reinhart worried over not, nor did he despise him.\n\n\"There, there,\" said Lori, patting his nearer knee with a twinkle in her hand, \"everybody knows you could have.\"\n\nThe doctor stared exhaustively, sightlessly, at Reinhart. Finally he spoke in his loud whisper: \"Let me for a change be honest. Obviously I cannot perform the operation. I could find a colleague to do it, of course. But I intend not to. I have come here and taken your time, and your pastilles, under false colors. My motive was simply to 'see' an American. Are you angry with me?\"\n\n\"No,\" Reinhart answered. \"Surely not.\"\n\n\"But you should be.\" The doctor was impatient. \"I can solve your problem, yet I will not. And as far as you know, for a capricious reason.\"\n\nReinhart smiled tolerance and dropped his cupped left hand on Lori's shoulder. \"I can't force you, can I?\"\n\n\"Then you are not serious?\" asked the doctor in dramatic astonishment. \"Disgrace for the lady, shame for you\u2014for although you may not be the other principal in the catastrophe, your honor is somehow involved, yes?, or you wouldn't be here. Come now, at least try to bribe me.\"\n\nSmiling again, Reinhart answered, conscious that when he had to speak without preparation his damnable German was certainly ungrammatical and, despite his \"good accent\" Americanized in pronunciation\u2014you cannot take care of everything simultaneously\u2014so that to these Germans he was ludicrous for another reason. _In their reality_ he sounded:\n\n\"I donnt tink dot so easy to corrupt you are.\"\n\n\"On the contrary, I am supremely corruptible. I have no honor whatsoever. For example, I would do anything to save my life.\"\n\nReinhart felt Lori stir against him, and he released her sweater-shaggy shoulder. \"Oh well, wouldn't anybody do that?\"\n\nFor the first time, but briefly, the doctor lost what had all this while been more nearly ebullience than anything else. And then, taking another, a purple, Lifesaver, he said, with the old aplomb and in the voiceless voice Reinhart had come to hear as oddly beautiful, \"On the other hand, if by necessity you have learned this fact about yourself, it is nice to know. Some American writer\u2014have you read him?\u2014wrote a verse about seeing a man eat of his own heart. 'Is it good?' he asked. 'Well,' said the man, 'it is bitter\u2014but I like it. First, because it is bitter, and second, because it is mine.' \"\n\nReinhart did not understand. And Lori had _not_ learned much English, therefore could only repeat the words more slowly, in her low-pitched music.\n\nHe shook his head. \"The funny thing is that I know all the words; it must be the combination.\"\n\n\"Bach!\" cried the doctor. \"Excuse me for a moment. Please give us the English for this.\"\n\nBach did, with an attitude of excessive expectation; sought to explicate, was halted.\n\n\" _Danke sehr._ Now just return to your lieutenant. We did not wish to disturb you.\"\n\nReinhart determined to read, when he went home, this author whom a non-English-speaking German knew better than he. However, the doctor had turned out to be the usual lunatic, in love with his own rhetoric. He returned to the subject which had become a great bore to Reinhart, who had decided at the first resistance to seek another physician through Schatzi.\n\n\"I have no scruples against abortion in itself\u2014\"\n\nHis speech came within an interval of breath-taking on the part of Bach, who heard it and answered: _\"Die meisten meiner Mitmenschen sind traurige Folgen einer unterlassenen Fruchtabtreibung.\"_\n\n\"Bach, don't you realize you are interrupting?\" chided Lori, seizing the hand with which Reinhart, bending forward, traced his trouser crease in the area of the shin. \"I assure you that if you persist Otto will avoid you. ... Please do not do that,\" she said to Reinhart. \"A hard object in your breast pocket jabs into my back.\"\n\nA pencil, which he removed to the other side. Nevertheless, he disliked a carping woman.\n\nBach desisted, and when Schild spoke, cautioned him with wrinkled forehead.\n\n\"Did you get that?\" Schild sadly asked Reinhart. \"Most men are the sad results of abortions never undertaken.\"\n\nBut by now, having adjusted to German, Reinhart heard English as somewhat dull upon the ear and difficult to follow. He believed that Schild was repeating his old objections to the plan for Very's salvation, and assured him resignedly that it was all off. \"You can stop worrying.\" He should, in the first place, have hired Schatzi and thus given no one an opportunity for humanitarianism, friendship, theory, oratory, and so forth: that was the way with intellectuals; from his old uneasiness towards them, for which he had blamed himself, he was at last liberated; worse than boring, they were of absolutely no utility; if you want a barrel built, hire a cooper.\n\n\"You have changed my mind,\" said Reinhart to the doctor. \"Forget it. I was foolish. I don't want to get into trouble.\"\n\nBach, still actively desisting from interruption, wrestling with himself, gave up suddenly on an interval of losing and said, with hysterical bravery: \"Tell him, Doctor, tell him about the Russian concentration camps! They were worse than the German ones!\"\n\nLori wrenched angrily within Reinhart's surround, Schild recoiled sickly upon himself, as if someone had hurled towards him a bucket of filth, and the doctor sighed.\n\nHis weary answer: \"Ah Bach, you take what you choose. But so be it, we shall leave it at that.\"\n\nReinhart somewhat rudely thrust Lori from his line of vision. She pushed back with unusual strength for so small a body, crumpling his outstretched fingers, and if in that second of pain he had been asked, do you still love her?, he would have said, sorely, because she is as tough as a root. Gently this time he raised himself from the slump and looked over her head.\n\n\"Are the Communists as bad as the Nazis? Were you in a Russian camp? I didn't even know the Russians had concentration camps.\" Saying which he looked haughtily at Schild, whom he had gauged as a pro-Russian liberal, and saw thereupon what he should have known from experience was more to be pitied than defied. He would never be able to match his moods, to meet aggression with the same, and humility in kind.\n\n\"Bach provides a much more effective torture than either,\" said the doctor genially. \"Whatever theories of coercion are developed in the future, they must take account of his method: admiration of the nonadmirable. He believes that because I was a prisoner I have a special and heroic wisdom. He is wrong, but my vanity insists otherwise; therefore, in my sense, which is nobody else's business, he is right. Why, however, should you permit me, or him, to inflict this nonsense on you? ...Now tell me, is it true that one can enter an American cinema while the motion picture is in progress? Isn't it queer to see middle, end, and then the beginning?\"\n\n\"Yes,\" Reinhart answered, \"yes, one can enter at any time. But American movies are made for an audience whose average mental age is twelve years old. You should have seen the pictures they made on Nazism. Such trash is almost criminal.\"\n\n\"The Nazis were presented as good men?\"\n\n\"Oh no, but either they were monsters who did not resemble human beings or they were ridiculous buffoons.\" He was making out all right with his primitive, do-it-yourself German, for the doctor seemed to understand.\n\n\" _Also,_ this was an error: too realistic. I agree with you, this theme should be dealt with as fantasy. Lenore, do the privileges of your job include Ami films?\"\n\n\"Not exactly, Otto,\" Lori answered brightly. \"But do you recall the old joke of Father's about the man who was asked if he had ever eaten hare? 'Not exactly,' he said. 'But yesterday I shook hands with a fellow whose cousin's brother-in-law lives next door to a widow whose late husband once saw someone eating hare.' It's not as bad as that with me. I make the beds of persons who see the pictures every night.\"\n\nThe reference to Veronica could not have been more obvious. Reinhart intended his response to be equally obvious in disregard.\n\n\"Your father has a good sense of humor?\" he asked. How strange for a German! But then he remembered that her father was a Jew.\n\n\"Well, yes,\" answered Lori, looking at him from the corner of her eye, he thrusting himself to the side so that she could do it, \"I have never thought about it so seriously, but I suppose he had.\"\n\n_Had?_ Yes, dumb Reinhart, not everyone is always young and American enough to have two living parents. Besides, he was a Jew. Yet he had to speak, he, Reinhart, one in five in this subterranean, brightly lighted urinal\u2014monstrosity, Jew, half-Jew, half-Jew, Siegfried.\n\n\"He was killed\u2014\"\n\n\"He is dead,\" said Lori.\n\n\"\u2014by the Nazis.\"\n\n\"He is dead.\"\n\n\"And who else, who else?\" If in all his life he had reached no goals, he would take this one.\n\nFrom his implacable face she turned away in embarrassment and towards the doctor gave her dirge: _\"Voter, zwei Br\u00fcder, Schw\u00e4gerin, Neffe, Nichte.\"_\n\nIn English, thus excluding his wife and brother-in-law, Bach cried: \"There is no wit like that of Berlin, of which since I am not a native I can assure you without immodesty. Hitler and his damned barbarians hated this city because they could never break its spirit, because they could not transform it into a N\u00fcrnberg. I confess to you that I am a separatist. I fervently hope we remain forever isolated from the Fatherland.\" He slapped his knee\u2014too hard, and winced.\n\n\"I wish I could do something,\" Reinhart said. \"I wish I could say something\u2014\"\n\n\"You can indeed,\" the doctor answered, impatiently stripping the paper tube from the remainder of the fruit drops, catching five of the six in the wire whisk of his left hand: one fell to the concrete and broke into three golden arcs and a modicum of sugar dust. \"A lemon, _ja_? I can smell it now it is crushed.\"\n\nEither Schild or Bach made a sound like the winding of a watch.\n\n\"You can,\" the doctor repeated, and whatever else he said wound through the holes of the five candies in his mouth and expired before finding the orifice of speech.\n\n_\"Ich habe ihn nicht verstanden,\"_ Reinhart whispered into Lori's hair.\n\n\" 'You can say something,' \" Lori answered loudly. \" 'You can tell us what you will make of yourself now the war is over.' \"\n\nHe raised his meditation to point at the ceiling, to macerate his vision on the fierce lightbulb: father, two brothers, sister-in-law, nephew, niece, like the roster of a holiday reunion.\n\n\"Well, I cannot bring them back, whatever I do,\" he shouted quietly. \"But in my own small way I can fight all hatreds based on race, color, or creed. In my own small way I can say: we must love one another or die!\" When he was moved, words came from nowhere, inspired; yet he was conscious of the falsity of those which had just arrived. It was fairly certain that of the six victims in Lori's roll he could not have loved at least one, so goes the world. And how did a fellow go about loving any of those who killed them? For a principle means either what it says or nothing; if we love one another, we love the murderers, every one. And finally, was love really the sole alternative to massacre?\n\n\"One must love himself,\" said the doctor. \"The men who killed my family did not. What are totalitarians but people who have no self-love and self-respect, who believe that the humanity into which they are born is contemptible?, who believe a thing is preferable to a person, because a thing is absolute.\"\n\n\"But a thing,\" said Bach, \"has a sense of its thingness. The Will works in inanimate as well as animate objects. That sofa may know very little, but it knows that it is a sofa.\"\n\n\"Of course I agree, Bach, that this sofa has a self: I have heard it most painfully groan when you sat upon it and chuckle when you arose, but we shall wait forever if we expect it to will itself into a chair. This poor couch is so predictable.\" He actually looked sad and patted its arm. \"If you prick it, will it not bleed? But that is not necessarily true of a man, who may spit in your eye, or, having a taste for pain, beg you to prick him again, only harder. And what might he not make of it as a moral act? That by taking his life you have confirmed his conviction that you are inferior to him, and for some men life is a small price to pay for such reward. Or that by causing him to die well you have relieved him of the need to live well, for any victim is willy-nilly a success. Or that by divesting him of everything but the naked self you have made it possible for him to accept that self. In the end he may have used you as you believed you were using him, and who can say who was the victor?\"\n\n\"Oh no,\" cried Reinhart, even though he thought it likely he had misunderstood, \"you cannot build some elaborate theory that in the end Nazism did good. That sounds like the idea of those old fellows in Neuengland\u2014the northern U.S.A.\u2014Rolf Valdo Emerson, _und so weiter,_ who wore frock coats and walked in the woods and never cared about women, and therefore had this dry belief that evil was only the servant of a greater good.\"\n\nDuring this\u2014how fluent?\u2014speech Lori twisted round and studied him, trying, he supposed, to be unnerving: a person without experience should sit silent as a vegetable. Well that, last time with Bach, he had done. He felt now as if _he_ were drunk, and finishing his representations to the doctor, he stared defiantly at her strong, straight nose.\n\n\"Otto can say anything he likes. You see, he has paid for the right.\"\n\n\"There you have the corruptive results of working for the Amis,\" laughed the doctor. \"If I paid for the privilege to be theoretical, then I was cheated, my dear Lenore. All other German males are born with that right and obligation. But how true if you imply that this chap from over the sea should not be permitted to speak further without paying tribute! Come, Herr Unteroffizier, surely you have some more candy about you.\" The doctor retrieved his stick from the floor and brandished it. \"Here comes some English\u2014you did not know I had some? _Komm on you dirty rat hand ovuh zuh goods._ This is what the racketeers order, no? Bach has a detective novel which he reads aloud to me\u2014\"\n\n\" _Ja, ja,_ I have it just here,\" Bach said eagerly, struggling to rise. \"I read with simultaneous translation\u2014\"\n\nReinhart grandly waved him down. \"That won't be necessary at present.\" He did, of course, have in his clothing another piece of sweet: a chocolate bar foolishly stored in his shirt pocket, over the heart. It was now limp. He gave it to the doctor and apologized.\n\n_\"Sehr gut,\"_ the doctor responded. He smelled it. \" _Schokolade!_ I will not eat this. I shall present it to the widow who lives across the hall from me.\" He placed his cane on the concrete, giving Reinhart another sight of the umbilicus of his right eye. \"I am trying to seduce her.\"\n\nReinhart grinned anxiously and withdrew an inch from Lori, as if it were a mistaken but justified statement of his own aims, but when the doctor's glasses were turned on him again he saw their terrible wistfulness.\n\n\"Oh God, Doctor, eat it, eat it,\" he said, his voice ragged in pity. \"Next time I can bring you a carton for your widow.\"\n\n\"If your motive is kindness, please do not. Such largesse, if I gave it to her, would earn me only contempt. And if I kept it for myself I would eat it all immediately and fall ill. In either case I should curse you. But why do you now wish to bribe me without profit for yourself when earlier you refused to do it for gain?\"\n\n\"Because he is a good man.\" It was Schild who spoke, and pleadingly, and Reinhart suffered for him in anticipation, for the doctor _was_ a kind of demon, after all; in revenge for his having been tortured by evil and falsity he would torture goodness and truth.\n\n\"And I suppose you are, too,\" sharply replied the doctor. \"I don't trust a man who would rather give than receive. I can't stand his damned pretense that he is too good for the world. He is mad. I disapprove of lunacy, illness, disability, and failure.\"\n\nReinhart could no longer contain himself. The mad doctor's ranting left him personally untouched, but poor Schild gulped it all down, sounding again and again that watch-winding noise in his throat, and poor Lori was limp against his shoulder, used, no doubt, to the habitual insane rhetoric of the cellar; she had, as before, gone to sleep, but the constant strain!; he would rescue her from it before the hour was out; if need be, kick Trudchen's cheap little ass into the street and give Lori her room. Meanwhile he must catch Schild before he disappeared round the bend.\n\nHe shouted: _\"Das ist National-sozialismus!_ I don't know what you are trying to do, Doctor\u2014I sympathize with you, I would give my own eyes to get yours back, believe me, I would give my life if your family could come back again, I have never done anything\u2014I couldn't even hold a gun because of the Geneva Convention\u2014but don't say the Nazis were right. If that is true, then it was all useless; your loved ones died for nothing. All those corpses\u2014I saw them in the photographs. Those beloved people, they were too good for the world. The rest of us are too bad for it...\" His voice had broken, broken, as he knew ever more poignantly that with whatever motive he had begun his defense of general reason, he continued it for the sake of his own.\n\nTherefore was the doctor right, even as he sought to repudiate him; therefore was he cramped with guilt for a crime he had not perpetrated and agonized by a suffering he had not had to endure. To be vicarious always is always to be base.\n\n\"Why do healthy people believe there is wisdom in a wound? _Mumble, mumble_...\" The doctor slipped the envelopes from the Hershey bar, which in his stark handbones had lost its borrowed warmth-of-Reinhart and returned to brittleness, and segment on segment inserted it into slit-mouth quick-lips, munched, munched, munched. Soon was the lower third of his face childishly smeared with brown. His hair, dark-blond, high, luxuriant-grown as a Zulu's, had burst forth from the cropped skull of the camps. Against Schild his whisper had gone hard, cruel; towards Reinhart, Reinhart now decided, it had always been a snicker.\n\nOn he went in the idiom of masticating chocolate, with a necessarily greater show of gesture than when he spoke audibly, which nevertheless stayed Greek. Schild, who had been slumped, wired up his spine and sat straight, neurasthenic. Lori slept, heavy for so light a girl.\n\nBach, however, listened eagerly and when the doctor, the last bit of candy down the hatch, gave off, the giant bobbed his peeled egg at Reinhart and said in English: \"There you have the doctor's world-outlook in a nutshell!\"\n\nThen it was that Reinhart realized the doctor was fake from the word go; that he was no more an alumnus of a concentration camp than Schild was a hangman.\n\nThe latter suddenly glared at him and snapped: \"Very well! Russian 'concentration camps.' _Sehr gut,_ ask the doctor about them! Simply the Buchenwalds of another fascism...\"\n\nThe doctor wiped his mouth on a handkerchief as holey as a net dishrag, to get which he had opened his coat and revealed the necklines of, at quick count, four gray sweaters and a shirt collar of brown.\n\n\"Certainly they are not,\" he said good-naturedly. \"If you won't let me avoid the subject\u2014it is not offensive to me, since it is mine, but it should be, I insist, to you. If I must talk on this theme, I'll take my stand on precision. Young Corporal, you talk of love. But perhaps love is for boys and girls and old ladies who love their dogs. For us professionals, consider precision. Love one another or die? But we die anyway, _ja_?\"\n\n\" 'The subject is not offensive to me,' \" Reinhart suspiciously repeated.\n\n\"I did not say pleasant or without pain. I said not offensive,\" said the doctor, impatient. \"Now you interpret it as you wish.\" He resumed: \"The Soviet camps: as you must know, Lieutenant, they have quite another purpose than the Nazis', which latter were in their most extreme form mere extermination-places. The aim of the Soviet camps is to change people. Sometimes, inadvertently, live men are there changed into corpses; well, at least they are no longer counterrevolutionaries.\n\n\"Each kind of camp has a favorite kind of prisoner. The Nazis preferred the man who by existence was a criminal, that is, the Jew. Good Jews, bad Jews, Jews who as individuals _were_ criminals by the usual definition, even those Jews who would have agreed with everything in the code of fascism but that all Jews should be exterminated\u2014no, this is not yet enough: even those Jews who might have helped the Nazi cause\u2014were murdered indiscriminately. There was some early plan for 'useful Jews,' but it was soon abandoned. An Einstein perhaps could have been forced or tricked into giving Hitler the atomic bomb. Nevertheless he would not have been saved from the gas chamber.\n\n\"Where in all history can we find another idealism comparable to this? Hitler did what we have always been told is the supreme glory of man, and apparently impossible to a god\u2014for what chance did Jesus of Nazareth take if he was immortal?\u2014Hitler sacrificed himself for that which is greater than the self, for he stuck to his guns and he is dead now. I think a name for that is Love.\n\n\"With the Soviets, however, no man is judged by what he is but rather by what he can become. Their favorite prisoner is the man capable of learning the error of his ways. He must do this through hard labor on projects useful to the state, and hence to mankind, and thus there is no waste. The penal system of a faith as inclusive as the Nazis' was exclusive, and for that reason psychologically superior to the latter. Here at last the Jew, for example, is not a second-class citizen: he can be as great a swine as a gentile. Did you know, until that desert tribe of Hebrews found the one authentic God and that they were His chosen, an exclusive religion had never been invented? Ever since, the gentiles, who never could take a joke, have been punishing the Jews for being so damned clever. To the Communists, however, this old strife is a great bore. A man's a man, and is capable of anything. And of course when you believe that, you are loving one another.\"\n\n\"Excuse me, Doctor,\" said Reinhart, adjusting a prickling shoulder under Lori's weight, \"when you opened your coat I saw your shirt. It looks like part of a uniform, but not quite the color of a U.S. Army shirt\u2014\"\n\n\"I should not suppose it does.\" The doctor's whisper lost strength in extended speech; Reinhart really helped him by interrupting. He cleared his throat with the soft yet dynamic sound one might make shaking out a floormop. \"You are wrong if you think the average German feels no guilt; he simply will not dance it to the tune of you people who were not involved. My widow gave me this shirt. I suspect it is a storm-trooper's garment, but naturally I cannot see it. ...\n\n\" _Also,_ Lieutenant, we have looked precisely at the differences. My brother-in-law insists, however\u2014since he cannot forgive himself for being a gentile German [Bach flushed and looked at his legs]\u2014on their similarities. His interest lies in proving Communism worse. Because I was once a Communist I am inclined to agree. The conscience is a Himmler as demented as the real one. Remorse, whose seat is in the memory, has a purpose. Guilt, the product of the conscience, is always useless, the wrong kind of self-concern, cheating, cowardly, immoral.\"\n\nSince the doctor's comments on his shirt, which had proved him as false as anything could, Reinhart had been rather nursing his shock than listening. He came back now to strike another blow for virtue.\n\n\"It isn't hard to be a murderer. The tough thing is to be a victim.\" He smiled so bitterly that Lori woke up on his shoulder, saying _\"Wie bitte?\"_ to which he answered, _\"Nichts, schlafen Sie noch.\"_\n\nFor the first time, Bach, who had been frozen in wonder and delight, noticed her.\n\n\"Rude!\" he cried in outrage. \"Your brother is speaking!\"\n\n_\"Ach,\"_ she said, _\"was kann man tun?_ He hasn't stopped since I was a little girl.\" Her head sank again.\n\nThe doctor laughed and laughed at the awful thing\u2014if he _was_ an authentic ex-prisoner\u2014she had said to him. \"When we were small she used to punch me if I talked too much. In the solar plexus. Very effective when struck just right: I couldn't speak for half an hour. Therefore would I take revenge by playing the Leonore Overture on the gramaphone, which, because I insisted she was named for it, she detested. Then in would come brother Leo, who couldn't study mathematics for the din, and he would shout in his shrill voice: 'Twins have only half a brain each.' But if the altercation continued until Father had to come upstairs, we were all for it. Father had a face like a weapon. He was a very severe man. I can recall nothing loving about him but much that was precise.\n\n\"Once when at table I spoke without permission he afterwards beat me so strenuously he sprained his arm. Feeling guilty, as I usually did upon such an event, but not remorseful, I offered to fit him out with a sling\u2014already, you see, the future physician. 'Do you want another whipping?' he asked. 'This time for being a fool? From your point of view my sprain is richly deserved.' That is to say, he was a self-respecting man. I hated him for years. But now I think he must have died well.\"\n\n\"That old Prussian authoritarianism,\" said Reinhart, remembering an argument of Cronin's. \"There you have the origin of Nazism.\"\n\n\"Except that my father was a Jew,\" said the doctor.\n\n\"Jews can be tyrants, too.\" Reinhart was earnest, no longer baited or tested the doctor. \"Isn't that what we mean when we say racism is a lie? Everybody gets his chance to be a bastard.\"\n\n\"Yes, and we should not deny it even to, especially to, a victim. For there are victims and there are victims. If you read _Mein Kampf_ you will find Hitler believed himself a victim, and because when he became a master he failed to do his job well, I am still able to agree with him in that early appraisal of himself.\"\n\n\"Haha,\" jeered Reinhart. \"Victim of what?\"\n\n\"Of indifference. The German people never understood what he wanted of them. Being normal people, they were always interested principally in themselves.\"\n\n\"While the innocent were being murdered all around them... to you this is right?\"\n\n\"If you think I shall tell you what is right or wrong, my friend, you are mistaken. That is your own affair. I care only for practical matters.\"\n\nReinhart rubbed his head. Fresh from yesterday's close haircut, it felt to his hand small, hard, monkeylike, and shiny as a convict's.\n\n\"I give up,\" he said, without knowing whether the idiom was feasible in German. \"The trouble is, Doctor, I just don't know what you want. If everything we have always thought is decent, is wrong, false, misguided, or useless, what alternative is there? The only thing I can see is the contradiction of decency; Nazism is as good a name as any, so long as we understand that Nazism in this sense is not just a German but a human thing. The Russians, then, if they have concentration camps, are Nazis. Perhaps there was some Nazism in dropping the atomic bomb on Japan, which must have killed a lot of women and children and at least some Japanese who never wanted to go to war in the first place.\n\n\"The British, someone once told me, invented the concentration camp during the Boer War. The French, so I heard, put German refugees in concentration camps at the beginning of this war. In democracies there are white people who lynch Negroes; there is anti-Semitism. _I_ have been guilty of Nazism when I used force or threatened to on someone weaker than I or outnumbered, or when I had bad thoughts about Jews and other defenseless people\u2014because I have done these things.\" He looked proudly guilty.\n\n\"I should hope so,\" said the doctor. \"What's good enough for everybody else should be good enough for you.\"\n\n\"But isn't selfishness the terrible crime of the modern era, selfishly being concerned with oneself and therefore thinking the other fellow is garbage?\" He took his arm off Lori's shoulder so that he could rub his head with both hands. \" _I_ want power, _I_ want money, _I_ want to be superior to a man with a colored skin or with a hooked nose\"\u2014from his tumult he was able to call time, to say \"Excuse me, it was just an example\" to Schild, who, in the reverse of Schatzi's habit, was looking at him but not seeing\u2014\"therefore I tell myself he does not matter, is not even human. Then I can go on to do what I wish with him, slavery, torture, murder.\"\n\n\"Imagine yourself a citizen of the American South,\" said the doctor, \"a person who is in daily contact with Negroes and thus must come to terms with the fact of their existence. Would you mistreat them?\"\n\n\"God, I should try not to.\"\n\n\"You might occasionally fail, _ja_?\"\n\n\"I am just a human being.\"\n\n\"No question of that, and so was Julius Streicher, as Hitler, who was no man's fool, said so well: 'He may have his faults, but well, probably none of us is entirely normal, and no great man would pass.' Yes. But why would you try not to mistreat Negroes? Is there profit in it?\"\n\n\"It would mean something to me,\" said Reinhart.\n\n\"So there is a profit after all.\" The doctor spoke as if he, himself, were making the discovery. To be sure, his manner throughout had been rather seeker than owner of fact; did he lack the courage of his confusions? \"You cannot get respect for yourself by robbing it from another man. As to the Negroes, they might not know or understand what you were doing and therefore show no gratitude, _ja_? But to a healthy man this would make no difference. The self is not a gallery with a claque. And it would not be necessary for him to love the Negroes or hate the brutal whites, or worship a god or history, or be a radical or conservative. Just to be a man were sufficient, _ja_?\"\n\n\"Your example is too easy. Excuse me for trying to tell _you_ about life, but is it not more complicated than that? I am not likely to live where Negroes are mistreated. I did not live in Germany in Hitler's time or in Russia. I am not a Jew, my father is not an oppressed worker or sharecropper. On the other hand, neither am I a fascist or a boss\u2014well, let's face it, _I_ am nothing in particular, but you know what I mean. What would I do in a situation where an Auschwitz is possible? ...I have not told you\u2014somewhere in Berlin, if they are still alive, I have some relatives. I hired a man to find them, but just now I realized I have always hoped he never could. What if they were Nazis?\"\n\nAs a further twist of the knife, the doctor removed his glasses and began to clean them with breath and handkerchief. Reinhart averted his eyes.\n\n\"Since I can't see through these things,\" said the doctor, \"I clean them from a motive of pure vanity. I do not wish to be thought a sloven.\" He replaced his spectacles and took up his cane. \"I should like to meet your relatives if you find them. By various accidents and choices, I have a foot in everybody's camp. I am a halfbreed of every persuasion. You claim to have done nothing. I have done everything. Every individual life is a questioning of the validity of all others.\"\n\n\"And also a confirmation of it?\" asked Schild.\n\n\"Ah now,\" answered the doctor, \"that is irrelevant, for why should I need you, or you need me, or either of us need, say, Hitler or Stalin to tell us what we are? _Ich bin kein Weltverbesserer und lasse Sie liegen._ \"\n\n\"Then you should be satisfied with your lot,\" said Reinhart, \"neither were the Germans who were not Nazis world-reformers, and they let you lie.\"\n\n\"True,\" said the doctor cruelly, \"and they were not the ones who killed my family and took away my freedom, were they? They heard the cries and turned away, but at least they did not come and help fire the ovens.\"\n\nReinhart had chewed his gum too long. It disintegrated. He tried to reassemble it with his tongue. He failed. Ashtrays here were unknown; the smokers had crushed out their butts on the floor. He swallowed his fragmented Spearmint and said\u2014\n\nBut the doctor had not waited for him: \"There is but one demand we can make on others: that they let us alone. Anything beyond that is a corruption or will be one within the hour.\" He rose easily and hunched over his cane, which his fingers grasped as an owl a branch. \"Do you think I say this because of what the others did to me? The others, I tell you, are irrelevant.\n\n\"I was a Communist. The day after Hitler came to power I fled to the Soviet Union with my family. Thanks to the tactics imposed on it by Stalin, the German Party was shortly wiped out by the Nazis. But we all knew that history was using the Nazis for our ends, so we\u2014those of us who got out in time, that is\u2014did not despair. The Jews? A kind of vermiform appendix on the body of history. An illusion. Science knows no definition of Jew or gentile. ... In Moscow I had a good job in the Medical Institute, doing research on skin cancer. I won two decorations for my work and soon rose to head my section. My family and I, four of us, lived in a modern apartment of four rooms\u2014had four times the space, that is, of the average Russian family. After the required time, we became citizens.\n\n\"My chief assistant, at whose cost I had been promoted, for he had worked there since its founding, was an old Russian Jew with, like so many of them, a German name: Kupstein. He was the sort who would always be an underling. He did nothing well, but what was worse he knew and admitted it. He broke slides, he misread calibrations, once he managed to fracture the lens in a microscope\u2014rather a difficult thing to do under ordinary conditions.\n\n\"But we human beings were not so ready to exploit our power over him. Obviously he could not help it, and his constant contrition! He could, naturally, not only have been discharged but also imprisoned for his failures. Indeed, in the Soviet view he should have been; insofar as I made allowances for his good intent I was a bad Communist and perhaps an outright traitor\u2014and when I say this I do not refer to the disguised GPU informer on our staff. I speak of my Communist conscience. The secret police are given too much credit; for the important things we never need them.\"\n\nCrazed old man, leaning on a cane, rasping in _Deutsch._ Why had Reinhart almost flunked German 2? He understood every word, every nuance. The doctor condemned guilt in others but loved his own. He suffered retroactively for being sloppy years ago in Russia. ... If he had been in Russia how could the Nazis have got at him? Lori stirred. Without prior planning he whispered in her ear: \"I love you.\" She smiled sleepily and closed her lashes again, muttering _\"Knorke mit Ei.\"_ Something with an egg. Total misunderstanding.\n\n\"... after that episode I had no choice but to relieve him of his duties. We could all have been killed. Yet I still could not report him, sentimentalist that I was. And quite rightly was I punished for that weakness. With nothing to do he hung about my elbows all day and interfered with my own work. Titration tube in mouth, I would hear his squeaky voice and almost swallow some septic liquid. Bending over the microscope I would suddenly smell his breath, vile from some horrible cheese, as he bent alongside.\n\n\"And what did he speak of? Palestine, which he called Israel. He had been there for two weeks in the 1920's with a Soviet scientific team and was terribly impressed by everything from communal farms to climate. 'Believe me, my dear Doctor,' he would squeak, 'working on the _kibutzim_ seems a pleasure for these strange Jews. Imagine Jews as farmers! The sun turns their skin black as Africans' and has bleached the hair of some as blond as a Pole's\u2014or, as your own. Sabotage is unknown, yet one never sees a policeman. Is this possible? I doubt it. But it is the witness of my own eyes. And oranges! As many as you can eat. And the young people. Imagine happy Jews!'\n\n\" 'Hirsch Davidovitch,' said I, 'your satires are very clever but they may be misunderstood. Besides, you are interfering with the experiment. Really, this sort of time-wasting is more appropriate to a bourgeois-capitalist laboratory'\u2014I spoke that way in those days, and not simply for the GPU informer\u2014'we work here for the health of the international working classes and have not a moment to spare, please.' But next day he would start in again: 'My dear Doctor, the olives! I have seen them large as this.' Pointing to the bulb of a Florence flask, he would knock over a rack of test tubes and then, sponging up the mess, strike the flask from table to floor.\n\n\"Kupstein, Kupstein, of course you were winning,\" said the doctor, sinking an inch into the orifice of his coat collar; he had once been a tall man, but that too was now a memory. \"From the first time I had tolerated his statements without an effective rebuttal, I was a fellow conspirator. It was 1938. In Germany the N\u00fcrnberg Laws had sealed the fate of the Jews\u2014foolish Jews, one beats another and shouts 'help,' as the saying goes. My father, the lifelong reactionary who ordered me from his house when he found my copy of Marx, loses his department store to the Nazis, brings suit in the bourgeois courts he trusts so much, leaving the Nazis no choice but to send him to Buchenwald. Almost did I ask: well, what does he expect? With my brothers Leo and Viktor, who had given neurotic importance to their Jewish halves and turned active Zionists, they had been doomed by their stupidity and cowardice. Marxism, they agreed, was 'no answer.'\n\n\"In the Soviet Union, meanwhile, the great purges which had begun in 1936 were now in full fury; among the high Government and Party officials only Stalin seemed secure. Could our entire leadership, except Stalin, be corrupt? Yes, no question that it _could be._ Communism, as I said before, admits unlimited possibility. A man can be anything history needs him to be. No chosen people here, either for good or evil. For example, among the condemned officials were many Jews, and of course the commander-in-chief of the whole plot was Trotsky, born Lev Bronstein. He had conspired with Nazi Germany to destroy the Soviet state. Impossible? _But nothing is!_ By definition a state built and maintained by the proletariat is just, and whom it charges with a crime is guilty.\n\n\"When the rosters of the eminent were depleted, the purge began to claim the malefactors among the technicians and managerial workers. I at last discovered who had been the police informer in my department\u2014Rostov, a biochemist\u2014for he disappeared soon after Yezhov, the head of the GPU, was purged. The director of the institute had not survived through 1937; three successors, with only a month or two between turns, followed him to the wall or to Siberia. Dr. Narovkin, in effect my chief assistant, though Kupstein still held the title, was called to a corridor telephone one afternoon and never came back. His replacement, a simian type by the name of Gorky, sent by the personnel section without consulting me, did not bother even to imitate a scientist. All day long he sat in a corner of the laboratory, behind two carboys of acid, watching the rest of us.\n\n\"Dr. Narovkin's work had been essential to the experiment. He had done months of research on malignancies in lymphoidal tissues. If I could at least have had his notes! But they too had vanished, the day after his own disappearance. The project was hopeless? You must remember that this was a Soviet laboratory. We had been _ordered_ to discover, first, a preventive against sarcoma and, second, a cure for it. I reinstated Kupstein in his old post. What difference could it make now? None but for the better. Kupstein had worked in Soviet laboratories since 1919, and one thing he could do well was write reports. On his own initiative and with a perfectly straight face he now composed a manuscript of fifty thousand words reporting the successful achievement of our goal: we had found both a preventive and a cure for fleshy malignancies, and in one year less than our allotted time. I solemnly read and appended my signature to this handsomely written nonsense and forwarded it to the newest director of the institute. Not long afterward I received another decoration.\"\n\n\"Doctor,\" said Reinhart. \"Aren't you uncomfortable standing up?\"\n\n_\"Schweigen Sie!\"_ Schild ordered in an offensive, Prussian manner, so startling Reinhart that he answered, as Prussianly, _\"Jawohl!\"_ and did shut up most smartly. Bach smothered a giggle behind a trembling hand.\n\n\"Now there was no restraining Kupstein,\" the doctor went on. \"Defying Gorky's unwavering surveillance, he no longer whispered. Now he spoke his heresies in the tone of normal conversation. 'Do not despair over your loved ones back in Germany, Doctor, every death there is a life for Israel. The Jews one day will leave the cities and return to the land. Olives, lemons, palm trees!' I could not admit that he was mad, you see, because then I should have had to accept that I also was a lunatic\u2014for from the first his rantings had taken malignant growth in my imagination, like that very sarcoma which he and I so successfully defeated in our report. Damn the Jews\u2014my relation to them had always been an embarrassment; now it became a poison. 'The Law,' Kupstein would sometimes say, 'the immutable Law. The Jews have little else, but they have the Law and it does not change.'\n\n\"One day, speaking so, he followed me into a storage room at the other end of the laboratory from Gorky, who as usual sat at his table, but would come after us if we did not soon reappear. I took quick advantage of the situation. I seized Kupstein and said: What would you have had me do? Stay in Germany and die like a fool? You know how Nazis deal with Communists!'\n\n\"Brushing my hands away, he answered in a loud voice: 'Just yesterday there was an unopened crate of new test tubes right there. Now where could they be?' His eyes were innocent behind their pince-nez.\n\n\"I seized him again. 'Kupstein, have mercy, I beg of you. We here in this country, in this very laboratory, are working for not only the Jews but the entire human race.'\n\n\" 'I don't understand,' he said, again very loud, 'since the end of the sarcoma project one can't find a thing here. How can we proceed to defeat carcinoma without test tubes?'\n\n\"He referred to our new assignment: a preventive for bone cancer. At any moment Gorky would come snooping. 'I warn you, Kupstein,' I whispered. 'I have heard enough to have you sent away for twenty years, if not executed, as a foreign agent. Have you forgotten that Palestine is a British colony?'\n\n\"In astonishment he answered: ' _I_? Have you forgotten'\u2014there was the slightest pause, perhaps not really in Kupstein's speech but rather in my hearing\u2014'that central supply holds you responsible for every piece of equipment?'\n\n\"Gorky stood in the doorway, his thick eyebrows gathered in upon the root of his nose. 'Doctors,' he said, 'I must confess I have those test tubes in back of my table. I have been taking them out one by one from the straw and shining them with a bit of cloth, being ever so careful. They are now ready to go into the sterilizer\u2014may I operate the sterilizer, Doctor? You will see I can do a good job.' His face, menacing until a moment ago, was a cretin's.\n\n\"Two days later, at three o'clock in the morning, I was arrested by the NKVD and taken to 22 Lubianka Street. I never saw my family again. For what I estimate to be seventy-two hours\u2014there was no window in the room\u2014I was interrogated without pause. I received no food, and water was administered\u2014a glassful was dashed against my face\u2014only when I attempted to collapse. For at least forty-eight of those hours I was given no idea of the charges against me. The NKVD officer\u2014he was replaced by another from time to time, but they all looked the same\u2014insisted again and again that I confess, that my crimes were known to him but, consonant with the just laws of the Soviet Union, he must hear the details from me. By turns he addressed me as villain, child, poor idiot, honorable but misguided patriot, personal friend. At the idiot level I had an opportunity to think... that devil Kupstein! Obviously he, and not Gorky, had been the police spy. Being a loyal and convinced Communist, I knew too well I had no hope this side of a full admission, but of what? Kupstein had surely turned me in on a charge of Jewish chauvinism. I could not confess to that, of all things. In an access of shame and hatred I asked for pen and ink. I wrote a statement which in style, if not quite in length, rivaled the sarcoma report. I revealed myself as an espionage agent for the National Socialist government of Germany.\n\n\"My interrogator read it with satisfaction. 'Excellent,' he said. 'I'm sure you feel better for having got this off your chest.' He flipped through the pages. 'You see, you cannot fool us, although you are a most clever man. As a half-Jew you did not think we would suspect you of working for the Nazis, eh? And marrying a Jewish wife was also shrewd, eh? But we are shrewder yet, eh? Now name your accomplices and we will be finished with this unpleasant business.'\n\n\"My accomplices. To be sure, I had neglected this all-important matter. I wrote fifteen pages more, implicating Kupstein. This was a grim joke for which I was prepared to pay: since he worked for the NKVD, I had no doubt they would reject it. But here I intended to take my stand if it killed me, as well it might.\n\n\" 'Splendid.' The interrogator smiled. 'Now your conscience is clean. You understand that we already knew everything about the entire conspiracy. Your fellow agents in Leningrad and Kiev were arrested last week. Kupstein is also certainly no news to us; for years we have known of his fascist, Zionist intrigues as an agent of Trotsky.'\n\n\"Which in the language of the NKVD meant precisely the opposite. Somehow Kupstein the _Verderber,_ the spoiler, had blundered through two decades in his own kind of peace\u2014until I betrayed him.\n\n\"I was sentenced to fifteen years of hard labor\u2014a mild sentence considering my grave crimes\u2014and sent to the Kotlas camp in the region of Arkhangelsk. The details of that servitude are not as relevant as Bach maintains. The Nazi camps were worse. To make a comparison of the two, Lieutenant, is pointless. A single principle applies to both: in both the prisoners properly are innocent. I represented a grievous error on the part of the Soviet authorities. As you have heard, I was guilty.\"\n\n\"And Kupstein?\" asked Schild.\n\n\"And,\" said Reinhart, \"will you kindly explain how you got to Germany from Siberia?\"\n\nThe doctor pulled a blue muffler from inside his coat and draped it around his head as a woman would; but when he brought down his hands Reinhart saw he looked rather like Mahatma Ghandi.\n\n\"Through the camp intelligence, I heard that Kupstein was executed. My wife and children were not arrested, but they had to leave the apartment and it was made difficult for my wife to find work. I don't know how they survived. Before long the question was academic. I was arrested in July, 1938. A year later, when Stalin and Hitler signed their pact and divided Poland, I was brought back from the camp and deported to Germany.\"\n\n\"Oh _no_ ,\" Reinhart gasped, a sound applicable to whichever judgment he would finally make on the doctor's tale.\n\n\"My Soviet citizenship was revoked upon my conviction for the crime of espionage. In the pact each side agreed to return the other's nationals it held prisoner. The Gestapo met us at the border between German and Russian Poland. My wife and children were included in the transport, I understand. I was not allowed to see them. ... They died, I believe, at Buchenwald, where my father and brothers had earlier.\n\n\"The Nazi methods of interrogation were second-rate\u2014exclusively physical brutality; there has really been nothing new in that line since the ancient Chinese.\" He shook his head almost regretfully. \"The Nazis were a mediocre lot with only one idea: audacity succeeds; the _id\u00e9e fixe_ of the suicide. Where, other than poor stupid Germany, could they have got twelve years to discredit it? ...To the Nazis I was the same kind of embarrassment that the Jews had been to me. I repudiated my Communist affiliation, citing as evidence my treason to the Soviet Union, and demanded to be held as a Jew. If I had been interested in preserving my life, I chose the correct strategy. For here was another point of difference between the two systems.\n\n\"In the USSR one is given just what he asks for: at the end of my confession I asked for punishment. My request was honored. Not so with the Nazis. In their Neanderthal psychology a man asks for one thing to conceal his aim in another direction. Besides, they thought, who being something better would ask to be a Jew? I went into their dossier as Communist first, Jew second; and that took my eyes\u2014convinced I could give them information on the Communist underground, they tortured me\u2014but saved my life.\"\n\nPlucking at the floor with his cane, the doctor walked to the door. They all rose. Reinhart reached him first and took his arm.\n\nThe doctor shook him off irritably, then repented, saying with a smile: _\"Es geht allein schon schwer genug!,_ it is hard enough alone.\"\n\nTough old cuss, said Reinhart sotto voce, and then he saw him pass a skeleton hand across the dark glasses, as if to verify he was indeed sightless, but the very movement was evidence of an unextinguished hope that he was not.\n\n\"Twins have but half a brain each.\" The doctor grinned and pointed in Lori's direction. \"She still sleeps. _Knorke,_ I go.\"\n\nTwins, he and Lori. Which meant the doctor looked twenty years older than he was and Lori was twenty years older than she looked. Unless it was another lie.\n\nThe doctor shook Reinhart's hand, and then Schild's, and finally that of Bach, who had just reached them.\n\n\"Gentlemen, I say good night. You no doubt agree with me that an inconvenient means to self-respect is to undergo punishment for a crime you have not committed\u2014as you tonight have been punished. What a lunatic way for two young men to spend an evening! Have we nothing here in our Germany with which to entertain you? Especially you, old chap.\" He punched at Reinhart with his cane. \"Why so solemn? Doesn't it bore you?\"\n\nReinhart had imperfectly understood the doctor's story (his mark in German 2 had, after all, approached justice), but on the basis of the experience with Bach, he smelled the self-hatred in it and understood, anyway, that people in their most serious monologues depreciate rather than celebrate themselves, and are given to exaggeration besides.\n\n\"Well,\" he said. \"Do you expect me to laugh at life in our time?\"\n\nInstead of answering\u2014he should have known better than to expect him to\u2014the doctor said: \"Perhaps it will be as well if your relatives turn out to be Nazis; they have nothing further to lose.\"\n\nReinhart said: \"I personally don't think Schatzi will find them.\"\n\n\"What was that name?\" asked the doctor.\n\n\"Clever fellow,\" said Bach. \"He gives a job to his sweetheart. But she won't try very hard if it means the food you give her must be shared with them.\"\n\n\"No, 'Sweetheart' is this man's name. Don't ask me why.\"\n\nReinhart raised his nose nobly. \"And who cares? He was three years in Auschwitz.\"\n\n\"There could be only one,\" the doctor murmured, as if to himself, and then he gave a succinct reminiscence of Schatzi. Which, Reinhart observed as he fell through space, yet clubbed Schild harder.\n\n\"I will kill him,\" he said quietly. The great cables in his biceps expanded and split both sleeves at the seam.\n\n\"Good,\" said the doctor. \"But I hope not in ignorance. Kill him because he, as much as any of us, is a victim.\"\n\nHe insisted that Bach not disturb Lori: he knew the contour of every broken brick between this cellar and his own, which was close by. Again he said _es geht allein schon schwer genug,_ and went out.\n\n# _CHAPTER 20_\n\nSCHILD THOUGHT: HOW AWFUL for Reinhart, now he knows how it feels to be a Jew. He himself was weary of trust and mistrust, weary of hatred, of victims, especially weary of Jews, as, he thought, only a Jew can be. His predominant emotion towards Schatzi still was envy, now unconditional: the freedom he had seen in him was no illusion.\n\nWhen the door banged behind the departing doctor, Bach's wife woke up. A plain girl, but Reinhart, as unrepresentative an American GI as you could wish, seemed taken with her. He was not as innocent as he had seemed. Perhaps he was even sinister, now that Schatzi no longer was. What did he want of Schild? asked Schild unfairly, for it was he who had pressed himself on Reinhart, but unfairness is also a freedom. Schild liked Bach, therefore he must keep Reinhart from seducing his wife. But illicit love is also love, which must not be opposed. _Ah, but we die anyway, ja?_ said the doctor, forgetting to add: _alone._\n\nWho weeps for a Jew? he had asked with respect to Lichenko, one of the little men, symbolic Jews, for the love of whom we\u2014they\u2014control experience. Lichenko did not, but Reinhart and Bach did. Perhaps even Schatzi did. _Give to a man a chance,_ he had said so plaintively. He also was a victim, a kind of Trotskyite of Nazism, and though privileged\u2014for the Nazis were more tolerant of their heretics than were these others\u2014though a labor supervisor, also a prisoner. Schatzi's present allegiance signalized his reformation. Communism excludes no one, denies nobody his opportunity to alter, recognizes no people intrinsically chosen or condemned.\n\nStanding large and slumped before the sofa, Reinhart spoke low to the girl. So as not to jinx him, Schild made his cong\u00e9 to Bach, whose great kindly face looked down like a benevolent Buddha's, and opened the door\u2014or tried to. Five minutes ago a blind skeleton had flung it back as easily as if it were a curtain; for him, Schild, the door was frozen. The knob, a European type, a curved lever, broke off in his hand. And no putative seduction stayed Reinhart's, Mr. Fixit's, prompt assistance.\n\nUsing his elbows like Schild's father commandeering the telephone, Reinhart forced the _Brecher_ to give ground, examined the damage, described it as negligible, made temporary repairs.\n\n\"It will come off again if it is pulled too hard,\" he said to Bach, in German. \"Now if you had a bit of wire\u2014\"\n\nBach answered in English: \"My dear fellow, do not concern yourself about that. We live beneath a heap of ironmongery. Tomorrow, in the full sun, I shall grub in it for wires. What gauge is to be recommended for this purpose?\"\n\n_\"Bach hat kein Draht,\"_ said Mrs. Bach, who had a certain animation, but Schild decided Reinhart's interest in her owed to the incapacity of her husband; thus it was a sinister thing, the sexual excitement of betrayal, in which she herself at least connived: \"Bach has no wire.\"\n\nLichenko's way had been wholesome, to take the German woman by force. Last night when in sleepless midnight clarity he labored on the pillow, adding sums, he believed he had denied her to Lichenko because he wanted her for himself. Holy as a monk dreaming of the Virgin, he crept down to the kitchen and sacrificed himself upon the altar between her hard legs, she soundless except for piston hips upon the mattress. At seven o'clock, tame, she knocked upon his bedroom door and entered bearing breakfast on the last tray with which he served Lichenko and had no stomach to return for the last time to the messhall. In another land it would have been touching: bread, jam, coffee, from her own meager rations\u2014her pantry was no Army larder\u2014but the old hatred, now compounded, moved him rather to strike it to the floor.\n\n\"Bach has no wire,\" Frau Bach repeated, and now Schild heard the contempt fall on Reinhart, not the giant. \"If you wish something in this place, you must ask _me_.\"\n\nA flush of embarrassed lust suffused Reinhart's skin, although she proceeded to define the precise limits of her statement. She drew a pin from her hair and threaded it through the lever's empty screwhole. _\"Also.\"_ Tense with pride, she opened the door.\n\nReinhart shook Bach's hand. \"We must go. Did I tell you that I like your suit?\"\n\nBach perspired with gratitude. As high above Reinhart as the latter towered over Schild, as Schild himself loomed over Schatzi\u2014but there ended the stairway of heads, whose lower steps would bear most weight, carrying as they did the others. But he had excluded Lichenko, smaller than he, larger than Schatzi, a truly free man who would fit in no progression.\n\n\"A gift,\" said Bach, \"of my kind wife. She adorns me rather than herself, probably because I am good for nothing else. But that, too, one learns to accept. The mystery remains, for whom was such a garment made? For it is my perfect size, and no tailor came to call with his tape measure. Singular!\"\n\nReinhart, lifting away up, felt a lapel, and Schild remembered an old anti-Semitic routine: 'Sam, the customer wants a green suit. Toin on the green light!' Bach's horn buttons were his proper interest: how much the gross, less the usual two percent for cash?\n\nHe supposed he saw in Frau Bach's smile, which was entitled to it by half, the Hebraic celebration of a shrewd purchase as she spoke to Reinhart: \" _M\u00f6gen Sie den Anzug,_ do you like the suit? I bought it from this 'Schatzi,' little Trudchen's friend.\"\n\nReinhart gave her his large, gentile blandness: \"It is beautiful.\" Schild shook hands with everyone.\n\n\"You are always welcome here,\" said Bach from the heart. \"Next time perhaps things will be better and we can serve coffee!\"\n\nSchild permitted himself briefly to see that vision of Schild to which Bach had given, and offered to give again, hospitality; it was not unloving and it was not unloved, it was not institutional. Perhaps it also was free\u2014but it passed too quickly into the dark cloaca of the cellar hall, and he had time only to call, in simulated enthusiasm: _\"Knorke mit Ei!\"_\n\n\"Berlin slang, meaning 'Splendid.' \" He answered Reinhart's question as they clung, Alpinists, to the summit of Monte Klamotte, Mount Rubble, and searched in darkness for the comb so marked in daylight.\n\n\" 'Splendid,' \" Reinhart repeated, \" 'splendid with an egg.' There's something about Berlin that gets you, isn't there?\"\n\n\"Me?\" asked Schild.\n\n\"That gets a person, I mean.\" Reinhart turned his ankle on a broken brick, starting a minor avalanche. \"It always used to have an evil ring\u2014also awesome and faraway, like 'Mars,' or 'Jupiter.' But here it is, and it is real. Strange to say, I just realized I love it.\"\n\n\"Because it is broken,\" said Schild.\n\n\"I guess so. All the crap has been blasted away, leaving something honest, and I think what the doctor meant was that honesty really does win out in the end. That is horrible and at the same time funny. ... Funnier yet because I believe the doctor himself is a fake.\" By the poor, cloud-filtered light of an introvert moon he checked Schild's face. \"You see, I have been to that cellar before. The other time Bach told me a long story which turned out to be a lie.\"\n\n\"A lie?\"\n\n\"The whole cloth. Imagine him in the SS!\"\n\n\"I can't imagine anyone in the SS,\" Schild lied. \"Maybe that was a fake, too.\" He did not understand why he could not speak straight to Reinhart; the good intent was there.\n\n\"Would to God it had been,\" Reinhart answered fervently, and tripped himself up on a naked concrete-reinforcing rod, fell, kept talking: \"Like the murder of the Belgian babies in World War I\u2014give me a hand please?, I feel a hollow under here that I'll break into if I make a commotion myself. ... Thanks\u2014which was a propaganda lie. Dirty Nazis! They made it impossible to lie about the Germans. Thus Martin Luther and Frederick the Great and Johann Wolfgang von Goethe are swine, too, because they helped to make all this. N\u00fcrnberg, were you ever in N\u00fcrnberg? I used to think there was something fine there\u2014\" He crashed through the intervals of a grounded metal bedstead.\n\nSchild took a lower way, through a shallow trough which yielded underfoot as if he walked across a human body. \"When?\" he asked.\n\n\"Never,\" said Reinhart. \"I was never there, _naturally._ I saw a book once. Albrecht D\u00fcrer's house stands to this day, Albrecht D\u00fcrer, the old artist of the Middle Ages. He made one etching called 'Ritter, Tod, und Teufel.' When I first saw it I couldn't read German, I didn't know what that name meant, I knew only _Teufel,_ and he was easy to spot: a face like a wolf, with mad eyes and one crescent-shaped horn in the back of his head and two like a ram's curving out from under his ears. His ears were donkey's. On the other side of the picture is Death, on a crummy, melancholy old horse. He has a long white beard, a hole for a nose, and wears a crown full of snakes, holds an hourglass. The scene takes place in a gully full of junk, lizards, skulls, tree-roots, etc.; it looks something like Berlin today. A sneaky-looking hound runs along the bottom, and there is D\u00fcrer's trademark and the date on a little sort of tombstone.\"\n\nThey had reached the bottom of their own declivity, which egressed to nowhere, and attacked the next smoking slope, Reinhart continuing to walk point.\n\n\"But in the distance you can see the towers of a great castle. Death and the Devil may have entree everywhere, but they are not in that castle, which I believe must represent a heaven. And neither is the Knight, who I'm coming to in a minute. Because he would not be a knight unless he served his time in the gully of death and the devil. Well, the Knight\u2014there he is in the foreground, on his splendid charger walking stately through the crap, the Devil leering over the horse's rump, old Death wheezing at him in front, the dog _sehleichend_ along below, the castle far away\u2014they could do him in and nobody in those towers would know it until too late, but even if they did, what good would it be? What help can anybody else give you against Death and the Devil?\n\n\"The castle is not relevant, as the doctor would say.\" Reinhart passed through a doorway and was immediately again in the free air, for the wall stood alone in the world with no building as relative; Schild followed.\n\n\"Welcome to mine house,\" said Reinhart. \"I wish I knew where the hell we are, I think we're coming back to Bach's cellar.\"\n\nHe stopped abruptly and Schild bumped into him and excused himself and said: \"If you'd wait a minute I could show you.\" He knew the way and wondered why he did not seize the leadership from Reinhart.\n\nBut Reinhart pistoled a hand and shot at a great concrete box on the dim horizon, an entire basement blown intact from the earth. \"No, I see what I've been looking for. ... Neither are the Death and Devil relevant. The Knight rides through the gully as if he doesn't see them. Of course he does\u2014the style D\u00fcrer draws in, there's not room for the enormous horse let alone anything else; they are packed in that lousy gulch like a frankfurter in its skin. Therefore the Knight sees them\u2014but he walks on. And I tell you, they look pretty squalid. If you glance quickly at the picture you won't see anything but the Knight, with his long straight spear, a bit of fur towards the tip, the splendid armor with which he is, as they say, caparisoned, but most of all that wonderful tough face, sure of itself, looking not at the airy castle or horseshit Death or the mangy Devil, because they'll all three get him soon enough, but he doesn't care. He is complete in himself\u2014isn't that what integrity means?\u2014and he is proud of it, because he is smiling a little.\"\n\nReinhart reached the caisson, where he waited till Schild climbed the rise and stood puffing beside him.\n\n\"And he is not en route to do combat with an unarmed enemy. He is a man and needs no helpless victim to give him respect. When I think of him there, walking forever across the pages of a moldy old book\u2014and I guess not even there now, since my father burned it\u2014I could... I could smile, I suppose, because I do not feel sorry for him.\"\n\nSchild smiled wryly and said: \"You never saw the serf who had to help him into that heavy armor and take care of the splendid horse, or the bonded peasants who tilled his field, so that the knight could strut about as he pleased while the underlings did the work.\" Perversely he clung to his loyalties while still older ones besieged him: stifling summer on the ramparts above Manhattan, windows sealed and blinds lowered as antithermal charm, faint sounds of street serfs playing stickball, Sir Nathan riding the rug, charging through a bowdlerized Malory in which Launcelot and King Arthur's wife exchanged ethereal admiration. _For the French book saith that Sir Servause had never courage nor lust to do battle against no man, but if it were against giants, and against dragons, and wild beasts._\n\n\"No,\" said Reinhart. He tore off a chunk of loose mortar from the wholesale cellar\u2014astonishing that such strength was accompanied by any mind at all\u2014and pitched it like a baseball, although it must have weighed fifteen pounds, far across the rubble range and down night's black throat without a murmur.\n\n\"No,\" Reinhart repeated, \"you don't get the idea. There were no serfs or vassals in this picture. This Knight was real, but not real. How can I say it? I just thought, he was not necessarily even a German. He is just a drawing\u2014just art, is all\u2014a lie, if you like. He belongs as much to a serf as he would to a real knight. A picture belongs to anybody who looks at it. It can even be burned, and somebody will still have it in his mind. Besides, you admit anyway that Death and the Devil are free to all\u2014why not then the Knight?\"\n\nBecause Jews were never knights, even though they had lived in Germany since long before the Middle Ages; was it in Heine that one read of the ancient Jewish communities along the Rhine?, who said: Don't blame us for the killing of Christ, we were living here at that time! But riding the rug, working at the exalted old language to which he then had not yet realized he was historically a newcomer (but so, in his day, was Reinhart), neither did Sir Nathan admit his native disqualification for the quest of the Holy Grail. _Sir Launcelot let them say what they would, and straight he went into the castle, and tied his horse to a ring in the wall; and there he saw a fair green court, and thither he dressed himself, for there him thought was a fair place to fight in. So he looked about, and saw much people in doors and windows, that said, Fair knight thou art unhappy._\n\n\"But,\" Reinhart said unhappily, \"if you want to say they don't make them like that nowadays, I agree with you. That's progress for you: get rid of the whole works, serfs, peasants, castles\u2014and knights, not to mention _Tod_ and _Teufel._ Where do these kinds of Death and Devil fit in the doctor's story\u2014even if he is a fake?\"\n\n\"He was real, all right,\" Schild snapped. \"I'm not sure about you and me, but he was real.\"\n\n\"Nobody in that cellar ever shows you any evidence.\"\n\nSchild laughed in sharp anger and answered in his birthright idiom: \"So whadduh you, district attorney?\" It sounded authentic; he had not come so far; his temper softened. \"You just said it is impossible to lie about the Nazis\u2014\"\n\nReinhart had found a chairleg and now slowly, inexorably bruised it against the concrete wall, until its end was fibrous as a brush.\n\n\"The Germans, I said, but I am glad to hear _you_ think there is a difference.\"\n\nQuite right, the error was his, but why the special punishment? And why should Reinhart bring it, whom he trusted, to whom he was in a unique relationship of owing nothing and vice versa, his friend. ... The moon had eluded its cloud but was still niggardly, showing Reinhart as a large pale blob belonging to the powdered landscape. The gentile is everywhere at home. Reinhart leaned against the basement as if he owned it, waiting for the Jewish opinion.\n\n\"Why _me_?\" Schild shouted in fear and loathing.\n\nReinhart was hurt, but calm. \"Because you're the only other German-American I've got to talk to. We have a common interest in those potato pancakes we were fed as boys.\" His irony surprised him; he grinned and wrinkled his brow low, like an ape.\n\n\"For Christ's sake,\" said Schild, \"don't tell me you don't know I'm a Jew.\"\n\nHe had been wrong about Reinhart's face; its contempt was as acute as its good feeling had been blunt.\n\n\"All right,\" said Reinhart. \"You're better than I am, you know everything without having to try, and you can stick it up your ass.\"\n\nHe shuffled along the basement wall, kicking up brick dust, which filtered through the hairs of the inner nose smelling like cordite. He now looked rather more resigned than angry, and at the corner of the concrete he threw up his head, pointed, and called: \"The path is here!\"\n\nHe had known where it was all the while. Why had he led them to wander? He was sinister, but he was also good. He descended an excavation, his round head falling evenly from sight.\n\n\"Wait!\" Schild shouted, pelting after, through the crying, broken turf. When he reached the bombhole Reinhart's broad back was laboring across the other rim. \"I gave you an order!\" He suffered fear that the man would deny him again, this time in insubordination\u2014the first irregularity had been merely personal\u2014and he would be required to turn him in for arrest. 'You are always arresting someone,' St. George, whose Army it was and not Schild's, had complained.\n\nHe scrambled across the chasm as Reinhart, obeying, waited. He had trouble, too, at the rim, and not being as tall as Reinhart, could not have made it without help. Which he received, unrequested. Reinhart's hand was cold and dirty.\n\nReaching the upper level, he began to speak his amends, which, as always, altered during their travel from source to mouth. Hysteria was, finally, the only cause he had ever served, but at least he was loyal to that. He accepted his uniqueness, and remembered an old story told him by a fellow traveler undergoing the transition to simple liberal and eventually no doubt to worse\u2014the typical American politics of _pis aller_ \u2014and that was his respects to Reinhart.\n\n\"When Trotsky and Stalin first fell out, the Politburo met to resolve their differences. Since Stalin controlled a majority of its members, it soon decided in his favor and demanded that Trotsky recant. 'You are ordered,' the decision read, 'to stand up and say: \"Comrade Stalin, you are right. I am wrong. I apologize.\" 'Very well,' Trotsky answered, 'I accept the decision.' He stood up and said in a heavy Yiddish rhythm: 'You are _right_? I am _wrong?_ I _apologize_?\"\n\nReinhart grinned. \"Neither do I, sir. ... Since we are speaking freely, I can say I knew that whatever else might be said of you, you weren't chicken-shit. Jewish officers never are. They have too much pride to be. They are free.\"\n\n\"No,\" Schild answered quietly. \"If you believe that you believe in a lie and you make it too hard on the Jews.\"\n\n\"But I have seen it. I have three years' service\u2014I enlisted,\" said Reinhart in pride. \"If you don't mind my saying it, Jews are sometimes know-it-alls and their manners could stand improvement, but that doesn't have anything to do with decency and is anyway a proof of their freedom\u2014\" He checked on Schild's reaction with the defiant self-righteousness, nose slightly flared, of the man who by his general benevolence is sanctioned to be specifically offensive; he wished to hurt Schild, Schild could see, in the interests of some comprehensive good that would finally bankrupt him, Reinhart, but first he would take a small profit.\n\n\"\u2014and don't tell me that is anti-Semitism,\" said Reinhart, cowering, for all his size. \"I'm sick of being made to feel a swine because I'm of German descent. I'm sick of being in the privileged class that nothing ever happens to. I'm tired of being big and healthy, but I can't help it, I was born that way. If you would be a prisoner in any concentration camp ever made, I would be a guard. Now, you know everything\u2014but do you know that? How that makes a person feel? Do you know what it is to be in debt to everybody? Not you, you are always right.\"\n\n\"I?\" said Schild. He sat down on a ridge of waste. The sudden armistice within had relaxed his muscles. He repeated the grammatical fiction almost genially: _I,_ the pronoun of rectitude: \"I am a murderer.\"\n\nReinhart took seat beside him, and with the added weight the ridge of brick-halves squashed out about their ankles.\n\n\"Ah,\" said Reinhart, \"you should have a pair of these boots. Now your shoes will be filled with that junk.\"\n\n\"That's all right,\" Schild said, although he too, with a sense of expansiveness, granted its tragedy; he, the rude _Besserwisser,_ accepted this Middle Western, gentile horror of discomfort and unrespectability, opened his shoes and dumped them clean. His right sock had a large hole revealing his largest toe.\n\n\"Why don't you turn that in to salvage?\" paternally asked Reinhart, pointing rudely.\n\n\"No salvage for officers,\" he answered, self-consciously pitiful. \"We have to buy our own.\"\n\n\"I keep forgetting.\" Reinhart searched his pockets. \"You got a butt?\u2014wait, by God, here's that little pack of Fleetwoods you yourself gave me last month. Well, they're as good now as ever. They are made stale.\"\n\nSchild took one and found he was quite right; Reinhart knew everything.\n\n\"Now don't you worry,\" Reinhart said, \"all that was just talk. Berlin does something to everybody; makes one want to accuse himself.\" He blew a smoke-mustache from his nostrils. \"In a war there's no such thing as murder. It's kill or be killed. I don't blame the regular German army, for example, for fighting against the Allies\u2014even if their cause was wrong; that's a very different deal from the particular Nazi outrages. To be precise\u2014when I said the doctor might be a fake, I meant in the unimportant things, such as whether or not he was in those camps, whether or not he was a Communist or a twin of Lori, and so on. I never for a minute doubted he was honest in the fundamental human things\u2014you see he could be an ex-Nazi and still be straight on those. Did you ever think of Hitler as just a man eating jelly omelets, needing a haircut, clearing his throat, getting out of bed in the morning and yawning? Did you ever think of someone saying to him at such a time: 'Come on, Adolf, I see a bit of dandruff on your collar and I heard you belch, and I know you have your troubles. Come on now, you can't crap me, you're a man like any other.'\n\n\"But I started by wanting to be precise. Precisely, I can conceive of an honorable German hating Hitler yet fighting for his country in the Wehrmacht. I can also imagine a German Jew who in spite of what was done to him thinks of Germany as his own country, for he is a _German,_ isn't he? And if he has permitted the Nazis to convince him he isn't, he has let them win\u2014in a way they never did with all their bullies and gas ovens. _They_ are the non-Aryans, _they_ are the degenerate race who rotted and betrayed a great people, not the Jews. I can conceive of such a man, I don't mean I expect any particular individual to be one, you can't blame a man for _not_ being a hero.\"\n\nDespite his fervor Reinhart spoke slowly, and Schild for once was not impatient. Having confessed, he had awaited the question of a pure-hearted fool, which, the old legends promised, would heal his wound. Instead he found himself cured of Germanic whimsy. He, and not Reinhart, was the romantic; fools there are in abundance, but not one is innocent.\n\n\"Reinhart,\" he said evenly, \"now listen to me. I forgive you. Do you understand? I forgive you.\"\n\n\"That is not what I want\u2014\"\n\n\"But that is what you get from me, nevertheless. And if you won't take it\"\u2014he grinned and shot his cigarette-end in a high rocket which no sooner exploded on the wasteland than two shadowy children filtered from behind a rubble hillock and claimed it as prize, quarreling on who should pinch its ember, whose ragged smock-pocket should tote it to their used-tobacco Shylock\u2014\"you can stick it up your ass.\"\n\n\"It doesn't do me any good,\" said Reinhart. \"Now them\u2014forgive those kids. They really had nothing to do with it, unless you believe with Hitler that a whole people can be degenerate.\"\n\nBut he would not let a gentile be sanctimonious with him. On the other hand, he again cleaned his shoes for Reinhart's sake and rose, saying: \"Do you know we have to walk back to Zehlendorf?\"\n\n\"Unless we can hitch a ride.\"\n\n\"This late?\" asked Schild, looking at his bare wrist. In what bleaker field was his watch ticking now? To Reinhart, he knew all the answers, yet why was his every emotion another question? \"Do those children stay awake all night on the chance an American will come by and throw away a butt?\"\n\n\"What else have they got to do?\" Reinhart asked toughly. He field-stripped his own cigarette and hooved it into the ground.\n\n\"What do _you_ have against them?\"\n\n\"A private grudge,\" said Reinhart, \"that's my own damned business. Well, if we have to walk, that makes it easy, no choice.\" He rebloused his pants, tightened his belt, adjusted the jacket, made his cap smart, and, ready for any D-Day, motioned Schild to take the lead.\n\nOnce they were out of the rubblefield and in the open gray streets gulching the ruins, Schild fell back beside him in an aesthetic revulsion against captaining one man all the way to the Grunewald Forest. With no one before him to control the pace, Reinhart increased his stride, measuring off a yard per step. Schild fell behind. On the bicycle path of the Hohenzollerndamm, in Wilmersdorf\u2014they were beyond the congestion and, hence, the worst damage, on a wide thoroughfare becoming suburban, with streetcar tracks, bounded by greenery and particular rather than mass ruins\u2014Schild leaned against a poster-pillar and took air.\n\nMarching with loud slaps of his rubber soles, head fixed as if he were in ranks, Reinhart went on unheeding. Schild watched him for a hundred yards in the light of Berlin's dawn, which came early in the small hours\u2014therefore it was later than he had supposed. Reinhart would soon look back. On a childish impulse Schild stepped behind the pillar and waited. The footsteps rapidly tramped beyond earshot.\n\nHe found that inadvertently he had kept Reinhart's veteran Fleetwoods. Going in through the cellophane and limp pasteboard, his fingers made inordinate noise, and had he still been a nervous man he might have mistaken the sounds for those of someone creeping out of ambush behind him. He fired his cigarette and took a lungful of corrosive smoke, toying with a paradox: the one man he knew who was the ambush type had least need of concealment. In proof of this he saw Schatzi standing nearby on the sidewalk, hiding in the open air and light, a concrete apparition.\n\n\"I have followed you like a sickly conscience,\" said his courier, who wore a motley of olive-drab clothing.\n\n\"You are out of uniform,\" Schild answered, laughing softly. \"If the MPs come along I can have you arrested.\"\n\n\"I'm doing you no harm,\" Schatzi said in some worry. Then he smirked weakly. \"Come Fritz, you make the joke with your old comrade with whom you have already deceived, so that I am in trouble across the boundary.\" He pointed over his shoulder. \"The Russian is gone, _ja_?\"\n\nSchild asked: \"Do I throw off an odor, that you can follow me with your nose?\"\n\n\"Perhaps you will not believe, what can one do?\" He shrugged. \"Having some business on the Tauentzien Strasse\u2014very well, being exact, in the basement of the KaDeWe\u2014ah Fritz, what a pity that excellent compartment store must be bombed!\" Tears coursed the runoffs on either side of his crag-nose. \"Ah, Fritz, I must confess I have had a drop\u2014I am in my glasses, as it were.\" He wove across the bicycle path and rested against the pillar. \" _Verzeihung, Herr Litfass! ..._ Why should I care about this ugly place? What have they done to my N\u00fcrnberg? Because I am not _Saupreuss,_ a Prussian pig, _beileibe nicht._ Pure Bavarian, _verfluchte Scheiss_!\"\n\nHis American overseas cap was pulled low and round as a sailor's. His nose began to run; he cleared it onto the dark green of his new field jacket in two short swipes marking the chevrons of snot-corporal. \"From the Ranke Platz I saw you creeping over the ruins with that oaf and I thought, this Fritz has lost his Russian fairy-boy and got him a nice young American in its stead. You have been foolish, Fritz, and they know about it\u2014they know everything\u2014you don't deal now wiss stupid Nazis.\"\n\nHe reached for Schild's sleeve and, missing, fell to the ground on his hands, yet caught himself arched, and backed spiderlike till his rump was against the pillar. From the point of contact he rose inch by inch along his spine, cleaving to the shaft.\n\nErect, coughing vacantly, he whined: \"They killed my dear dog, Fritz, with a machine pistol shot him through the head. That is their kind of people! I loved that creature, to which they should not have done this harm. I gave to him food from out my own mouth.\"\n\nSchild began to walk away, in peace.\n\n\"Come again here and listen, you bit of turd!\" Schatzi screamed. \"In Auschwitz I liquidated better men as you by the thousands. _Du kannst mich im Arsche Lecken._ \"\n\n\"No,\" said Schild, calmly smoking, \"no, you did not. You only buried them. You were forced to, you yourself were a prisoner.\"\n\n\" 'Forced to,' \" Schatzi repeated drunkenly. \"I carried a club, Fritz, but one must be careful how hard one beats them, or the SS will rage with jealousy and take the post away. Then too, these thin bones were easily cracked, which meant the job would be nonsense because they must remain strong enough to dig\u2014I always knew you were a double agent, didn't I always say so? You yourself are Intelligence! Pity me, Fritz, they have murdered my dog. Dirty Russians! It unsecured itself from the chain and came by my heels already, unknown to me until I was stopped by this sentry at Sergeyev's building. The dear dog has been thinking, 'Ah my master is attacked!' He sprang at the soldier and the Russian shot him.\"\n\n\"I am sorry. Really I am,\" said Schild.\n\n\"Brown on the outside, red on the inside like a beefsteak, we were in the early _Sturmabteilung._ We had many similarities to the Communists, Fritz. Idealism, we were idealists, and we died for it\u2014like the Jews. We were the first Jews. Thus I can understand you. I too hate this filthy Germany.\" He wiped his nose again, promoting himself to snot-sergeant. \"You are a soldier, but you were shrewd enough to get for yourself a safe position behind the lines of battles. Why should you not, if you are clever enough? I do not criticize. In the Great War I was not a shrewd fellow like you, but a simple foot-soldier. Just see this.\" He raised his trouser cuff and lowered the stocking. \"Verdun, February 1916\"\u2014a blind, purple hole in his calf. He opened the jacket sleeve and that of the wool shirt beneath it, and drew back the arm of heavy, dirty underwear: \"Verdun, September 1916\" \u2014a masticated chicken leg was his left forearm. \"August 1918, mustard gas in the lungs, the forest of the Argonne. As you known, I still today cough. While I collected these thanks, I must not tell you what was occurring behind our back in Germany, you would believe me insulting to you and your peo\u2014no, one does not say that, but there existed fat swine who profited by our blood. And when after the war we went to settle wiss them, these Nazis killed us instead. _Berufsverbrecher,_ professional criminal, I am called in the camp\u2014\" The liquid discharges of the eyes and nose left prison-bar traces on his dusty face.\n\nSchatzi continued the catalogue of wrongs done him, and Schild thought, they are as real as anyone's, as Reinhart's, as his own: _who among us is not a Jew?_\n\nHe said: \"All right. Now you'd better get yourself together. Perhaps you can find another dog\u2014\"\n\n\"The only thing in years I wished to love!\" Schatzi threw his head back against the pillar and unabashedly wailed.\n\nTwice tonight Schild had been chosen to hear a candid heart; it was the old choice and fitted his old gift. For the first time he knew it as a tribute to what he was, or what they supposed him to be, and perhaps after all these were one and the same. If Hitler had not died in the Chancellery garden he would one day seek Schild out and tell him, weeping, of being twice denied a career in art by the academic examiners; rejected by his sweetheart niece who then blew out her life; a bum in a Vienna flophouse, befriended by a Jewish old-clothes dealer; gassed in the war; and, finally, of his last defeat as the Red Army swarmed over the Spree. And Schild would say, All right, Hitler, we shall weep together.\n\nTo Schatzi he repeated: \"Collect yourself, man. Sergeyev will have your head if you are reported drunk.\"\n\nImmediately Schatzi dried from within and became one hard instrument of suspicion. \"Whom did you say?\"\n\n\"Sergeyev. You just mentioned going to Sergeyev's building\u2014\"\n\n\"Ah, but did I mention why?\" He fell into his usual semi-crouch, which put his head four feet off ground, and Schild, who had always believed this the stance of attack, realized at last its purpose was rather to make Schatzi a small target.\n\nWith supreme distaste, but nothing else would serve, he grasped Schatzi's jacket and pulled him upright and vulnerable. \"The next time you see him, report that Fritz is finished.\" He watched the red respect flood Schatzi's eyes. \"Do you understand?\" Schatzi trembled in admiring assent. \"If you do not tell him, I shall let Corporal Reinhart beat you to death.\"\n\n\"This great beast?\" whispered Schatzi.\n\n\"All I have to do is nod to him.\" Schild released his grip, requiring all his muscles to hold his face stern. \"He also knows your story and, because he is a gentile, holds a grudge. Do you remember a Dr. Otto Knebel in Auschwitz?\"\n\n\"They all looked alike to me,\" Schatzi answered without thought, then taking a sober one: \"Perhaps he was in Monowitz, another section of the camp from mine.\"\n\n\"He remembers you.\"\n\n\"Maybe he lies. The SS marched them out to Germany when the Russians approached, and who would survive such an ordeal? Lucky, I escaped. Luckier yet, you were never there in any case.\" He was returning to his old self, with both relief and disappointment at Schild's apparent decision not to molest him further. \"But accept from me this warning, Fritz. Serg\u2014 _they_ do not recognize luck. And they have also their camps. You did better to transfer from Berlin, where they can easily get at you, before playing the renegahd.\"\n\nWithout feeling, Schild said: \"I'm no renegade. You can also tell him I won't talk.\"\n\n\"Fritz,\" said Schatzi. He came close in a reek of liquor, eyes drifting: \"I have some regret for mistakes in my life. Wiss my family was not the love you Jews have for each another. You can not understand how my father was beating me always. I have had another dog at ten years of age. My father struck that dog to death when it slipped its chain and entered the house and fed upon his slippers.\"\n\nBehind him Schild heard the noise of a vehicle in Hohenzollern Platz.\n\n\"Was that in N\u00fcrnberg?\" he asked.\n\nSchatzi was caught up short, made his eyes keen, and answered: \"Precisely. Do you know the city? In the Altstadt, below the cahstle wall.\"\n\n\"Near the _D\u00fcrerhaus_?\"\n\n\"In fact, overlooking,\" Schatzi answered. \"I have heard D\u00fcrer's house is _kaputt_ from the bombing. Is it so?\"\n\n\"I don't know. I have never been there.\"\n\n_\"D\u00fcrerhaus, Scheisshaus,_ what should we care, eh Fritz?\"\n\nSchild backstepped from his camaraderie, turned and saw the jeep bumping over the streetcar tracks. It was now as light as an overcast afternoon. The tall MP beside the driver saluted, and Schild knew a moment's qualm. But it was not he who arrested Lichenko.\n\n\"You want a ride, Lieutenant? Is that crumb bothering you? Hey Hitler, spricken see English?\" He smacked his billyclub into his palm. \"C'mere. I'll give you some democracy right in the nuts.\"\n\n\"He's with me,\" said Schild, officerly factual, showing his ID card. \"If you drive on down this street you will see a corporal. I want you to give him a lift if you are going that way. He too was with me on official business, so don't bother him about a pass.\"\n\nThe MP obsequiously lowered his club. Likely had he seen Schatzi alone, he would not even have made the threat; he wished merely to be appreciated.\n\n\"I hope,\" Schild continued nevertheless, \"you don't speak in that loose fashion to every German you meet. You might run into an anti-Nazi.\"\n\nAgain the MP assented, careful in his policeman way to give excuse without a show of confusion. \"I didn't know there were any.\"\n\n\"Neither did I,\" said Schild. \"But we can't let that make a difference.\"\n\nThe jeep snorted down the vacant Hohenzollerndamm.\n\n\"You Amis are strangest of the strange,\" said Schatzi. By means of the MP's menace he had regained full dignity. \"This I first believed was a weakness of the mind, and next for me it was a sinister thing. Finally, I see, and it is harmless: you really believe that you are the master race.\" This time he wiped his nose on a handkerchief. \"The Germans, you know, never did, and least of all when this crazy sissy Adolf, and this cripple Goebbels, and that fat Zeppelin with the large mouth Goering, told them they were. A German knows he is not anysing. Instead for a time he thinks that _they_ are, Adolf _und Gesellschaft._ Never himself. A French waiter makes a German feel like an ox. An Englishman makes him feel ill dressed. His great philosophers either talk so he cannot understand them, like Hegel, or tell him what a disgusting lout he is, like Nietzsche. And then there are the Jews, always so clever and so successful. See the magnificent land where they run things, America! ...Fritz, I am speaking earlier of my mistakes. I work for the Communists because they force me. When I am a young man I spilled much of their blood, but now I am old and weak. Unless I serve they will denounce me to the American police\u2014this thing with R\u00f6hm and the early SA. I will be treated like a Nazi, _ja_? At least this way I am free. But can you get me to America, I shall not inform _them_ you will go. Is it an honest arrangement?\"\n\n\"Perfectly,\" said Schild, \"except that I don't get a profit. Now I'll make you a deal. First, you report to Sergeyev that Fritz is done. Second, you make certain I never see you again. On my part I'll keep Corporal Reinhart from killing you. Now\"\u2014he seized Schatzi and turned him around\u2014\"that way is east. Go already, in peace and freedom.\"\n\nSchatzi went, looking back from time to time with the reproach and puzzlement of an exiled pet, but going. Schild watched him as far as the Platz and, reminded by his animal progress, pitied him again for the loss of his dog.\n\nReinhart was at Roseneck, Rose Corner, when he heard the jeep engine and, because his permanent pass was good not later than 0100 hours, he crept into an empty beer garden and hid behind a tree. The car made the turn and vanished into Rheinbabenallee. Emerging, he saw the darkness of the Grunewald woods a couple more football-field lengths down the street. He had lead in his ass and his feet were aflame. Distances elsewhere standard, in Berlin were triple; and he had taken no real exercise in years. As well he was a chair-medic, the Rangers and paratroopers were lucky not to have him. He regretted having pulled on ahead of Schild, for not only was he tired, he was lonely. But the Jews and their mad pride, he would never learn to cope with it.\n\nCrossing Kronprinzenallee at last, he saw where someone had chopped down a tree in the Grunewald. He walked in and sat on the fallen trunk. He searched in vain for a cigarette, but the Pall Malls were at Bach's, the Fleetwoods with Schild. No matter, his lungs were weak enough. He struck himself in the chest and coughed histrionically, feeling a certain softness in the pectorals. Weight lifters out of training develop breasts like women, look worse than the ninety-pound weaklings they originally were, he remembered. Undoubtedly the same thing happens to the muscles of the trained mind: in time intellectuals' heads grow flabby. The morality of Puritans becomes mushy. Life mocks those who try.\n\nNow that he had found Kronprinzenallee he knew the way home: straight down it about fifty miles to Argentinische Allee, around that crescent about halfway, another twenty, until you reached a patch of trees and sandbags and excavations, traversing which you came finally upon the farthermost limbs of the detachment headquarters building. Trudchen would be long gone to the bosom of her family, obeying her parents' ukase against staying in bed with a man after ten o'clock at night. He had his joke; actually, she told them she had to work overtime at the office. They were, he supposed, a typical German familial unit, of which he should make a sociological investigation\u2014except that he knew all about normal people, who are everywhere the same.\n\nRest in his condition only made it more difficult to return to movement. He checked the blouse of his trousers, that precise indicator of a soldier's smartness\u2014Schild, for example, had he worn boots would have stuffed the cuffs crudely into their mouths and buckled the straps. The contraceptive around his right boot proved to be frayed. He took a new one from his watch pocket, peeled it, tied it in place. The Kraut who found the discarded rubber would never figure it out.\n\nReady to move, he saw in Hohenzollern's distance the insignificant form of Lieutenant Schild, walking steadily, nothing ambitious but with a certainty in his carriage that he would get there, wherever it was. A tough little guy, in his own way. If I could be like Schild, Reinhart believed, I would not complain. So he waited for him.\n\nArriving, Schild said: \"The MPs didn't find you?\"\n\nReinhart boasted: \"I was too quick for them.\"\n\n\"They were going to give you a ride.\"\n\n\"I can make it all right. Why didn't you take one?\"\n\n\"I have an aversion to the police.\"\n\n\"You and me both.\"\n\n\"I wanted to ask you,\" said Schild, \"what are you going to do about your friend Nurse Leary?\"\n\n\"That's a difficulty.\" He was getting nervous again at having to walk so slowly. \"Let her go to hell, I guess. Except that I gave my word.\"\n\n\"What do you owe huh?\" Schild asked, New Yorkly.\n\n\"Nothing whatsoever. That is exactly why I cannot go back on my word.\"\n\n\"I'd think it would be the other way around.\"\n\nReinhart felt the newly arranged cuff working loose with his stride. Screw it. He smiled down at Schild and said: \"What you mean is you thought _I_ would think so. But I don't. It would be letting the other fellow decide what you yourself should feel. I never have been able to stand that. That's what I like about the Army, where you are told what to do and eat and wear, but never what to think and feel. Everybody but me seems to hate it, on the grounds that it takes away their 'freedom.' When did you last see a free man in civilian life?\" He pushed back his sweat-heavy cap and snorted. \"Look at me. I alone am right. Ha! Join the Reinhart Party!\"\n\nPaired, the travel had improved; already they had crossed the sandy P\u00fccklerstrasse and the apartment houses of Argentinische Allee lay in the field of vision.\n\nSchild said: \"The knights of Cornwall are no men of worship, as other knights are. And because of that, they hate all men of worship.\"\n\n\"What is that?\"\n\n\"From King Arthur. You put me onto him with your 'Ritter, Tod, und Teufel.' \" Schild slowed. \"Here, let's have the last two of your Fleetwoods. ... You think a lot, don't you?\"\n\n\"Too much,\" Reinhart complained with a mouthful of smoke. \"Indeed I am a drone. However, I don't usually do the talking. By nature I am a listener.\"\n\n\"Do you ever get any snatch?\"\n\nAstounded, Reinhart asked him to come again. The same, and this intellectual was not even grinning.\n\n\"Since you ask, Lieutenant, only that little Trudchen\u2014just as you predicted. She was no virgin. She is depraved, in fact, was already, which makes me feel less badly about it.\"\n\n\"Well,\" said Schild, \"if she's old enough to have it, she's old enough to use it.\"\n\n\"War is terrible when it corrupts a young kid like that,\" Reinhart said piously.\n\nCigarette in the side of his mouth, head cocked so the smoke could not catch in his glasses, Schild asked: \"Are you serious?\"\n\n\"No.\"\n\nThey joined in pragmatic, male laughter, the kind that would have stimulated the heroines of those movies Very loved to heat up their castrating irons.\n\nThen it was only fair that Reinhart interrogate Schild. Who confessed to having been a teacher in civil life, specializing in English, in a private school that Reinhart suspected was \"progressive,\" where the students did whatever they wished and called the instructors by their first names. Was it? In part, Schild admitted, laughing more than ever.\n\n\"Frankly, that's just the kind of thing I would have loathed as a kid. I always got a lot of satisfaction from believing I was more progressive than the school. Your place would take that away. Don't you think it is better for superiors not to understand the people under them too well? I like a rather stern authority that I can hate and feel morally better than.\"\n\n\"And overthrow?\" Because he had done less talking, Schild's cigarette was down to a nub carrying a long, quivering ash. A sudden burst of fresh morning wind snowed it across his blouse.\n\n\"Sure, sure, but there will always be something else.\" Throat parched, Reinhart threw away his half-smoked smoke and said: \"I accept life. Some things in it are by nature hateful.\"\n\n\"You are the most extreme reactionary I have ever met,\" said Schild, but pleasantly; almost, one could imagine, with approval.\n\nAs they turned into Argentinische they met a light, drifting film of rain, which was refreshing to the warm cheeks but also a douche on Reinhart's spirit. He had run off at the mouth, revealed the location of his defenses and their strength, while wise Schild had really said nothing. Worse, he could not have faith in his own honesty: in action he had always proved to be the least independent of men, not reactionary at all. This evening, for example, he had needed Schild's open ear.\n\nThey cut through the little woods and came out by quiet detachment headquarters, passed the sleeping hospital, and in the now generous rain took each other's leave at the corner of officers' row. Schild dripped water from the end of his obvious nose and smelled of wet wool, even as Reinhart did himself, and had trouble with his spectacles.\n\n\"I'm supposed to wear glasses myself,\" Reinhart said. \"For reading. I am farsighted. But I broke them in England. ... Do you feel all right now, Lieutenant? Frankly, I thought you acted a bit odd early this evening.\"\n\nSchild removed his cap and wrung it like a sponge, put it back all wrinkly. Then he saw Reinhart's frown, took it off again and smoothed it across his knee. \"Okay now? Reinhart, you are a fop. Why yes, I feel good. But I thought you were interested only in yourself.\"\n\n\"Never did I say that,\" Reinhart answered dolefully. \"You have any idea of how late it is? We must have walked ten or fifteen miles.\"\n\n\"Three-thirty perhaps, four, who knows? If you get in trouble at your outfit I'll fix it.\" He returned Reinhart's salute and said: \"I never have anybody to talk to, either. Thank you for letting me come along.\"\n\nReinhart watched him all the way to the gate of his billet, thinking, I have done you a favor? His own waterladen cap weighed on his head like a sandbag; he removed and wrung it \u00e0 la Schild. When he looked again through the rain his friend was stepping safely over the threshold.\n\nReinhart approached the rear of his apartment building on the alley that was but an unpaved continuation of the officers' street. He stifled an impulse to climb up and enter his flat through the balcony, which might have incited the half-awakened Marsala to witless mayhem. Similarly, before going around front he took a leak in the bushes lest toilet-flushing would wake his buddy. While in midstream he heard a door down the street and there, inexplicably, came out Schild again, walking to the corner at which they had parted, and then out of sight up Possweg. Cursing the capacity of his bladder, he at length finished. At the corner he saw Schild enter the dark grove where the mess tents were pitched. It's too early to get coffee! The guard there will shoot him! were among his angry self-expostulations. Reaching there himself, he saw the tents were farther to the left than he had remembered; besides, Schild was fifty yards into the trees and still going.\n\nLike an Iroquois, Reinhart crept silently from pine to pine until there were few left and a plain like a soccer field showed light before him. At the edge of the grove Schild stood with two civilian persons, one of thickset middle height and the other a great lump of fellow larger than Reinhart by three inches in every dimension and, by the set of his massive shoulders, no Bach. Drawn up on the soccer field beyond, a black European sedan.\n\nPerhaps because the wind was wrong\u2014at that moment he realized the rain had stopped and the wind risen, cold against damp clothing\u2014he heard nothing of their speech, knew only that they looked at Schild and Schild at the ground. But the evil voice sounded within him: _The black market, how like a Jew._ As if upon that signal, the two men seized his friend, each on an arm, and dragged him towards the car.\n\nFear's fat serpent squirmed down Reinhart's throat, circled the belly, and undulated through his intestines. Even the smaller guy looked as if he were built of bricks\u2014the larger one was a monster; he could not have felled him with a baseball bat. They wore cloth caps and neckerchiefs and dark clothing, were some European kind of thugs, ranged against a little Jew and an over-sized boy. Oh, unfair! he whimpered and had every intent to hide, but was too limp to stand still, too weak to walk away, so no choice was left for a coward but to run towards them.\n\nHe squished over the wet sand and was nowhere near when they heard him and turned. The large one released Schild and stalked forward.\n\n\"Go away, boy,\" he growled in German. \"This is no affair of yours.\"\n\nReinhart slowed but kept coming, still too scared to stop.\n\n\"He means no harm,\" said Schild. \"Let me talk to him.\"\n\nBrick-built, maintaining his hold, answered: \"All right, but not in English.\" And told Monster to stand aside.\n\n\"This is private business,\" Schild said harshly. \"Intelligence work. I'll thank you to keep your nose out of it.\"\n\nReinhart stopped three feet from the giant. It was so strange to be addressed in German by his friend. Groping for vocabulary, he said: \"What kind of Intelligence needs the capture of an American?\"\n\n\"Damn you,\" Schild yelled furiously, shaking off Bricks's arm. \"Don't come here with your na\u00efve bungling. I give you a direct order to leave this minute if you value your stripes.\"\n\nPlanning something, an old trick of movie combat, Reinhart trembled in anticipation\u2014for it never could be worked in real life, on this damp plain, in wet clothing, by a coward who was sure he had misjudged appearances. With relief he heard the threat to his rank. A man in authentic danger would hardly be so precise.\n\n\"All right.\" Shamefaced, he added: \"I forgot to tell you earlier: I have never understood the Jews, but I'm not proud of it.\"\n\nSchild answered: \"Neither have I, neither am I.\" Yet his head rose in pride.\n\nMonster mockingly repeated: _\"Die Juden habe ich nie verstanden\u2014\"_\n\nKnowing his fist would shatter, and caring desperately about it\u2014he hated to be hurt\u2014certain that as usual he was wrong and lost and impotent, he released what little reason he had accumulated in twenty-one years, wheeled badly, plunged slippingly, and weakly struck into the giant's armored belly. Wondrously he felt his hand prevail as if it had punched a cushion. The man's deep guts wormed against his knuckles. Monster buckled, retching. Reinhart kicked his face.\n\nHe turned towards Bricks, just in time to save Schild's blood, for the man exposed a paratrooper's gravity knife, dropped the blade, and waded in low.\n\nHe screamed: \"Get away you fool!\" Which brave little Schild ignored, waiting defenseless, calmly, Jewlike, for his fate.\n\nReinhart sprang, Bricks did quick footwork, Reinhart fell flat in muck and looking up saw Schild professionally elude the blade, simultaneously knee Brick's groin and chop his neck. Wilting, Bricks cried in pain, to which Schild's cruel answer was a hacking at his forearm, precision hands above and below, that snapped the bone.\n\nBut Monster, face of gore, had meanwhile lumbered over. With his hobnailed sole he opened Reinhart's cheek as you would boot a melon. On all fours, Reinhart took another, ill aimed; still, his cropped skull was grooved from fore to aft and red fluid flowed out and blinded him. A third and he would be dead. It was all very real.\n\nUnseeing, he crabbed as Monster swung again; he tumbled over, cleared his eyes. His life's dear blood left gout on gout; his bare cheekbone sorely caught the wind; but he got up. He stalked Monster, who great as he was now retreated; who could not have been an ex-SS man, for they were not craven. He caught him, took the battering of the leaden fists, bore in inexorably, embraced him in murderous love. Monster's hands belabored his kidneys, tried for his neck, but he was now in too close; therefore they tightened around his own small-of-back and sought to break it.\n\nHis head within the hollow of Monster's neck, he bit for the jugular. The skin was tough as chain mail, and besides he could not close his jaws, having an obsession this would push his senses through that cranial wound which Monster was opening further with each chin-stab. Then did he turn his face sidewise, upon the good cheek, and join his hands\u2014he could just barely, around that iron barrel\u2014and compressed, and it was hopeless.\n\nFrom his good eye he saw Schild leave the fallen, whining Bricks and come to punish Monster's back, futilely, without a weapon. The rabbit punches which felled Bricks bounced harmlessly from Monster's invulnerable nape. Slowly Reinhart's spine began to crack. But then within the clasp he believed so weak, so did Monster's ribs, fibrously, like celery, yet not in sufficient time. For there was Bricks rising from the ground, crippled, twisted, knife in a left hand sufficient for the job on Schild's unguarded back.\n\n\"Lieutenant... behind you,\" he panted, his voice loose air and too little of that. At the cost of his life he loosed the hold on Monster that curtailed his own breath, and Monster exploited it. Off his axis now he shouted: \"Schild for the love of Christ\u2014\" Still was Schild deaf, the bastard; he would give his life for Reinhart's which was already gone. A last hope was to call the worst he could; to stir his friend, if only by hate, to preserve his own hide. And surely he hated him enough then to frame the cry, as one can only hate him who makes you beneficiary of his total sacrifice. _Jew, I want them to kill you._\n\nHe never said it aloud; too authentically had it sounded through the chambers of his heart. Rather have him dead than hear that knell.\n\nSo, looking into his eyes, he saw Schild get it once, twice, thrice, in terrible thumps up to the knife's haft, and squint in agony and sink. His thick glasses slid down his thin nose. He fell behind Monster, sparing Reinhart further sight, but his feet were in view and writhing.\n\nNow came Reinhart's turn. Monster was killing him as it was, but Brick's dagger were quicker. Yearning for peace he awaited its first nick; getting it, heard a queer noise which he supposed was his heart ticking out. Monster loosed him slightly, turned head to look at Bricks in the sedan, stripping gears, driving off.\n\nMonster roared, and was cut short by the vise of Reinhart's arms. He pleaded, shedding tears and blood from his raw face, and Reinhart was moved but could not oppose his own awful will. Not even when he heard the tearing of the vertebral column beneath his wrists could he free poor Monster, who thus died in his embrace. Life all gone, he let him fall. He knelt by Schild and searched for a pulse. He found none. He retrieved the spectacles, which were unbroken, and mounted them on his friend: he recognized him again.\n\nHe stood up, victor, and surveyed the field. Then jealous Death, who wins all battles, wound him in its dark sheet.\n\n# _CHAPTER 21_\n\nEACH NIGHT AFTER HIS error with the agent Fritz, Major Sergeyev went to bed in his street clothes. Nail file, lighter, toothpicks, etc., remained in the pockets. Checking their location was his first concern on arising, unarrested, in the morning. On the nearby camp table, a foxed and worn edition of _The Foundations of Leninism,_ by J. V. Stalin, lay ready to be seized as one went to answer the knock upon the door. Beside it, a toothbrush, a bit of salt twisted in a paper, a safety razor, a sliver of soap, and a hand towel, in a small cloth bag.\n\nSeven mornings he arose in a Soviet officers' billet in Lichtenberg, ate breakfast at a mess in the basement of a commandeered factory, was driven to his office in a confiscated German Opel sedan.\n\nEmerging from the messhall on the eighth morning, he saw, ten yards away, that his driver not only had a different profile from his usual but wore a blue cap. The man got out and politely opened the rear door of the automobile. His trousers were piped in red and blue. Within were two more bluecaps. Silently they cleared a space for Sergeyev to sit between them. He said: \" _Spasibo,_ thanks.\"\n\nThey drove for a time on the wide thoroughfare which when he had first come to Berlin as an agent in the Thirties was called Frankfurter Allee, but now he understood was to be renamed for Stalin. It had been badly bombed. He tried to go to sleep, but whenever the bluecaps saw his eyelids droop they jolted him with their elbows, in silence and without malice. Thereafter he slept with his eyes open, a technique he had developed while interrogating Social Fascists, Trotskyists, members of the POUM, and other mad-dog wreckers and counterrevolutionary jackals in Spain.\n\nHe awoke as the car stopped before a prison in Pankow. The bluecaps accompanied him to the gate house, where they signed him over and he was searched. Two prison guards, also in blue caps, were his companions on a walk of moderate length inside the building, down a damp corridor, into a bare room with a boarded window. Before they gave him the order he had begun to disrobe. Naked, he pressed himself against the concrete wall. The guards examined the seams of his garments, looked between his toes, searched the hair of armpits and pubis, peered into his mouth, probed his anus. They confiscated the pocket articles.\n\nHe dressed. They conducted him to a small cell four floors above the ground. Its window was boarded; in its iron door, a spyhole and a letter-sized slot. After some time a pan of gruel was passed through the latter. He wished he had his packet of salt. To keep fit he strolled occasionally from the door to the slop bucket at the back wall of the cell, three steps, then from his bunk to the other wall, one step. He wished he had his _Foundations of Leninism._ The ceiling bulb burned all night.\n\nNext day he got a boiled potato, and at another meal found a bubble of fat in his hot-water soup. He wished he had his manual for espionage agents, but it was at the office. The toilet articles he did not yearn for, not having been permitted to wash.\n\nOn what he estimated, by the number of times he had been fed, seven, to be the fourth day\u2014not having seen the sky since he entered, he did not try to fix the hour\u2014the guards took him to a room containing a desk, one empty chair and one filled one. In the latter, behind the desk, sat a uniformed man, lean and elegant, drinking from a china cup. He wore long hair, graying at the temples. He motioned Sergeyev to sit.\n\nHaving swallowed, he said pleasantly: \"My name is Chepurnik. Of course you can see my rank.\"\n\n\"Yes, Comrade Major.\"\n\n\"You yourself were once a major, were you not? Of course you were!\" He poured himself another cup of water from the glass carafe, drank it off, and said: \"Now Sergeyev, tell me like a good fellow, have you been fed decently here?\"\n\n\"Excellently, Comrade Major.\"\n\n\"And have you been given something to read, to put in the hours profitably?\"\n\n\"I made no request, sir. My book was left at the billet.\"\n\nChepurnik opened a drawer. \"I believe I have it just here. ... Ah yes, _The Foundations of Leninism._ Splendid.\" He leafed through the pages. \"I see you follow the practice of placing little brackets about certain passages that you should like to turn to again. Here is something: 'the proletariat cannot and ought not to seize power if it does not itself constitute a majority in the country.' \"\n\n\"Yes, sir. But you have not read what comes just before: 'The opportunists assert that the proletariat, etc.' \"\n\nWith no change in his expression of encouragement Chepurnik half-rose and threw the contents of the carafe in Sergeyev's face. \"You see,\" he said, with fox-bark laughter, \"it is not vodka, but pure water!\"\n\nReaching for his handkerchief, Sergeyev remembered it had been taken from him in the search; no doubt, so that he could not knot it about his neck and hang himself. He wished he had his towel. He was surprised by Chepurnik's sudden offer.\n\n\"Go on, use it!\" The major tossed a handkerchief at him, which floated just out of reach. As he bent to fetch it, Chepurnik rose again and, leaning across the desk, with an inexorable meter-stick pushed the chair-edge slowly backward: Sergeyev fell to his rump. Chepurnik came around and helped him up.\n\n\"There,\" he said, returning, \"is a lesson. Observe how lean and muscular fact upsets dull brutishness. And you a major in Red Army Intelligence! Poor fellow, you could not have been an officer's orderly in the NKVD. You, with your low grade of cunning. Use Stalin's _Foundations_ as your codebook, leave it out where anybody can see, this will fool everyone! Poor chap, I would pity you were it not that I am nauseated by treason. ... Your only hope is to convince me you were misled in your criminal ventures.\"\n\nIt was still too soon for Sergeyev to know how and what he must confess to, as experienced in the area, from his years on the other side of the desk, and willing as he was. He lowered his head and said nothing.\n\nChepurnick raged: \"You upset my stomach. You look like a syphilitic chancre. Get out!\"\n\nThe guards came in and took Sergeyev back to his cell. He asked for writing materials. They were provided. He composed a _mea culpa_ referring to sins as far back as his residence in a seminary just before the Revolution. And admitted having at that time entered into a long-term conspiracy of priests and fellow novices to overthrow the rule of the proletariat in favor of a clerical dictatorship. As an agent in Hitler Germany he betrayed sub rosa Communists to the Gestapo. In Spain he took Franco money. Currently, at the time of his arrest, he had been employed by the Joint Distribution Committee, a Zionist branch of the American FBI. Yet his capture had revealed to him the overwhelming might and right of the International Workers' Movement and he expressed contrition. He asked that he be punished mercilessly.\n\nFinally he again faced the examiner. Chepurnik now wore golden pince-nez. For some reason he seemed to cultivate the appearance of an Old Bolshevik. Sergeyev could not understand why, since they had all been put to death as traitors.\n\nThe major drank from his cup, but the carafe was missing. Wiping his mouth on a beige silk handkerchief, filmy as a cobweb, he said: \"Ah yes. I have read your lies.\" This time it was vodka, and not water, that dashed against Sergeyev's cheeks and fierily into his eyes. \"Your face reminds me of a pig's rectum.\"\n\nBack in the cell, as soon as his sight returned, Sergeyev began to write a new confession. He admitted having been lured by the American Intelligence agent Schild (\"Fritz\") and the Fascist homosexual Ernst (\"Schatzi\") into a plot to restore the Nazi regime in Germany. The leader of the movement was Hitler's lieutenant Martin Bormann, whose whereabouts the Allies had sought unsuccessfully since the fall of Berlin. Sergeyev could reveal that Bormann had been flown out to Lisbon and there awaited recall.\n\nAt the next interview Chepurnik gave him a cigarette.\n\n\"My pitiable fellow,\" he said, \"you have convinced me of one thing: that you are honestly trying to tell the truth. But it is most difficult when everything one has to work with is as corrupt as a boil. For example, your so-called information about Bormann. I can assure you that he was captured by the NKVD on the second day of the fall of Berlin and has long ago been executed. And while we are on the subject, you probably also do not know that Hitler did not die in the Kanzlei as is popularly supposed. The NKVD got him and he has since been held secretly in the Kremlin, pending Stalin's decision on how best to make use of him, which is to say, as prisoner or as corpse. Also the Braun woman.\" Removing his pince-nez, he winked. \"She was imprisoned here for a week before being sent on to Moscow. French underwear. Too skinny. But... _o\u00f9 sont les neiges d'antan?_ This is how the French say, all that is past.\" Chepurnik was indeed a good-looking man, with a high forehead and long jaw. Sergeyev could smell his cologne.\n\n\"But to your problem,\" said the major, \"from what principal did you get orders to kill the agent Fritz?\"\n\nSergeyev collected his forehead sweat on a bladed hand and rubbed it into his frayed, stained trousers. \"A terrible error,\" he answered. \"I sent my men, these Germans, to bring Fritz for an interview with me. He resisted. In the ensuing fight he and my man Hans were killed.\"\n\n\"If you insist on telling me what I already have, and lying to boot, the Soviet people will be merciless. Fritz was your agent, and yet you did not know he went everywhere with a bodyguard, a professional athlete named\u2014\" he brought a dossier from a drawer and leafed through it\u2014\"yes, named Reingart. This man is in the hire of the Counterintelligence Department of the United States Army. Before the war he lifted weights in the Radio Music Hall, which is a sports arena in New York, U.S.A.\"\n\n\"No, I did not suspect that, Comrade Major,\" Sergeyev answered in profound shame. \"I did not know that the bringing in of Fritz would entail difficulties. Those two worthless Germans should have been able to take care of anything. Just as well for them they did not come back.\"\n\n\"And why did they not, Sergeyev?\"\n\nHe could not meet the major's eye. \"Well, as you know, the one was murdered by this weight lifter. The other, I am afraid, had fled to the British Zone.\"\n\nChepurnik shook his head in tragedy. \"The Soviet people gave you great responsibility, high rank, absolute trust. And you cannot live up to the most primitive concept of honor: a superior never hangs the blame on his underlings. Aren't you ashamed of yourself? What do you suppose these unfortunate Germans thought of the Soviet Union when they looked at you, its representative, a heap of garbage. ... No, I refuse to listen to any more.\" He put his hands over his ears and summoned the guards.\n\nAgain and again Sergeyev rewrote the confession. He admitted his complicity in every crime against the Soviet state since its founding. He begged to be sentenced to lifelong imprisonment at hard labor. He implicated his wife and children, who lived in Leningrad, and asked that they be arrested. In his eighth revision he requested the death penalty for himself.\n\nAll to no avail. Chepurnik took every admission as evidence of a greater concealment. On the other hand, Sergeyev's infrequent and weak protestations of a particular innocence\u2014in the context of the established general crime\u2014outraged the major.\n\n\"How dare you assert you did not trade in American cigarettes on the black market!\" he would scream, hurling the contents of his cup and carafe, or when those were not at hand, his meter-stick, which was rather more dangerous. \"We discovered a hundred packages in the stuffing of your mattress!\" And Sergeyev would return to his cell and incorporate this new failing into his latest confession. Which meant: in detail, for Chepurnik cast an especially cold eye on his prisoner's use of anything, he, Chepurnik, had given him. He was, that is, a man who could not be defrauded. Sergeyev, who had never seen a packet of American cigarettes, had to invent a brand: \"Tom Smith Variety\"; and to be precise in his count: \"At the period of my greatest activity in this illegal and treacherous commerce\u2014the purpose of which was to sow the seeds of dissension among Red Army troops to whom I distributed the cigarettes\u2014I kept on hand approximately 523 packets, which, at 24 the packet, would in sum amount to 12,552 cigarettes.\"\n\nChepurnik hurled it into his face. \"What kind of trick is this? Everybody in the entire world knows Tom Smith Brand is sold only in packages of ten cigarettes each! ...By the way, don't you ever wash? You give off the odor of horse urine.\"\n\nChepurnik was still reading the nineteenth confession when the guards brought Sergeyev into the room. He scowled, and Sergeyev's heart mounted like steam from a samovar. No matter how enraged, the major had never scowled. Therefore it could mean only that he approved.\n\nHe did. He turned the manuscript to face Sergeyev, who saw with delight that it had been typed in the official form, and presenting a fountain pen asked him to sign it.\n\n\"Now,\" said the major, with the pursed lips of a French dandy blowing the ink dry, \"now that should take a great weight off you.\"\n\n\"Sir, may I ask one question?\"\n\nChepurnik began an ominous half-smile. \"Careful now... just make certain it is not some punishable folly, and yes, you may.\"\n\n\"Has the Fascist homosexual Ernst, alias 'Schatzi,' been arrested?\"\n\nChepurnik laughed: \"Alas, you force me to do it. Your rations will be reduced by half for one week. I warned you! Herr Ernst is a loyal Communist of impeccable character and I advise you to discontinue your persistent attempts to involve him in your criminal activities. Without Germans of his kind we should have a most grievous struggle to create a Socialist society here. I shall not tolerate your Great Russian chauvinism!\"\n\nThe major grasped his cup as if he might throw it, but instead he took a drink of water or vodka and wiped his lips. He went on: \"Had it not been for Ernst we might have taken longer to uncover your crimes.\" He brought the old dossier from a drawer and leafed through its early pages. \"Do you recognize this? 'Hitler cleverly crushed without mercy that foulness.' \"\n\n\"No, sir.\"\n\n\"NO?\" Chepurnik screamed. \"How dare you say no? I did not speak these words, Ernst did not say them. Who did?\"\n\nSergeyev remembered. \"I am sorry, sir. I did, to the agent Ernst, in reference to the R\u00f6hm movement.\"\n\n\"Now do you doubt our tolerance? Can you imagine what would happen to an American or an English officer who praised Adolf Hitler? ...Secondly, Herr Ernst learns of the defection of the agent Schild. Immediately, in the prescribed manner, he comes to give his report\u2014only he cannot find you. The great Sergeyev is not at his desk, as the Soviet people expect their officers to be every minute of the day. No, the megalomaniac Sergeyev has, totally uninformed as to the condition, the whereabouts, the state of mind, and the companions of the agent Schild, already sent his men to fetch him for a 'talk,' and then himself gone with a German whore and a liter of vodka to the billet. Where did you plan to interview the agent Schild, between the whore's legs?\n\n\"No, even that would have been more sensible. You were going to have him held all night for your 'talk' in the morning, so that he would be reported missing from his unit and the whole American nation, from President Truman down, would protest to Comrade Stalin about another so-called kidnapping.\"\n\n\"My crime grows ever larger,\" Sergeyev muttered. He held himself erect only with supreme effort; so skinny was he the chair wished to eject him.\n\n\"I see,\" Chepurnik said. He closed his green eyes for a moment. Before opening them again, he slowly tore the confession in half. \"Then this, too, is false. _Il faudra toujours recommencer._ That is French for 'we must begin all over again.' When will you learn that you do not have the intelligence for a large crime?\"\n\n# _CHAPTER 22_\n\nREINHART TURNED ON HIS side in bed and played it cool, studying the little blue light at the end of the ward. He saw Very's large, maternal shadow in the darker cavity of the office doorway. She had been his first concern on awakening from that positive death on the bloody field\u2014somewhere back, weeks, he supposed; part of his trouble was a derangement of the sense of time. ... No, he would not lie. Be fair to yourself, the doctors told him, but surely that did not mean believing falsehoods. His first occupation had been resentment and self-pity, for Schild stayed dead.\n\nHe passed out again when his wounds were treated in the emergency clinic, not from pain but in another attempt to die. In vain. You could not beat the Jews at sacrifice; it was their profession. Next he had come conscious as a patient in the ward for Superficial Wounds and Contusions, of which he did not remember Marsala was master until he heard the buddy's raucous complaints issuing from the treatment room: an underling wardboy had loused up the bandage-count. But the evidence of normality in the world outside his head terrified him, and when Marsala came to the bedside Reinhart simulated coma.\n\nLater, en route to the night shift on the psycho ward, Veronica stopped in. Marsala was goofing off someplace, so Reinhart showed life. Then it was that he thought of her troubles and forgot for a moment his own.\n\n\"I'm sorry, Very, I tried as I promised but ran into a snag.\"\n\nHe felt her pat his brush and wondered where the wound up there had gone. The gash in his cheek he still had; its bandage refracted the vision of his left eye.\n\n\"Honey...\" Poor Very suffered tears. \"... was this terrible fight because of me?\" Yet she once again looked full-blown, her splendid flesh bursting, wherever it could, from the commonplace seersucker uniform.\n\n\"No, I never fight for any purpose. If I had wanted something from those Germans I would have licked their boots.\" He now licked his lips and found the cuts towards the left corner and the bitter medication upon them.\n\n\"Don't be so fresh with yourself,\" she said. Later, in his need to tabulate things, he recalled this as the first of a series of such admonitions from practically everybody.\n\n\"Anyway, I'm stuck here and I don't know for how long.\" He reached for her hand and then, remembering the other patients, gave it up.\n\nBending, she displayed the partition of her breasts and whispered: \"Don't worry about me any more\u2014I'm O.K. now\u2014false alarm.\"\n\nHe laughed in a hysterical, private place, for one reason, because he could not in public: his face was cracked. There you had a capsule history of human affairs, amidst the larger one in which they participated with everyone else, including the nearby patients who gawked innocently at Veronica's body: what began in birth ended in death. Except that this one was all a mistake.\n\n\"Schild\u2014you know I thought for a while that Schild was your lover\"\u2014she caught at her mouth\u2014\"no, that had nothing to do with this trouble, believe me... and he thought I was, and now none of it matters. ... Very, look at the top of my head and tell me what you see.\"\n\nShe did more, exploring with a finger. \"I think it is a slight bruise and nothing worse. You'll be better in no time.\"\n\n\"Are you sure? He kicked me bad. I was certain my scalp was laid open.\"\n\n\"You know it's all bone, with only a thin layer of skin and hair\u2014\" Her big teeth glistened in fun. \"Excuse me, well, everybody has a bonehead, me too.\"\n\n\"Only mine is solid\u2014but are you sure?\"\n\n\"Clear the way for added cargo!\" She bounced-sat on the edge of the bed and waylaid her rising hem at the bulge of rolled nylon. \"It's pretty hard to 'lay open' a scalp; there's not much to cut and it would take something awful to break the bone wide open. Though of course there's fractures, but you don't usually know they're there until you look at the x-ray. ... Know who's ward nurse here? Eleanor Leek, the cute little plump girl from the party where we met. She danced with that Russian. Sure you do! I'll put in a good word for you. Now I have to go, the schizzes all start crying if I'm not on time. Oh, did you want to talk about the fight? But I don't think it's good yet. Rest awhile. Now kiddy, I'll say goodbye. I would kiss you but everybody's lookin'.\"\n\nAs the _Santa Maria_ must have swept from the Bahaman harbor, past the awed little brown men in their crummy dugouts, proceeding westward still, so Veronica sailed in splendor up the ward aisle and out the door, flying the high standard of her winged cap, and the natives returned to their fishing and coconuts.\n\nSoon afterwards Lieutenant Leek, whom when he saw her he remembered, the fat, homely, merry person, hurried in from the corridor.\n\n\"Good, you're conscious. Holy cow, you kept the brass waiting all day. Can you talk to them now?\"\n\n\"Who?\" With Very's departure he stepped on a merry-go-round which turned slowly to no music. \"I don't feel so good.\"\n\n\"I'll give you a pain pill soon as they leave.\" She left his sight and in a moment or two he was ringed by many male uniforms.\n\nFor one, the commander of the 1209th General Hospital, Lieutenant Colonel Fester, whom in three years' service with the outfit he was seeing for the fourth time, despite the legend that Fester was ubiquitous.\n\n\"Now Steinhart, look sharp,\" the colonel said in a clarion tenor. He wore white gloves, like a doorman. \"This is a terrible thing you are a party to, but I know any man of mine can defend his actions. Handpicked, every man Jack of you. Remember how we kept those niggers out of our latrine on the troopship coming over? Medics, maybe. They don't let us carry guns, but by Jesus we've got fists. I'd put my hand in the fire\u2014if I didn't have this eczema\u2014for any one of you and know you'd return the favor\u2014say, are you awake? Here you, Teats, or whatever your name is. Nurse! Give this man a hypo of something. What do you use nowadays? You've got all the drugs in the world nowadays. It wasn't like that in the old days. By God, APC capsules, gentian violet, and you had it; after that, the pine box. Remember the old days, Major, or was that before your time?\"\n\nReinhart opened his eyes. Next to the colonel stood a major with a young face, yet old gray sideburns.\n\n\"We'll talk about that later, sir,\" the major answered with short patience. \"Here, the fellow is awake\u2014\"\n\n\"Coming around, Steinhart?\" the colonel cried. \"Good, now stay awake for a moment. This is Major Koenig from G-2, Berlin District. I don't have to tell you he is a Very Important Person so far as we are concerned here in our humble way. He wants to ask you about last night.\"\n\nReinhart also saw Captain St. George, lachrymose; an enlisted man, PFC Walter Walsh, swelled with gravity; Lieutenant Nader, resentfully watching the colonel; and finally, a brutish-faced captain who wore the crossed-pistols badge of the military police.\n\n\"Your name is Reinhart, correct?\" asked Major Koenig. \"How are you feeling, Corporal?\"\n\n\"Carlo T., 15302320, and a little dizzy, sir.\"\n\n\"Well, who isn't? And I haven't just broken anybody's back, either,\" Koenig said. \"By the way, how did you do that?\"\n\n\"Only because he would have broken mine if I didn't.\"\n\n\"I asked _how_.\"\n\n\"Just caught him around the waist and bent him backwards.\"\n\n\"Good fellow!\" broke in the colonel. \"I used to watch you wrestle at Camp Pickett every Friday night, Reinkoenig. You made me lots of money. That's why I chose you for the 1209th. You still a corporal? Months ago I told that goddamned Lovett to put you on orders for a third stripe.\"\n\n\"Thank you, sir, but I had basic at Camp Barkeley\u2014\"\n\n\"Quite all right, my boy. Just answer these questions\u2014\"\n\nThe major asked: \"Do you feel well enough to get up for a few minutes? It's difficult to talk here. The nurse said we may use the ward office.\"\n\nReinhart lay quiet for a moment, his right as a casualty, then indicated he would try. Blackness flooded his brain as he sat upright, and he heard their voices as if through the closed window of a ballroom. His wrist was seized.\n\n\"Come on, fellow,\" the colonel shouted.\n\nIn transit Reinhart slept awhile and when he came to, watching the red-black ocean recede, thought they all had gone.\n\n\"You need a pick-me-up!\" the colonel roared. \"Teats! Mix an ounce of medical alcohol with grapefruit juice and bring it to this soldier.\" But Lieutenant Leek had crept off to hide.\n\n\"It's all right, Major,\" Reinhart said to Koenig, who offered no aid nor sympathy. \"I can make it.\"\n\nThe major walked smartly towards the office. Reinhart shook himself, feeling a twinge in his cheek, slipped into the dirty canvas slippers waiting below the bed, rose and followed. With all manner of noise the colonel dogged him but was denied at the door.\n\n\"This,\" said Koenig, standing just within, \"is an Intelligence matter, sir. Captain St. George and I will have to speak privately with Corporal Reinhart. If you gentlemen can give us a few moments?\"\n\n\"Me neither?\" The MP officer's growl betrayed a fright at his exclusion. He put a broken cigarette into his mouth and tried to light it, getting only air. From the patients out in the ward arose an anonymous murmur of ridicule, which was tonic to the colonel.\n\nHe said: \"As to me and Nader and PFC Walter, we'll mix here with the men till you need us.\" Followed by his reluctant entourage he went back down the aisle between the beds and shortly, among his bursts of loud, merry scatology, came the obstreperous derision which he was famous for misunderstanding as popularity.\n\nMaking an effort, Reinhart indeed felt better and stronger. The major, however, who sat upon a white-enameled chair, directed him to lie upon the operating table.\n\nThere was no allowance for discussion, so he did. St. George\u2014he saw the genuine sadness on the fat face, and pitied him, and liked him\u2014slumped against the wall.\n\n\"Now, PFC Walsh,\" said Koenig, \"who was mess guard last night, heard noises on the sports field and went to investigate. By the time he got there you were unconscious and the two other men were dead. He states he heard an automobile engine, and there were tire tracks in the sand. May we hear your account?\"\n\nOn his back, unable to see his interrogator, Reinhart spouted perspiration and anticipated a nameless catastrophe. Unknown enemies held him supine and prepared to work upon him an obscene damage; he felt womanly, about to be raped. Yet all through this, his fluent voice romped on, as if it were rather the child of another man. The voice told of the chance, friendly encounter early in the evening between Reinhart and Schild, of a purposeless wander to the Tiergarten, since the black-market contact never appeared and they thus could not buy their Meissen china. Then they took a drink in a jerry-built cafe on the Ku-damm, looked for a ride home and finding none began to walk. They lost their way temporarily. Finally they reached Zehlendorf. Then the straight story of seeing Schild enter the grove, and the fight.\n\n\"There must be more,\" said Koenig in his ominous, factual way.\n\nSt. George spoke for the first time: \"Lieutenant Schild had some of his own contacts whom I knew nothing about. We worked in that manner. Perhaps it wasn't SOP\u2014\"\n\n\"You said all that.\"\n\nBut once begun, St. George was briefly invincible. He owed it to his late colleague. And Reinhart thought, Schild was closer to him than to me; he was never really my friend, yet I did what I could to save him; why do I tell myself I was his killer?\n\n\"Perhaps it wasn't SOP, but I respected his intelligence. Then he was a Jew, you know. I never thought about it before, but it could hardly have been pleasant service here where they did such horrible things to his people. ... One of his German contacts was a little old fellow dressed like a workingman, who rode a bike. He came once to the billet when the Russian stayed with us. But perhaps he wasn't there for Nate. When I saw him he was talking with the landlady.\"\n\n\"Russian!\" blurted Koenig. He reassumed self-control. \"You can tell me all that later, Captain. At the moment we are interested in the corporal.\"\n\nKoenig did not trust Reinhart, so much was clear. But Reinhart had changed since he killed a man. Earlier he would have hated Koenig. Now he was beholden to him; wished he would let him rise, but knew he deserved no favors.\n\nThe major asked: \"This little old fellow that Captain St. George mentions\u2014was he one of the two Germans on the sports field?\"\n\nReinhart answered no. Schatzi\u2014Schild knew him too. He remembered the doctor's revelation and his own bombastic threat to kill this complex person both victimizer and victim. Doubtless no one took it seriously. Could they have seen him a few hours later! But Schild had, and thought him inadequate, and come to help, and died.\n\n\"I take it then you know the man St. George means, if you are sure he was _not_ there.\"\n\n\"I believe so,\" said Reinhart, \"he hangs out around here. He is a big wheel in the black market.\"\n\n\"Could this have been a dispute over a black-market deal?\"\n\nSt. George answered, scandalized: \"Certainly not! I never knew a man less interested in money than Nate.\"\n\nKoenig sighed. \"The corporal has just testi\u2014stated he and Lieutenant Schild went to the Tiergarten, were driven to that area by you, yourself, in which you concur, to meet someone who offered a set of Meissen china for sale.\"\n\n\"Sure,\" St. George laughed indignantly, \"but that was for Reinhart!\"\n\n\"That's right,\" said Reinhart to the major he could not see, endeavoring to meet St. George's eye with a message of loyalty. But the captain seemed to avoid him.\n\n\"A do-gooder, the late Lieutenant Schild.\"\n\nSt. George answered: \"Always,\" and hung his head.\n\nKoenig continued his keen probing, to which his immaculate and subtle contempt was an additional tool. Reinhart dissembled in the only way he could, by blondly, wholesomely baring all but his suspicions, which anyway was legally impeccable. Later, the MP officer was let in, and Nader and Walsh, and, perhaps with an idea to stop his noise, briefly, the colonel.\n\nKoenig suddenly finished; whether for good and all, naturally he did not indicate. Nader and the MP, although they showed a personal distaste for Reinhart, seemed in the absence of contrary evidence to believe his story and agree he must stand a court-martial which would formally find him guilty of homicide in the line of duty, sentence one dollar. This to forestall an attempt by Monster's heirs, if they could be found\u2014he remained unidentified\u2014to bring charges.\n\nEverybody having left, Reinhart assumed he could get up, and did so, and was frightened by the appearance of St. George, who lingered behind the operating table.\n\n\"Listen,\" said the captain, with suppressed dislike, \"maybe you know. Does Lieutenant Schild have any family? We don't know who to inform. For some reason he gave as next-of-kin the name of a prostitute in Paris, Texas. I never had occasion to look at the record until this morning, and then I recalled her name from when we served together at Camp Maxey.\"\n\n\"I never knew him well,\" said Reinhart, whoozily standing.\n\n\"Who did? ...He had a strange sense of humor, and this shows he would go all the way with it.\" Still with obvious unfriendliness, he came to Reinhart's support. \"You see, we were in combat zones since D-Day. He could have been killed at any time. But for the joke he gave the name of this streetwalker.\"\n\nReinhart took the offered arm. They moved together into the ward. At his bed, first one on the right-hand line, he thanked the captain and shook hands, and saw astonished gratitude, and understood merely another error: St. George did not dislike, but rather fearing being disliked.\n\n\"Oh that's all right,\" said the captain, pumping his fingers. \"If you don't mind, maybe I can drop in from time to time to see you. But you'll be better soon.\" He left anxiously. He returned and placed a just-opened package of Parliament cigarettes on the night table. \"Have a luxury smoke.\" At the foot of the bed he turned and said: \"He was a good fellow,\" and waited.\n\n\"Yes, he was,\" Reinhart answered and blacked out. He dreamed he was twelve years old; selling newspapers from door to door he accumulated money for a bicycle; someone stole the money but when he went outside there was the bike on the porch; a Negro applied Simonize to the fenders; _so you're a Negro,_ he said, _isn't that fine!;_ the black man rose in terror, great white eyeballs gleaming, and ran down the street. When Reinhart awakened, the same Negro, whom he had never before seen in life, carrying a tray of food walked past the bed and to his own, number five, where he sat near its head and ate rather insolently, winding spaghetti into a spoon.\n\nLeek appeared with a tray for Reinhart containing various forms and colors of mush. He was suddenly horny; she was not so bad. He invited her to come sit upon the palm of his hand. She thought he waved her off, and went. He called her back and asked the time. Six-ten. He slept for an hour. Awakening, he asked the time of the fellow in the next bunk, who had a wart in the center of a bushy red eyebrow. Six-eleven. He denigrated the fellow's watch, cursed its owner. The fellow slyly turned his back, and Reinhart cried into the pillow because he could not hurt him.\n\nWhen everybody had gone to sleep he wandered into the toilets and counting them again and again at last made his choice of one to sit upon and read a comic book. He had not finished a page when a wardboy whom he did not recognize entered and ordered him back to bed.\n\n\"You been in here two hours.\"\n\nReinhart snarled contempt. \"I've been in the Army since Christ was a PFC, and don't you forget it, you prick of misery.\"\n\nBut he went. Someone kept putting a flashlight in his eyes and forced him to eat sulfa pills and drink four glasses of water.\n\nOne day Marsala, whom he was forced to admit knowing, sat on the edge of the bed and whispered, so that the bastard with the red eyebrows couldn't hear: \"Carlo, whadduh yuh doin'? You been here three weeks, your cheek is almost healed. But you keep acting crazy, they send you to Psycho. I don't shit you, pal. I heard Captain Cage talk about it this morning.\"\n\nReinhart had all he could do to keep from spitting in his ugly face. \"Here's what I say to you: go to hell.\"\n\n\"See what I mean. Whadduh yuh want to be sore for? Jesus, I'm distracted.\" He rubbed his thick and whorled temples. \"So you took too much sulfa, but that don't stay on permanent. Your white-corpuscle count is okay\u2014\"\n\n\"You flunky, what do you know about medicine? You traitor, you make me puke.\" He stared fiercely at the quondam buddy, stared through him as if he were cellophane\u2014a gift he had nowadays and would have done anything to get rid of.\n\n\"Okay,\" said Marsala. \"Okay then. You and I are through.\n\nGet it? As soon as I get back to the apartment your crap goes out inna street.\" He symbolically spat. \"And the same goes for your lousy _putana,_ that little kid who's young enough to be ya granddaughter, dirty guy.\"\n\nThe return on his aggression soothed Reinhart, convinced him that even wounded and mad he was potent. In delight, he said: \"I hurt your feelings, didn't I?\"\n\nMarsala looked at him a long time, his ferocity melting into a kind of grief. \"Nah, I consider the source. ... Look, what for did you tell that kid Trudy she could have your extra OD shirt and pants? Don't you think you will ever get out of here?\"\n\n\"Did you give them to her?\" He saw the whole thing and was serene.\n\nMarsala clicked his teeth in lascivious regret. \"You didn't say she could have them, you ain't even seen her since you're here, am I right? She talked me into it, kid. I'm sorry. When we get through and are in there washing up she says she is thirteen. Jesus I'm a dirty guy.\" He slapped his wrist with two fingers.\n\nHappily, Reinhart lied: \"Of course I did. I sent her a note. I'm going home soon and don't need that extra stuff. Give it all to her and take her for yourself. She is really sixteen and if she's old enough to have it, that's old enough to use it. I apologize for being nasty. You're the best buddy I ever had, and when I get home I'll write you a letter once a month. ...\" He closed his eyes and kept on talking. When he opened them again Marsala was gone and Red Eyebrows, who he also noticed had red hair, was peering at him most curiously.\n\n\"Hey Red,\" he called. \"I didn't mean what I said yesterday about your watch. I was still a little dizzy from this trouble I had the other night. Have a luxury cigarette.\" He picked up the Parliaments and handed them over. They were strangely dry and friable for a fresh pack.\n\n\"Yesterday?\" asked Red. \"That was almost a month ago.\" He laughed as if he were insane.\n\nBut when later in the day they transferred a patient to the Neuropsychiatry Ward, it was not Red.\n\nVeronica's shadow flowed back into the black cavity of the office, meaning all was quiet on the ward. Reinhart himself certainly never made a sound. In the latrine he had even perfected a technique for micturating without noise. He wished to call no attention to himself, because he was altogether mad.\n\nIt owed to that kick in the head which couldn't be proved. The staff in Superficial Wounds assured him he suffered from a mild toxic psychosis, the effects of an overdose of sulfa, for which they took full responsibility. Having admitted their guilt, they insisted it make him free, especially since the technical manual, _Guides to Therapy for Medical Officers,_ called the reaction rare. And as to Reinhart's confession that he habitually swung the pills into the deep socket of his jaw, drank the water, and spit them out when the nurse turned her back: in their view this illusion was rather an index to how many he had swallowed and been deranged by. Apologizing, they force-fed him gallons of water. Drowning, he was still mad.\n\nThe Psycho people, on the other hand, kept their convictions secret. Lieutenant Llewellyn walked on eggs from bed to bed on his morning tour of inspection, wearing the silky, untrimmed mustache to make himself look older and the plastic-rimmed eyeglasses for wisdom, carrying his mouth slack and moist in an advertisement of patience. He was rather leery of Reinhart; few indeed of his patients had killed a man with their bare hands.\n\nCaptain Millet, the chief, stayed always in the office and one went to see him at intervals. From crown to temple he shone bald as Bach; around the ears, a ballet tutu of salt-and-pepper hair. As Llewellyn was listener, Millet questioned, and had a talent for the irrelevant: Do you like girls, did you ever play with yourself, do you have headaches, did you dress up in your mother's clothes when a boy, what do you think other people think of you, what do you want to be?\n\nTo the last Reinhart invariably answered: \"Able to tell time again.\" For this was the heart of the matter, but Millet, bored, toyed with his pen and never took a note.\n\nHis head he had stopped bothering to mention; if Superficial Wounds, in whose area of interest it lay, could not find that seepage of brain fluid, Psycho, devoted to the impalpable, would hardly. On the basis of many motion pictures about amnesiacs he drew up his own strategy of treatment: he could be cured by another raking blow on the skull. But owing to the queer angle, he could not slug himself sufficiently hard, and he was afraid to ask one of the nuts to do it, who might kill him. Which brought to mind an essential feature of his condition: a lack of interest in death as therapy.\n\nOnce he had tried strenuously to die, and again the next morning, when it had seemed necessary to the _Gestalt_ of himself-Schild-and-Germany. Now it would be a simple missing of the point, for the self within him was already unearthly and losing the rest were impertinent. If someone sought to kill him he might not resist, but he would not raise his hand against himself.\n\nHis inner cautions to the contrary, in a burst of bravado he delivered this information to Captain Millet. Who blankly answered: \"That is comforting.\" And Reinhart was ashamed of his vanity and of his suddenly revealed wish for Millet's affection, whom he didn't even like and to whom he had bragged only because, he thought, Millet didn't care.\n\nThe captain went on: \"You mean, you will not commit suicide by violence. That is too easy, whereas what always attracts you is the difficult.\"\n\n\"No,\" Reinhart confessed. \"The impossible.\"\n\nAn ear fringe grew as fast as a full head of hair; Millet needed a haircut, which deficiency, however, and now a vulnerable smile\u2014his teeth were crooked\u2014canceled the disapproval from his next remark: \"Why do you think you are so important?\"\n\n\"Because\u2014\" Reinhart groped for something smashing; in his bare cupboard was one bone; he seized it\u2014\"because I am insane.\"\n\nMillet said seriously: \"The Army may make errors in assignment, but they were right about me. I can show you my diplomas. I assure you, you are not insane and will not be.\"\n\n\"Then I am a fake.\"\n\nMillet's pen scratched upon his notepad, but Reinhart saw only doodles, and not imaginative ones at that. \"As late as the nineteenth century they used to chain patients to the wall and whip the disorders out of them. The treatment was oftentimes successful. It might be used today except that its good effects were, I believe, only temporary and it required enormous physical exertion on the therapists' part. Now we have the lazy man's method. When you decide whether or not you are a fake, come in and tell me.\"\n\nWell, he guessed he _had_ made a mark on Millet, if Millet talked to him in that ironical way. The captain was softer with the other patients, according to them\u2014for Reinhart sometimes conversed with those who were articulate. The enuretic poseur of a paratrooper, for example, whom Very talked about back in August, had returned. Perhaps he falsified the one symptom, but he had plenty more, couldn't use a tableknife, thought people were after him, etc.\n\nBut having got his special notice from Millet, Reinhart went back to where he started. Because his case was irrelevant to the fundamental proposition by which lunatics and psychiatrists are one: Life goes on. And not only proceeds to the measure of the ticking second hand, but also abides in wondrous detail which perhaps one can only know when on furlough from the process.\n\nWho ever before had opportunity to study the fabric of a pillowcase? The close and naked eye saw no two threads the same. And the canvas slippers: their weave black with dirt, rich with memories of various feet walking diverse floors in many lands; their old human smell, sour, interesting. Chipped was the white paint on the bedstead, revealing multiform corrosions, patina, wounds in ancient iron; whom had it supported and in the aftermath of what: Caesarean sections, irrigations of the maxillary sinus, removal of the vermiform appendix, mere hang-overs, some deaths. Blankets of wealthy white wool, shrunken gray pajamas gaping at the fly and over the heart USAMD embroidered in red; maroon robe of weary corduroy, too short; night table all one's own offering water in pitcher and glass, and beneath, on the low-slung shelf, colored books random and in shadow.\n\nAnd through the window\u2014lingering on the glass itself, marvelous substance almost invisible, metamorphosis of gritty sand, just as the butterfly comes from a worm and remembers it not\u2014a view of this side of the grove on the other side of which, on the sand, some fellows murdered his only friend while he watched through another window, that glass bell under which he was wax fruit.\n\nIn this celebration of matter he got through his mornings, which were worst. From within came spontaneous improvement as the sun traveled towards America; afternoons were fair, he could sleep, and wake up in early evening, glad of life's refuge from dreams. As natural light failed and Edison's took over, he was better. Finally, each dark midnight, the absolute cure: bored with the soul's business he lay unsleeping, yet not sleepless, believing in these hours of exuberant health that everybody should have a goal. During such a period of clarity and courage he decided to take his discharge, when it came, in Berlin and marry Lori.\n\nOr join with her in whatever other relationship external conditions would allow, the mode was irrelevant; internal coherence was all. Even _m\u00e9nage \u00e0 trois,_ in thinking of which he signified his affection, respect, and pity for Bach, nay his downright love for this man who needed and had a nurse, not a wife. She would continue in that role, plus which he would gain a friend to listen interminably. Reinhart spoke frankly to himself of its romanticism: this boy from distant and simple Ohio oh beautiful for spacious skies and amber waves of grain, in a rathole under the rubble of a dark and evil idea, living in adultery and cuckoldry sanctioned by mutual love, talking art and philosophy: there at last was the old German idealism he had searched for so long.\n\nOn the third night of his planning, in the second week of his residence in Psycho, he believed it politic to leave the bed and steal to the office. The paratrooper, next to him, sobbed peacefully; from elsewhere sounded placid onanistic rustles; the coast was clear.\n\nVeronica, back to doorway, sorted files. Before Reinhart could announce himself\u2014because he meant no harm\u2014he was seized from behind by two husky wardboys leaping out of ambush, who were lucky to remind him poignantly of Monster's dread embrace, and he offered no resistance.\n\n\"Oh that's okay, fellows,\" said Very when she saw, holding up parallel fingers\u2014for some reason, all five instead of the standard two\u2014\"this kid and I are just like that.\" She directed them to the treatment room, to prepare wet cocoons against an expected need towards dawn. They left, grumbling fealty.\n\n\"I was wondering when you'd come, you ingrate. I got put on nights so you could.\"\n\nShe almost leered at him, and he thought: working here gets them all eventually. They sat on either side of the desk, which had kneeholes on both sides, so that his and her legs touched. Soon she squeezed one of his between both of hers and crooned: \"I've been feeling rational guilt lately. I thought of all I owe you, Carlo, and I could just cry. You were my friend when I had nobody else to turn to, and the fact that it all came to nothing doesn't make any difference.\" She slapped on top of his the right hand of the high-scorer on St. Something's girls' basketball squad of 1940.\n\n\"Glad to do it, Very,\" he answered quickly, for she was in the mood for something and he had little time; at that cursed early first light of Berlin he would lose his wits again. \"I\u2014\"\n\n\"And I thought regardless of what went on you've always been my best boy friend, right here.\" She indicated her left melon, underneath which lay the heart. \"Because you stuck with me, and whether you ever said it or not, that is love.\" She winced in ecstasy and pile-drove her linked fists into the back of that same old hand of his, flat upon the table. \"Oh darling, you won't regret it!\"\n\nHe withdrew; another such love and he was crippled for life. \"Look, Very, what I wanted to talk about was\u2014\"\n\n\"I've been a fool,\" she said. \"All the other men I ever knew wanted only one thing, like, excuse my French, this son of a bitch\u2014\"\n\n\"I don't want to know who he was,\" Reinhart interrupted. \"And I'll tell you something about me.\" He had to do this, it was the only means by which he would ever get to his business. \"So do I. Whatta you think I am, a fairy? I just use a different strategy. Now this thing about the abortion. If I could have arranged that, then I would always have something over you, get it? You'd be forced to let me have what I want.\" He feared it was too strong: what business was so pressing that one must for its sake kick another human being in love's groin?\n\nHer quick answer spared his recantation. Through tears of happiness she sang, \"Darling, I knew you loved me. You will never get a job in Hollywood, you are a terrible actor! You're afraid your feelings will be hurt, poor dear. But I tell you it's all right, I dote on you. I don't care if you are an enlisted man!\"\n\nSo. One should not always walk against the wind. He rose and called her to him. Checking the door, she came. She had found him out, he admitted. He must have her, for love, and _now._\n\nOh, oh, oh.\n\n_Now._\n\nNo, no, no.\n\n_Now._\n\nImpossible. Duty. No. Where?\n\nHer bailiwick. He was only a visitor.\n\nMaybe\u2014but no.\n\n_Now._\n\nOhhh. Terrible. Yet love was good.\n\nTell Tweedledum and Tweedledee to watch the shop.\n\nThey'll know.\n\nSo? A couple of privates.\n\nSo while he waited in the corridor, Very stopped by the treatment room and gave her excuse for ten minutes' absence. Then, down the hall, they found an empty, moon-illuminated ward whose patients had been transferred to another on the first floor, but the beds remained.\n\nNot in love, he made gentle approaches. In love, sitting on the bed-edge, she grew fiercely reluctant. He had to take every button of her uniform as it were a separate fort. In her white slip she cried for shame and changed her mind, and having no effect on his, slapped his face but left her hand there and coyly squashed his nose. Dead weight he must lift to draw slip skirt over bottom. Opposing her own divestiture, she nevertheless stripped off his pajama shirt. His cheek wound throbbed in each little red hole left by the stitches; the invisible scalp-ache ached as if it would have a separate orgasm. In the sexiest presentation she did not match: brassiere of pink, pants of blue. A coldness on his back foretold that the swelling former was a hoax of sponge rubber or wadded powder puffs, and he knew he could not perform. But as he retreated, so did she charge. She liberated the strained hammock and held it conquered and limp as an enemy flag. Real? By Magellan, if they were not real, there were no Eastern and Western Hemispheres, which had sat as their models. _En voyage,_ his trousers were suddenly gone, and also the canvas slippers. He dove towards her sea-blue pants. Then did she bound, like the well-known main, and give him a struggle beside which poor Monster's had been as a schoolgirl's in a pillow fight. Trudchen's old lacerations, which had healed, were reopened in his earlobes, and Very's teeth were twice as large. His solar was plexed and his clavicle cleaved. She probed for that rib which Adam had given to make her. When they fell to the floor, he hit lowmost, heel-ass-head. His only purpose was tenderness. Under incessant punishment he got her again to the upper level, dropped her on the mattress, _goyng, goyng_ said the springs as she bounced with flying members. She gathered herself and shuddered, blurted: \"My God, the night supervisor is due any minute!\" She crawled towards the footboard and her clothes. \"Shh,\" said Reinhart, \"I think I hear her now!\" She closed her legs, ivory in the half-light, pillars of the world; stood up and listened with flowing hair and sensate, rose-marked, goddess breasts, with belly-swell of satin and velvet groin. On Olympus sounded ox-eyed Hera's jealous thunder and Aphrodite practiced _Selbstmord._ \"Where?\" She heard the silence of the corridor, and was caught _en face_ to Reinhart and borne down through the wine-dark sea.\n\nLater, beached and dripping, she kissed his ten fingers and remarked: \"You didn't hear the supervisor at all.\" He grinned splendidly, Zeus-like, and with his godlike ear heard her all over again.\n\nNext morning he arose without his symptoms and with a grand conviction they were no more. In hubris he dared them to appear, dared also to draw up their roster: the quivering wire in his bowels; the cold sweat and hot chill; the vacancy of a head yet heavy; the apprehension of attack; the sense he shared the skin of another man; a feeling of insupport towards the sacroiliac, as if two segments there were rather gristle than bone; the famous derangement of time; a horror over possible events: Would Trooper, writing a letter in the next bunk, ever finish that line? Would Lieutenant Llewellyn start his tour on right or left side? Would, next time he looked, a straight pin still gleam from the crack in the floor?\n\nHard as he tried, he stayed healthy. Llewellyn, when he came and heard, was happy in his innocent, brotherly way and advised him to counsel with Millet. Trooper, waiting with his own troubles, in his turn told the lieutenant of the old dream of jumping without a chute.\n\nReinhart dawdled for more self-tests. When finally he was ready to see the captain, he was last in line. Waiting, he felt his euphoria fall into a dull headache of resentment towards the other patients, leavened by a sharp distrust of Millet.\n\nMillet turned his head and blew a large nose into an olive-drab handkerchief, very insulting. \"Of course your problems are important,\" he said. \"More important than any other patient's. And so are those of each one of them\u2014when they sit before this desk. That is a fact. Do you know what a fact is?\"\n\nReinhart looked defiant. \"Yes, something that cannot be changed.\"\n\nThe captain had finally got a haircut, the ballet skirt was trimmed to a gray fuzz. He sloppily put away his handkerchief.\n\n\"Isn't it rather, something that should not be ignored?\"\n\nAll right, he knew everything. But Reinhart had seen him blow his nose; he was omnipotent and all-knowing, but he also caught colds.\n\n\"Well, I'll tell you a fact,\" Reinhart said. \"In this fight, which I got into to help my friend, I killed the big German. It is a terrible thing to kill a man with your bare hands. I regret it, I think from now on I'll turn the other cheek, but I didn't have a choice then. But I don't feel _guilty,_ if you know what I mean. It was a good fight, a fair one, I mean, for him. He was bigger and stronger than me, and we all take our chances. This is a fact. Why then instead do I feel a guilt for Schild's death? Ill tell you. Because I could have saved him.\"\n\nMillet drew some rectangles on his pad. Nothing touched him. He said indifferently: \"Why didn't you?\"\n\nReinhart's symptoms had returned, full flood. While his chest shivered, bloodless, his suffused head burned; he could not recall whether he had sat in this interview one minute or all day; his whole spine was superimposed rings of lard; he looked for Millet any moment now to draw a long, keen blade and leap upon him.\n\nStill looking away, Millet suddenly ordered him, as captain, not doctor, to answer.\n\nReinhart shouted, in glorious hatred. \"Because I wanted you to die, you bastard.\"\n\n\"Not me,\" said Millet. \"I was not there. That is a fact.\"\n\nTerrible, deep remorse for the error. Not Millet, certainly: Reinhart wished to kill the only man he could ever talk to, and that was Millet, who wasn't even a Jew.\n\n\"Well, I don't feel so good. I'm not even sure I'm sitting here right now. Maybe I died back there on the field. What living man always feels guilty of what he hasn't done?\"\n\n\"Every single one of us,\" Millet answered, although it had not been a question. \"You are not special in that regard. In the heat of combat, soldiers always wish their comrades would get hit, as a kind of charm against their being hit themselves, and then experience guilt if their wish comes true\u2014but not till the battle is over and they have time and security enough to brood about, rather than preserve, themselves.\"\n\n\"But,\" cried Reinhart, \"that is all just personal. What I am involved in is the murder of a whole continent of Jews by my people.\"\n\n\"Excuse me.\" Millet reddened his nose with the handkerchief.\n\n\"Do you know what is good for that?\" Reinhart asked. \"One of those benzedrine inhalers.\"\n\n\"Thank you,\" said the doctor. \"I will try one.\"\n\n\"Only not just before you go to bed. It will keep you awake. The benzedrine, you know.\"\n\nMillet again expressed gratitude, and said: \"The personal thing is very interesting. In the three weeks of our talks\u2014\"\n\n\"Is it so long? I can't remember, you see.\"\n\n\"Oh you will, you will. ... Not once have you spoken of Lieutenant Schild as a person. Was he really your friend?\"\n\nHe understood Millet's technique well enough. It was always to oppose the freely given and dig for, what was on Millet's terms and not his own, the withheld. Simulating anger and hurt\u2014for his true feeling was of challenge to a battle of wits\u2014he concluded the interview.\n\nThen, back in bed, which had new, icy sheets, he found as usual he could not organize his thinking. Instead he tasted, in fancy, Veronica's aphrodisiac body and felt relief that tonight was her night off. Too rich for the blood. There was another crime for which he knew no remorse: taking advantage of her love. And now he compounded it. He wrote a note to Lori, asking her to come see him after work, and had it delivered by a wardboy, PFC Remington, whom he had done a favor for in England. \"And,\" he cautioned, while Remington studied him with the same uncomfortable eyes he had used since Reinhart became a patient, \"the German girl, and for Christ's sake not Miss Leary.\"\n\nLori came to the ward door an hour after the patients' suppertime. Nurse Bronson, Very's substitute, would have turned her away, but fortunately Lieutenant Llewellyn, permissive, dreamy type, had lingered late over his reports.\n\n\"A girl,\" he said encouragingly to Reinhart. \"A visitor. Well, isn't that kind.\"\n\n\"It is most important that I see her for at least five minutes. I believe, sir, it would be a kind of therapy for my disorder. Of course I know it is against the rules, and if you say so, I must get rid of her.\"\n\nPain, like a wave of heat, warped Llewellyn's plastic glasses. \"Oh no, Reinhart, we are absolutely opposed to duress! I hope you think better of us than that. I tend to agree with your feeling that you should see this kind lady.\"\n\n\"You won't think I'm a malingerer?\"\n\n\"Please free yourself of any such apprehension. Perhaps you will let me prescribe a mild sedative?\" He went, lankily nervous, to a glass-front cabinet.\n\n\"No thank you, Lieutenant, she is not upset! Hahaha,\" laughed Reinhart.\n\nAfter a moment Llewellyn bewilderedly smiled. Then he worried: \"Normal interpersonal relationships are too rare in this somewhat false environment. No, I agree with you in your feeling that you should see her. But may I ask, if you don't mind, it is better in my judgment, whatever that is worth, that you and she do not confer out in the ward. It would disturb the other poor fellows. I should be glad to have your opinion on that, however.\"\n\n\"That's quite right, sir, quite right.\"\n\n\"Oh good. Well then, I am sure Miss Bronson, who has a fine sense of these things, will be happy to let you borrow the treatment room.\"\n\n\"We could be in love for a while,\" said Lori, her strong, realistic face undisturbed by his proposal, the harsh light, or Miss Bronson's periodic doorchecks one of which still echoed in the metal furniture. \"But nothing else is practical.\"\n\nSuffering a partial aphasia for the German language, he asked her to repeat.\n\nIngenuously, she shook her hair and said in his own tongue: \"Uh little surp-rise: I study English already. ... Wiss one another we may to love for some time. But alvays is _untunlich._ \"\n\nIn his anticipatory fancies he had alternated between smugly hearing an absolute acceptance and listening with shame to an unqualified turndown. Instead, he had the usual compromise. He must learn, damn him, that people out there in the universe beyond his head were real and unimaginable. Had Schild really been his friend? What more could he, Reinhart, have done to prove it? Did he really love Lori? If not, why was he willing to live in that abominable cellar?\n\n_\"Liebling\"_ he answered in German, \"I don't understand what you mean.\"\n\n\"Then you never will if I try to explain, Unteroffizier Carlo Reinhart, because my talents are not in analysis. You have met my brother and my husband. They never have allowed me to do anything but listen.\"\n\nReinhart left his table-seat, went to her, and took her hand. \"Nobody has ever appreciated you.\"\n\nLaughing astonishment, she squeezed him back. \"What a strange remark! But I assure you that I have nothing to say, I have no ideas, why should I want to speak of nothing?\"\n\n\"That's the old Prussian nonsense, children, kitchen, church is all a woman's good for.\" He was made reckless by his indignation: \"Then come to America! I will send for you as soon as I arrive.\" Till that moment he had never believed he would go there again himself, but the sensible man, the Rotarian, the Philistine, who resides in the liver, somehow survives all blows to head and heart.\n\n_\"Kinder, K\u00fcche, Kirche...,\"_ she repeated. \"I have none of them. However, you would think my idea of American women just as funny, no doubt, but I shall spare you. America! This will interest Bach. You surely did not suspect he has long dabbled in technology. _Also,_ he now announces to me that he has invented some means to make a glass which withstands heat. He has done this without a laboratory, simply mathematical equations in a notebook. Is this possible?\u2014no. But in America someone will give money for it, perhaps. Is that likely?\u2014no. But\u2014\"\n\n\"I didn't mean you could bring Bach!\" Reinhart thought: besides, we already have Pyrex.\n\nShe shaped her thin lips as if to pronounce _o_ umlaut.\n\n\"You understand,\" he said. \"I even like him, but be fair once to yourself. That is no kind of life for a young woman. It isn't right to sacrifice oneself for somebody else, no matter who.\"\n\nPlacing upon him her famous direct look\u2014that for which he loved her\u2014she answered: \"Certainly. So do not do it for me. I don't know what 'Teutonic efficiency' is, since I have lived in Berlin all my life, but here you have an imitation: one, I love Bach very much; two, think of your self-respect! I am old enough to be your mother.\"\n\nIn confusion's rage, he shouted: \"Then what did you mean by all your hints? If you love Bach why do you say you and I can love each other for a little while? Either way it's a betrayal of something or other. ... I hate things that are dishonest and secret.\"\n\nHearing the nurse at the door, he withdrew his hand. Miss Bronson's beet-face, pickled, cautioned against further noise and gave him five minutes to conclude.\n\n\"Then you must hate love,\" said Lori, \"not to mention life\u2014no, I don't mean that. It has been a long day for me. Fr\u00e4ulein Leary stayed home from duty and had numerous requests\u2014to press her clothes and so on. I think she is in love again. Why not get yourself an American girl? People from different countries really don't understand each other, as Bach says.\"\n\nWith one or two other more important items to check off his list, Reinhart put them by, to insert here: \"That is why we have these tragic wars.\"\n\nLori rose and gathered her old coat about her waist. \"According to Otto, no. War is the one time when they really do understand one another. Therefore he champions obscurity in human affairs\u2014no,\" she raised a hand, \"I will not discuss it; they both say I never can get anything right.\"\n\nHe had not only recaptured his sense of time: he had got back a better one than he lost, with a precise second hand. Exactly four minutes of Bronson's ration remained.\n\n\"Lieutenant Leary is in love _again._ Who was it the first time?\"\n\nThe candid eyes were now impure. \"Yourself, of course.\"\n\n\"Don't do me any favors. I'm not really sick. I've been faking all the while. And by the way, does nothing affect you? If you remember, Schild and I were at your home only a few hours before he was killed.\"\n\n\"If you remember, I have lived in Berlin for twelve years of Hitler and five years of war.\"\n\n\"I'm sorry,\" he said truly. \"I just want you to tell me who was Miss Leary's lover in August.\"\n\n\"Facts, always facts, what will you do with them? _Oh-kay, it's ah deal!_ This captain who lives, lived, with Oberleutnant Schild.\"\n\nHe began loudly to laugh, then choked it off for fear of Bronson. In mirth he used his own language: \"He is shorter than her!\"\n\n\"Please? As yet I don't understand so much English.\"\n\n_\"Knorke,_ it doesn't matter. ... So you are old enough to be my mother. You really are a twin of the doctor? Which would make you sixty.\" He shook his head. Two minutes left.\n\n\"Sixteen February, 1905, for both of us. Otto was the younger-looking before he went to Russia. I did not see him again until after he had gone through the camps.\" She shook Reinhart's hand, once up, once down. \"If at eighteen I had had a son like you, and he survived, I would not be disappointed now.\"\n\nBronson stuck her head in and called time, and Reinhart growled: \"Go away or I'll tell Lieutenant Llewellyn you applied duress.\" She winced and left.\n\n\"However,\" Lori went on, \"I didn't and I'm not disappointed either.\"\n\n\"You would say then, life goes on.\"\n\nShe pushed a sportive lock behind her ear; she stood in need of a washing and combing; in the center of a general relief which he could not explain, Reinhart felt a twinge which he could: he would never provide the brush and soap.\n\n\"I do not!\" she answered fiercely. \"Life can do as it pleases.\" Still feral, she leaping captured his neck, drew down his head, and kissed his mouth.\n\nHe concealed his momentary anguish of regret: \"Thanks, anyway, for never caring about me.\"\n\n\"Have it your own way.\" Tough, small, unkempt, Lori marched modestly into the corridor, uneasy Bronson voiding the route. Once through the outer door, she returned to hovering, vacant, liberated Reinhart for her formal peroration.\n\n\"I have forgotten! Here comes some English: 'Ve mawrn zuh death of a man of honor, First Lieutenant Schild, zalute zuh gallant Corporal Reinhart, shall effer keep green zuh memory of the former, and await with affection and respect the... re-choining by the latter of our fellowship, Knebel, M.D., your dear Lenore, and yours truly Bach, Ph. D.' _Also,_ I have remembered every word!\"\n\nOld Sad Sack St. George had topped Veronica. Now Reinhart understood why the captain had not tried to visit him on the psycho ward. He should notify St. George that Very worked nights, up to suppertime the coast was clear; except that this action was as much as to admit he was privy to their quondam goings-on. And he detested having the goods on anybody, which were always squalid. Besides, the captain, who physically favored his father, carried to Reinhart a suggestion of what he, himself, would be in twenty years: middle-aged, ingratiating, secretly prurient. He didn't try to get in touch.\n\nWith Marsala, too, contact had been broken, which he laid to a primitive, Italianate superstition towards bats in the belfry: extravagance was permitted only in the service of lust, drink, and anarchy. Well, it had been an accident anyway that he was quartered with the damn guy; he was never so close to Marsala as the fellow ginzos with their home packages of sausage and cherry peppers.\n\nVeronica returned to duty the next evening and squirted him loving, guarded looks as she went about ward business, but not having taken his afternoon nap, he dropped off to sleep at lights-out and so did not get to the office. Next morning he suspected having been touched on the face sometime during the night, but it could have been just a dream. However, he did find under his pillow a note on unlined paper, which read: \"I'm going to knock myself off\u2014Jesus destroy this mesage.\"\n\nHe actually believed it was Veronica's until Trooper reached over a long, thin arm and tore it away, saying, \"I changed my mind.\"\n\nReinhart looked at his bird-dog face and said: \"That wouldn't have settled anything.\"\n\n\"You're wrong,\" Trooper answered. \"It would so have, but I just realized I don't want anything settled. That's my trouble.\"\n\n\"Well, what do I care about you?\" Reinhart said irritably.\n\n\"That's all right. Nobody does. That's why I used to piss the bed, to get somebody to. But they didn't.\" He pulled the sheets over his head and said, underneath: \"I don't care any more.\"\n\nFurious, Reinhart jumped across the aisle and re-exposed the forsaken face. \"Knock off that crap, Trooper. Tell me, is it true you got the Silver Star in the Holland jump?\"\n\n\"I didn't deserve it. The ones who did were all killed.\"\n\n\"Don't hand me that. The fact is I understand you were screwed. Anybody else who singlehanded bumped off ten Germans and captured fourteen more would have got the DSC. An officer would have got it.\"\n\n\"He would?\" He crept up on the pillow but still disbelieved, and they argued, Reinhart temporarily winning. However, it would be a long fight to get Trooper to understand that the world, and not himself, was wrong.\n\nHe concealed his new mission from Millet when they talked, and observed the captain's techniques. Afterwards, with his own variations, since Trooper was not so sophisticated a case as he, he used them on Trooper. Trooper ate a good lunch for the first time since he had come on the ward. Another two days, Reinhart had him traducing the doctors.\n\nHe said, almost smiling: \"Reinhart, you ought to take up this psycho stuff when you get out of the Army.\"\n\nReinhart winked. \"Have you been reading my mind?\"\n\nTrue, like knighthood, this profession gave you a permanent upper hand; like the priesthood, it made everybody else feel guilty and also grateful; like the Jews it was much reviled yet indispensable and always right. For example, Millet as a person was probably not much\u2014he looked as if in civil life his sport was golf; his tips to caddies, meager\u2014here he sat as universal daddy.\n\nHe sensed a certain competition with Millet in succeeding interviews, but was forced to simulate his old quest for approbation.\n\nTowards the end of the week he reported: \"I am all right again, Captain. I am sure now. I sleep well and in the regular hours, I realize that wound in my head was just imaginary, time is again just as it used to be, and I am not suspicious of anybody. Your treatment has been successful.\"\n\n\"That's good,\" admitted Millet. \"Why do you refuse the recreational therapy?\"\n\n\"Because I don't like to weave baskets and I already have a billfold.\"\n\nMillet said permissively: \"Uh-huh. Nurse Reynolds tells me\"\u2014 he found the place in a document\u2014\"you stated a wish to make a shoulder holster. Which she opposed. Were you\u2014\"\n\n\"Oh that was a kind of joke. I wanted to give it to my roommate Marsala. His brother's a hood in Murder, Incorporated.\"\n\n\"No, I don't question that. I merely wished to know if Reynolds' refusal made you angry.\"\n\n\"Yes\u2014well goddammit, she said no in that sweet, tolerant manner used towards psychos, yet I know what she was thinking\u2014don't let Reinhart do anything that suggests violence.\"\n\n\"What did you do then?\"\n\n\"I walked away and didn't say anything.\" He stared at Millet's pale, bored eyes and shouted: \"What in hell do you think I did, beat her up?\"\n\n\"Did you want to?\"\n\n\"If you don't mind my saying it, sir, you know about as much of a man's mind as a golfball.\" He glanced at Millet's desk, insultingly clear of letter openers, etc., even pencils, for obvious reasons. \"If you mean deep down, I probably wanted to screw her. All men want to make love to every woman and kill every man. Man is a savage only partially tamed.\"\n\nMillet smiled. \"Is that your own theory?\"\n\n\"I read it somewhere, and then consulted my own soul. I know you people don't think a man can help himself, but I have.\"\n\n\"Was Lieutenant Schild your friend?\"\n\nReinhart sighed. \"You want me to say no. But one thing I will not do to get out of here: lie. It seems very clever to look only for the deep secrets. What we see of a person is supposedly only the false exterior; what he _really_ is, is underneath and hidden. Thus a man who appears generous is really selfish, great lovers are secretly queers, and heroes are really cowards covering up. A fellow who feels guilty about the Jews is actually the worst anti-Semite of all, and so on. No doubt this is true. But out in the world we have no time to check these things. If a bully comes towards you with a club, you have no chance to reflect that he is actually not frightening but pitiful, that if you gave him love and understanding he would be your friend.\n\n\"Because if the front is a lie, so are the depths when taken alone. For himself, a hero may be a coward. For you, if he is on your side in a battle you do not want to know what he is in some reality outside yours. A Don Juan may be a fairy, but in practice he will make love to your girl and not to you. Do you see what I mean? The fa\u00e7ade, too, has a reality and truth. You sit here in front of me like a god, asking me questions which I cannot ask you. Why? For reasons of your own. Somewhere back no doubt you grew a guilt towards people with mental troubles because you really have contempt for them. But I don't want to hear about it and obviously you don't want to tell it.\n\n\"Now the Jews and me. My feelings about them are irrational. Actually the Jews bore me stiff. And so do the Germans. All I ever cared about was old medieval N\u00fcrnberg, and that is long gone. Italy, I think, is what I like, with sunshine and that melodic language. I also hate politics and sociology and all that crap that deals with people as groups. I hated those mobs of idiots screaming _Sieg Heil!_ and who didn't?, but I also dislike those hordes of Russians in Red Square, who in spite of Communism are supposed to be generally good, and also the 'starving multitudes' of Asia and the 'laboring masses' everywhere. I name these examples in an effort to be honest. I don't like conventions of generals and bosses any better, but there everybody agrees with me.\n\n\"So with the Jews, who seem to be a persistent mob throughout history, only acting in the reverse of the usual mob; they storm nothing but are stormed. They are always around with their dull troubles and their rituals and their foods, feeling special everywhere and superior. I confess I used to think it was a trick for the Jews to always complain about mistreatment. They seemed a race of gripers.\n\n\"Then the Nazis came. Or rather, I finally noticed the Nazis. And they were something new. When you speak badly about the Nazis you cannot tell a lie. Maybe, secretly, every gentile wants to kill every Jew, but the Nazis did it in practice and the other Germans, or many of them, didn't care. But you see, _someone must care._ \"\n\nMillet raised his head, which had been lowered as if in sleep, and asked: \"Why?\"\n\n\"So that Germany will not perish.\"\n\n\"But you were concerned about the Jews.\"\n\n\"If you want to understand anything, you must listen,\" Reinhart chided. \"I am concerned about myself.\"\n\nMillet's head sank again.\n\n\"So I met Schild that night. He forces himself on me. The motives get all mixed up, who is doing what for whom. We listen to a man who is himself confused. It is a grotesque evening, like everything in Berlin turns out to be: giants, twins who are apparently twenty years apart, blind men, would-be abortionists, experts on art, turncoats, Communists, ex-prisoners of the concentration camp, good Germans who turn out to be bad, and vice versa, and Schild and I.\"\n\n\"How many people were there?\"\n\n\"In addition to Schild and me, only three. I assure you it was fantastic and ridiculous. And all in this damp cellar, but we sat on a Goblin couch worth a thousand dollars. And afterwards we get in this mortal combat. But I'll tell you this: it all happened and is still easier to believe than the concentration camps\u2014which, by the way, the Russians have, too.\n\n\"Now I'm ready to answer. Was Schild my friend? On one hand, yours, no. I used him. If he hadn't been a Jew I wouldn't have given him a minute, for he was a kind of creep. I felt this definite satisfaction when he got it in the back, and it wasn't the one you spoke of. More complex than that. I felt it because, fighting for him as I was, _nobody could blame me for his death._ Well, here comes a joke: no one does but myself.\n\n\"But was he my friend? In my sense, yes. He was someone I could talk to, and not the way I am talking to you, which is a sort of fraud since you are invulnerable and never talk back. And then for another reason. When you hear it you will never let me out of Psycho, because I guess it means I really am nuts. When Schild was a boy he read the King Arthur stories. And he still believed them up to the time he died.\"\n\nMillet asked lazily: \"What's 'nuts' about that?\"\n\nReinhart groaned: \"Because so do I. Really.\"\n\n# _CHAPTER 23_\n\nTEMPELHOF AIRPORT WAS STILL A mess of cracked-eggshell buildings, but the Air Force had policed up the field and laid its steel-mesh runways. Grounded craft sat dirty and rather larger than they looked in the sky, on what Reinhart believed was in the jargon of the trade called the \"apron.\" Identification of airplanes was a prideful talent with some people, not him. The nearest fellow in the party, a tall thin T\/5 with heavy eyebrows arched in perpetual curiosity, pointed out a Liberator, joked: \"It looks like a pregnant dachshund.\"\n\nUpon application the T\/5 confessed to being a case of chronic dermatitis, showed a bandaged right hand, said with a smirk of self-hatred: \"I guess you were wounded.\"\n\n\"No,\" said Reinhart, pointing to Trooper, who stood sickly at his left, \"he and I are psychos.\" Succeeding that, Trooper dug him with an elbow of embarrassment; he turned to the gutless fellow and bawled him out; therefore he did not see the T\/5's reaction.\n\nBut he heard him say: \"Well, this skin trouble is supposed to be psychosomatic, so we're all in the same boat.\"\n\n\"It's nothing to brag about,\" Reinhart answered. Crushed, the T\/5 monkeyed with his duffle bag.\n\nStaff Sergeant Owens, in charge of the patient group from door of hospital to hatchway of plane, again called the roll and lost four names in the roar of revving engines and the braggadocio bellowing of mechanics.\n\n\"See that rusty heap over there behind the Liberator?\" Trooper asked Reinhart. \"I bet you beaucoup marks that's what we got to ride. And we won't get any chutes. Oh my busted back, I feel bad.\"\n\n\"Now Trooper, I'll tell you a thing. Know that Air Corps gunner down at the end of the ward? When I told him we were shipping out to Paris by plane, he said, 'Then I'll never get out of Berlin. I love to fly but one time two months ago I dreamed the engines conked and I had to jump.' That's why he ended up in Psycho\u2014the dream has haunted him ever since. He says he would rather go down in flames than hit the silk. Everybody has his own horror. You don't mind the jump but are leery of the plane.\"\n\n\"That's on account of my training, Carlo. Those instructors never had any elasticity.\"\n\nInstead of wondering what that meant, Reinhart hung himself up on his own term: he was very leery of Very Leary. Although as late as the evening before she had betrayed no knowledge of his leaving, he, the old victim of guile, now practitioner, would not feel safe until he soared the air. He looked towards the buildings and would not have been astonished had Veronica come sailing from them and taxied up the mesh, dwarfing the Liberator. What a piece to run away from!; he supposed again that he _was_ nuts. The T\/5 there, who stared hornily at the female member of a professional party heading towards them, would sell his country for a Veronica.\n\nHe was torn by a distant shout and in involuntary panic tried to hide behind emaciated Trooper, who, a blotter for anybody else's emotion, almost wept: \"They after you, too?\"\n\nReinhart regained his self-respect. \"Don't get your balls in an uproar. I'm looking out for you.\"\n\n\"It's not,\" said Trooper, \"that I'm afraid to get hurt. I just don't like the humiliation.\"\n\nThe shout was closer, and clearer, and in the two syllables of Reinhart's cognomen. He turned to face the firing squad and saw\u2014Marsala. He ran to meet him, ignoring Sergeant Owens' howl.\n\nTen yards away, Marsala slowed to a measured, inexorable pace, waded in, hosing his target with an abuse of great variety and color: scatophagous Reinhart, the traitor, the Oedipus Rex, the fornicator of infants, the defiler of graves, the double-barreled international bastard and revolving son of a bitch.\n\n\"Fuck you and fuck your friends,\" he at length concluded. He turned away. His eyes were wet.\n\n\"I was going to write you from Paris, buddy. They only told me yesterday I was on shipment, and wouldn't let me get out to say goodbye.\"\n\nMarsala wiped his nose and fired up a big black cigar, throwing the match over a shoulder.\n\n\"Well whaddo I care where you go in Paris, huh? What's it to me you die like a turd? You goin' on a plane, huh? I don't mean what I said then, I take off the curse, you die and ya blood will be on my heart. Here, you wanna cigar? I ain't mad no more. Besides you're a poor dumb cuckoo. ... You're shit, too. How'd you work it? I'll say this for you, you got a lot of guts and talent to fool that old Millet. I been wrong about you for years. I thought you was this college type. But for Christ in heaven, after looking at you I think we run my brother from Murder Inc. for chief of police. You make a whore out of this young kid, you knock off a guy with your bare hands, then you play nuts and get home before everybody else. What college you come from, I think it was reform school.\"\n\nReinhart modestly smiled at this somewhat inflated pr\u00e9cis of his career, which however was sound in the essentials\u2014including the last-named. Millet had been on the verge of sending him back to duty\u2014believing in the actuality of King Arthur turned out to be quite O.K. mentally\u2014when in the interests of a new scheme Reinhart relapsed into the old symptoms. Just as he had foreseen, the ward needing his bed for new arrivals, Millet got rid of him.\n\n\"I don't know if this is the best way. I might get hung up in Paris for months, but I have to take care of that paratrooper over there. Where do you think they'll send us?\"\n\nMarsala spit out a fragment of wet tobacco. \"The 179th General. That's on the north side in a place called Clitchy.\"\n\n\"Stinks, I guess.\"\n\n\"Oh no.\" Marsala's eyebrows climbed. \"I saw it. I ran down there when we was in Normandy. It ain't a sow pen like the 1209th, I tell you that much. And then you get a pass, you go to Pig Alley\u2014and don't try to crap me any more you would go to this Loo museyum.\"\n\nThe party of flight nurse, co-, and full pilot had passed them, and sure enough, skirted the Liberator for the rusty cargo plane behind it. Reinhart felt imminent-departure gas in his stomach.\n\n\"Well, this is it, buddy. I'll write you a letter, tell you how it goes. You'll get home yourself any day now, you got more than enough points.\" He shook his hand.\n\nMarsala diffidently picked his nose. \"I never answer.\"\n\n\"Why not? You going to hold a grudge?\"\n\n\"Whaaat grudge, you rummy?\" He punched Reinhart's hand aside. \"Give the Princess a smooch for me. ... Now I guess with all your twat here you forgot her: you know, that married chicken with a husband in the paratroops.\"\n\nOh by God, Dianne Cooley. He owed her a letter for three months. And her husband Ernie, in the 82nd Airborne, the bright shoulder patch of which he saw, across the field, on the narrow shoulder of Trooper. It was an off chance.\n\n\"To tell you the truth,\" he said. \"I'm not convinced that I ought to leave. I like the Army, as I always told you, and I like Berlin, but it seems to be a good time to get out of both. But I'll have to play it straight in Paris. I don't want a Section Eight discharge. That might affect my career.\"\n\nMarsala shivered in his overcoat. \"It's gonna be a cold winter here for Jesus sake. A week yet to Halloween and it's already like a witch's tit. They're cutting down trees in the Tier Garden. No coal. ... Career? I got your career.\" He squeezed himself in the crotch. \"You're gonna be a hood, that's what.\"\n\n\"A psychiatrist. How about that? Except for a couple of people, including you, everybody I see is sick, boy, and bad.\"\n\n\"Especially you,\" Marsala complained. \"I take back what I said about you fakin'. I knew old Millet couldn't be fooled.\"\n\nReinhart shook the buddy's hand again and saw the black eyes swim. \"So long, Jimmy, you were the best of them all. Have fun with Trudchen.\"\n\nHolding his back stiff, he rejoined the group of patients. Time, where did old Time go, what were its mysteries? Not the narrow time towards which some weeks ago he was disordered, but that great gray fog behind us and before us, into which our lovers and friends vanish, events pass, and which claims even our old selves as we stand here in the limited clearing, nude in our newest one. Having learned from the Italians that crying is no reflection on a fellow's manliness, Reinhart dropped a tear or two for the summer of 1945, already gone; the war, long gone; the Army, soon to go; his twenty-first year, going drop by drop; and inventoried in water the dear people known and lost in this adventure, Schild, Lori, Bach, even including Veronica, whom he now believed he really did love but even so intended to remain adamant towards, and that was the sadness of it.\n\nBy the time he rejoined Trooper his face had dried. He anyway reached for his handkerchief. A tractor was towing the cargo crate to a clear vista on the landing strip.\n\n\"Yep, that's it,\" said Trooper. \"Like I said, the old C-47. I'm gonna faint.\"\n\n\"Like hell you are,\" Reinhart muttered. \"Wait a minute, anyway, I'm looking for something.\" No handkerchief in his pocket. He opened his duffle bag. On top lay a little Red Cross sack of dirty socks and pinned to it was a note which he could, and did, read without undoing.\n\n> Kiddy\u2014thanks for not making a scene about leaving. You have always been decent about a person's feelings. I will always think of you close to my heart but I can't get in touch with you anymore like this or any other way, _because_ \u2014well, I never did tell you the name of my real boy friend and I better not now\u2014ha! what I called him in front of you was s.o.b.\u2014nasty to laugh tho, because I do love him very much and now we are back together. He has to get a divorce from his wife but is not a Roman Catholic so its O.K. I have sinned but true love conquers all. We plan a double wedding with Ann Lightner & Lt. Pound who is in the same fix as X. Don't know where we'll live\u2014all around, I expect, since X is Regular Army. Oops, maybe I told you too much. Anyway, I send you all the love I can without being disloyal to my Husband To Be. Your intimate friend,\n> \n> VERY\n\nHe got a handkerchief and blew his nose just as Owens called the roll again and, conveniently, just at his own name, and the sergeant took it as answer. They filed towards the open doors in the plane's belly. Trooper didn't collapse, because Reinhart threatened to forsake him in Paris if he did.\n\nReinhart was last in line. He took a final noseful of Berlin air, which was cold and fresh and yet carried a faint dust of ruin. German rubble-workers around the administration building conversed in their native argot, and by some acoustical principle he could hear them.\n\n_\"Kommste imma erst so sp\u00e4t nach Hause?\"_\n\n_\"Nee, nur wochentags. Der Sonntag jeh\u00f6rt meiner Familie_ \u2014 _da schlafe ick'n janzen Tag.\"_\n\nHe did not understand a word. From the air the city would look like the crater-pocked, man-void moon. Finally one foot, and then the other, stepped from Brandenburg sand-plain to echoing metal floorboard.\n\nThe flight nurse, who wore a long green coverall, took the roster from departing, sycophantic Owens and began her own count. This time Reinhart watched for Trooper's response. It came on \"Poteet, Hastings F., Jr.,\" a name Reinhart had heard as many times as the roll was called and never connected with his patient for the simple reason that Trooper did not answer properly but rather raised one finger and coughed.\n\nReinhart shouted \"ho\" at his own name, which came right after, and asked Trooper: \"Did you know a guy in the 82nd named Ernie Cooley?\"\n\nAnd Hastings F. Poteet said instantly, with no sense whatsoever of the coincidence: \"Oh you know him, too. They'll never get Cooley.\"\n\n\"I'll be damned. You really know him, Ernie Cooley, from Norwood, Ohio? I used to go out with his wife, if it's the same one.\" He expatiated on the theme of one small world.\n\nWhich made no impression on Trooper, whose delusion was that while the world is infinite, all things are simultaneous. He waited with his polite, beagle eyes until he had his chance to say that Cooley had deserted in Normandy in June, 1944, almost as soon as the chutes hit the ground in their first jump of the war, and that, again, they would never get him\u2014because if they did it was curtains.\n\n\"Why?\"\n\n\"Desertion in the face of the enemy. They shoot you in the heart for that\u2014and for other things too,\" he added darkly.\n\nThe T\/5, who sat on Reinhart's left and had been listening, struck his curious brows into their business: \"That's almost as bad as what sometimes happens in the hospital: desertion in the face of an enema. When they catch you for that, you get shot in the ass.\"\n\nReinhart thought it very funny\u2014he was near hysteria, anyway, at leaving Berlin to rejoin the earth-people; the doors were still open, the engine quiet, the pilot outside on the ground, lazily joking with a mechanic; he could still burst away and regain the great, ruined, dear city\u2014but a single slight smile and the T\/5 would own him for the rest of the flight.\n\nHe looked about for another victim on which to stick this adhesive fellow. Against the other wall, on the line of metal seats which paralleled his own, sat eight or nine types; on his side, eight or so more. In addition to Trooper and himself there were five other psychos, all quiet cases, whom he knew only by sight; one obvious traveler from the skin ward\u2014a sergeant of limited dimensions, whose acned cheeks were relief maps of Berlin; beyond himself, nobody from the staff of the 1209th.\n\nThe pilot climbed in and sauntered forward. Ground crew without, and nurse inside, sealed the doors, and probability surrendered to necessity. His chance was forever gone. Only Trooper's whine saved Reinhart from claustrophobic frenzy.\n\n\"We won't need chutes, old buddy,\" he told him with a pat on the shoulder patch. \"These machines never fail.\" He looked across to Sergeant Acne for confirmation and saw, in spite of the eruptions, the crewcut showing at one side of a cocked overseas cap, the OD overcoat\u2014he saw\u2014well, he saw, but sick in the gut from his hallucination he begged forgiveness of Jehovah Millet and would have given blood sacrifices to have Him there to say he did not see\u2014Schatzi. \"Do they, Sarge?\" he nevertheless asked.\n\nSarge silently turned his head towards the pilot's cabin. Poor chap, if he wasn't Schatzi\u2014in his profile, corrupted by the malady, there was little likeness\u2014he was to be pitied, for a hideous boil lived in the very orifice of his left ear. He had not heard.\n\nBut why should he be Schatzi? How could he be? From the second button of his coat hung the medical tag with which they each had been labeled, like laundry sacks, at the hospital. Then there were dogtags, medical records, shipping orders, and duplicate copies of the roster for everybody from Eisenhower down. And what of the ludicrous, revealing accent? Of course, some GIs were refugees, and many native Americans went through the Army with never a public word but \"sir.\"\n\n\"Y'all want some chewin' gum?\" The nurse stood before them, offering Juicy Fruit. \"Y'ears won' have diffi-culty with th'air preshah, you chew gum.\" Tall, serpentine, rather slack-titted in the coverall, wearing tawny hair a bit long for a servicewoman, she handed a slice to each\u2014her fingers touched Reinhart's and did they not linger?\u2014and turned to the other row.\n\nSarge accepted his piece, unwrapped it with enormous care, folded the paper and placed it in his breast pocket!, put the gum in his mouth, chewed\u2014and the largest boil beneath his left eye loosened and fell to the floor, where it stuck like the actor's putty it was.\n\nNow was Reinhart astonished at himself: despite this proof he could not believe sergeant and Schatzi were synonymous. In Berlin he had learned to doubt all appearances, which must also include a false one: that is, its falsity might consist in its being real. The world was strange\u2014and interesting.\n\nAnd difficult. For of course he recognized Schatzi and his problem was what to do about it, which he would rather avoid. Crucial times were not at an end with the simple killing of a Monster, the dying of a Schild, with an unrequited proposal, or with leave-taking of lovers and friends; nor even with personal _non compos mentis._\n\nBut the gods, to whom he was dear, no matter how far they had permitted him to wander alone, finally furnished aid. Apollo resolved himself into a sunbeam, came down through the livid overcast and penetrated the Plexiglas window, striking the T\/5 in the medulla oblongata, inspiring him to jar Reinhart with his elbow and add: \"That's what the sentries say in the hospital: 'Halt. Who goes there, friend or enema?' \"\n\n\"What did we do to deserve you!\" Reinhart cried in burlesque despair. \"Talk to Trooper. I see a guy I know.\" He rose and crossed the cabin.\n\nThe seat at Sarge's left had been used briefly by the nurse to sort her gear; now it was empty. Sarge turned the other way when Reinhart took it. Seen at six inches, the make-up was an outrageously poor job, the acne an obvious work of mucilage, eyebrow pencil, and lipstick (Trudchen's 'raddest of the rad'). Whom could it have taken in for a moment? Answer: Every typical person, who would no sooner see the disability than avert his eyes, so as not to embarrass the sufferer; so as for health's sake to suppress an interest in the corrupt; so as\u2014but Reinhart, enough! The typical person simply would not imagine such a fake and therefore would not see one.\n\nUnder the cover of the other passengers' conversation, which was amplified in the metal tube, he asked into the sergeant's pseudo-foul ear: \"What did you hope to gain?\"\n\nSchatzi faced front, seemingly watched the T\/5 across the aisle, and answered, quietly venomous: \"I vill get to America and you vill not try to stop me.\"\n\nReinhart checked: the nurse had gone into the cargo compartment in the rear; Trooper, the T\/5, and a redheaded fellow were pooling complaints about the Army.\n\n\"You are mad,\" he whispered, \"hopelessly, utterly mad, and I pity you.\"\n\nSchatzi choked on his gum, which he had been chewing all wrong anyway\u2014too consciously, like all Europeans, as if it were candy rather than a substitute for twitching\u2014choked and responded in desolation and fear: \"Let me alone or you'll be sorry.\"\n\nReinhart covertly withdrew a roll of Occupation marks from his pants pocket\u2014they had been too many for the wallet\u2014and without a glance at the denominations pulled off and retained two, and placed the rest under Schatzi's tight arm.\n\n\"I promised I would get your money from Schild. There it is.\"\n\nSchatzi was truly overcome; among the patches of false acne grew areas of real emotion's rash, mottled, hot. He grappled with his American uniform, then with himself. He wiped his chin and drew away a palm of smeared cosmetic. His eyes sprinkled. Yet he managed to stay inconspicuous. They still had no one's notice.\n\n\"I do not understand your tricks,\" he whisperingly wailed. \"Are you the new agent? But being an American still comes first\u2014I cast myself upon your merciness. Oh God do not give me to Chepurnik. You cannot know what they are like, they are not people as we are. They are objects without blood. See what happens to Schild. With this I had nothing to do, believe me.\" But towards the end he had forgotten and raised his voice. The T\/5 heard and in a mock soprano began to sing \"They Wouldn't Believe Me.\" Schatzi turned on him the old death-ray eyes and he shriveled in midnote.\n\n\"I don't care about your squalid black-market deals,\" said Reinhart.\n\nInstantly Schatzi dried and hardened. \"Oh yes, your lovely friend Schild, for whom you would, and did, kill. You saw none of his profits, _ja_? He used you as a sexual rubber.\" At last he gave him the whole hideous face. But it was more ludicrous than repulsive. He stank of Juicy Fruit. \"Black market! Black market was my trade. This swine Schild sold his country. This fine land America that we poor victims of to-tah-li-tahrianism would die for, he died to betray. With good fortune I happen to learn of these facts in the course of my business. I report them to the Ami FBI, who are ready to seize him just when comes this well-known fight.\"\n\nCalmly, Reinhart enjoyed the lies, a souvenir of Europe. They would be all too rare in America. But he must get to work before the engine started, the propellers revolved, and his initiative was gone. If he knew the pedantic ways of people who do such things as fly planes, the C-47 would not kill its motor, once started, for the end of the world. And just this time he did not want Schatzi to succeed in an imposture. Those of the past he forgave him\u2014yes, truly forgave, not like a god but like a man; he expected no reward\u2014but this one was too vulgar.\n\n\"What shall we do about you?\" he asked, preparing to rise.\n\n\"You harm me at your own cost!\"\n\n\"My dear fellow,\" said Reinhart. \"With all good will, I cannot understand you.\"\n\nSchatzi began a sneer of victory\u2014or, at any rate, what _he_ thought was one\u2014but the Juicy Fruit clogged in his teeth. Humiliated, he plucked it out and held it in his right hand. Obviously it felt nasty there, and no better in the left. He brought the paper wrapper from his breast pocket and was on the point of rolling the little gum ball therein, when the nurse came out of the cargo chamber and, undulating bow-wards, saw his heresy and warned: \"You don' chew, you gon' be dog-sick.\" He guiltily returned it to his mouth, where, according to his expression, it grew to baseball size.\n\n\"Why you grinnin'?\" she pseudo-sternly asked Reinhart. She bent and read his tag. \"What's this, an Eyetalian name? Carlo. Kind of cute, though. You a psycho? Well then what do the normal ones look like?\"\n\nWhen she left Schatzi threw in the towel. He gagged on the gum, finally swallowed it, and again begged for mercy in the name of the United States of America: \"You people believe a man is what he will become rather than what he has been, _ja_? I tell you I have reformed. Just this minute, sitting here amidst your fine comrades who love one another. I do not ever belong to anysing. Loneliness! Lack of love! These can make a man to a criminal. Have I been a rascal?\u2014no. Yet had impulses come to me which have been dangerously near. After I arrange with great difficulty and money to be included in this shipping-to-Paris I discover your name on the list thereof. Wal, I thought, this Reinhart causes trouble and I strike back. His German relatives! Yes, I have found them, Heinz Tischmacher, son of his grandfather's sister and second cousin to him. Tischmacher, Heinz: office worker, member of the Nazi Party. Tischmacher, Frau Emmi: likewise. Tischmacher, Reinhold: twenty-one years of age, graduate of Hitler Youth to the Waffen SS, killed on the Eastern Front in 1944. Tischmacher, Gertrud, Trudl, Trudchen: sixteen, member of the Jungm\u00e4del, girls' branch of Hitler Jugend.\n\n\"On the other side of his descent Tischmacher has a distant relation to this monstrosity Bach, whom he takes money from, for four years, not to reveal to his Nazi comrades that Bach, Lenore, _Mischling_ Jew, has not gone to Switzerland so much as does she hide in a closet of her man's flat so as to avoid the Gestapo and subsequent killing.\"\n\n\"These then are my people,\" said Reinhart. But he worried only over whether he had committed incest with Trudchen. \"You have done a good job. I'm afraid this is all I have left to pay you.\" He brought forth his last two notes.\n\nChuckling madly, Schatzi refused them. \"No, these are not your kinsfolk, dear boy! Is not this evidence of my reform? This is my untruth with which I prepared to threaten you. Which now I reveal and confess. This evil impulse to destroy you which I have conquered. So Christ said, _'Die Wahrheit wird Euch frei machen.' \"_\n\n\"Destroy _me_?\" asked Reinhart. He banged his head back against the fuselage, denting it (the fuselage), and guffawed.\n\nSchatzi smiled, frightened to death but also hopeful. \"Ah then,\" he whispered, \"mirth and good feeling. You will not expose me, _ja_? In the States we must make a partnership: you belong and have the handsomeness and the muscles\u2014however did you break that great swine's back?\u2014I provide the mental.\"\n\nThe nurse appeared at the door of the pilot's cabin, her hip reared to catch her sexy, sinous wrist. She said: \"Y'all settle down and connect your seat belts. We go in two seconds. ... Ah got my eye on you, laughin' Carlo!\" She would be a different kind of piece.\n\nReinhart shook Schatzi's hand and winked elaborately. He whispered: \"My friend, you have my word on it.\" Then he went to the nurse, and for another reason feeling her supple arm, betrayed him.\n\n## AUTHOR'S NOTE\n\nAs many readers will have recognized, I am indebted to Konrad Heiden's classic work _Der Fuehrer_ (tr. by Ralph Manheim, New York, 1944) for some of the events in the career of one of my imaginary people.\n\n# A Biography of Thomas Berger\n\nThomas Louis Berger (1924\u20132014) was an American novelist best known for his picaresque classic, _Little Big Man_ (1964). His other works include _Arthur Rex_ (1978), _Neighbors_ (1980), and _The Feud_ (1983), which was nominated for a Pulitzer Prize.\n\nBerger was born in Cincinnati, Ohio, the son of Thomas Charles, a public school business manager, and Mildred (n\u00e9e Bubbe) Berger. Berger grew up in the town of Lockland, Ohio, and one of his first jobs was working at a branch of the public library while in high school. After a brief period in college, Berger enlisted in the army in 1943 and served in Europe during World War II. His experiences with a medical unit in the American occupation zone of postwar Berlin inspired his first novel, _Crazy in Berlin_ (1958). This novel introduced protagonist Carlo Reinhart, who would appear in several more novels.\n\nIn 1946, Berger reentered college at the University of Cincinnati, earning a bachelor's degree two years later. In 1948, he moved to New York City and was hired as librarian of the Rand School of Social Science. While enrolled in a writer's workshop at the nearby New School for Social Research, Berger met artist Jeanne Redpath; they married in 1950. He subsequently entered Columbia University as a graduate student in English literature, but left the program after a year and a half without taking a degree. He next worked at the _New York Times Index_ ; at _Popular Science Monthly_ as an associate editor; and, for a decade, as a freelance copy editor for book publishers.\n\nFollowing the success of Rinehart in Love (1962), Berger was named a Dial Fellow. In 1965, he received the Western Heritage Award and the Richard and Hinda Rosenthal Award of the National Institute of Arts and Letters for _Little Big Man_ (1964), the success of which allowed him to write full time. In 1970, _Little Big Man_ was made into an acclaimed film, directed by Arthur Penn and starring Dustin Hoffman and Faye Dunaway.\n\nFollowing his job as _Esquire_ 's film critic from 1972 to 1973, Berger became a writer in residence at the University of Kansas in 1974. One year later, he became a Distinguished Visiting Professor at Southampton College, and went on to lecture at Yale University and the University of California, Davis.\n\nBerger's work continued to appear on the big screen. His novel _Neighbors_ (1980) was adapted for a 1981 film starring John Belushi and Dan Aykroyd. In 1984, his novel _The Feud_ (1983) was nominated for a Pulitzer Prize; in 1988, it too was made into a movie. His thriller _Meeting Evil_ (1992) was adapted as a 2012 film starring Samuel L. Jackson and Luke Wilson.\n\nIn 1999, Berger published _The Return of Little Big Man_ , a sequel to his literary classic. His most recent novel, _Adventures of the Artificial Woman_ , was published in 2004.\n\nBerger lived in New York's Hudson Valley.\n\nIn 1966, two years after he wrote _Little Big Man_ , Berger stands at Little Bighorn Battlefield National Monument, the site of Custer's last stand in 1876. This was Berger's first visit to the famous battlefield.\n\nThis black-and-white image became the readers' vision of Berger: dark and esoteric. (Photo courtesy of Gerry Bauer.)\n\nA snapshot of Berger with his friend Zulkifar Ghose, taken in midtown Manhattan in the summer of 1974. (Photo courtesy of Betty Sue Flowers.)\n\nThis marked-up manuscript page comes from a story called \"Gibberish,\" from Berger's original short story collection _Abnormal Occurrences._\n\nIn this 1984 letter to his agent, Don Congdon, Berger tells Congdon that he was mentioned on _The David Susskind Show_ , a television talk show.\n\nIn this 1997 letter, Berger writes to Roger Donald, his editor at Little, Brown, about characters, props, and plot points in _The Return of Little Big Man._\n\nIn 1997, Berger wrote to Congdon about communications from Michael Korda, editor in chief of the publisher Simon & Schuster, and Donald.\nAll rights reserved under International and Pan-American Copyright Conventions. By payment of the required fees, you have been granted the non-exclusive, non-transferable right to access and read the text of this ebook onscreen. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the express written permission of the publisher.\n\nThis is a work of fiction. Names, characters, places, and incidents either are the product of the author's imagination or are used fictitiously. Any resemblance to actual persons, living or dead, businesses, companies, events, or locales is entirely coincidental.\n\nAn earlier version of Chapter Ten appeared in New World Writing Number 8 under the title \"Confession of a Giant.\" Copyright \u00a9 1955 Thomas Berger.\n\ncopyright \u00a9 1958 by Thomas Berger\n\ncover design by Michael Vrana\n\n978-1-4804-0090-0\n\nThis edition published in 2013 by Open Road Integrated Media\n\n345 Hudson Street\n\nNew York, NY 10014\n\nwww.openroadmedia.com\n\n**THOMAS BERGER**\n\nFROM OPEN ROAD MEDIA\n\nFind a full list of our authors and\n\ntitles at www.openroadmedia.com\n\nFOLLOW US\n\n@OpenRoadMedia\n\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":"\n\nPatricia Cleveland-Peck\n\nIllustrated by David Tazzyman\n\nYou\n\ncan\n\n'\n\nt\n\ntake an elephant on the bus . . .\n\nIt would simply cause a terrible fuss!\n\nElephants\n\n'\n\nbottoms are heavy and fat,\n\nand would certainly squash the seats quite flat.\n\nAnd\n\ndon\n\n'\n\nt\n\nsit a monkey in a\n\nshopping trolley . . .\n\nFor monkeys are naughty and find it jolly\n\nto snatch your shopping and chuck it about.\n\nNo, leave monkey at home when you go out.\n\nNor should a tiger travel by train . . .\n\nThink of the panic. Think of the pain.\n\nTigers are built to spring and to leap.\n\nThink of the passengers half-asleep.\n\nAnd\n\ndon\n\n'\n\nt\n\nhail a taxi if the\n\ndriver\n\n'\n\ns\n\na seal . . .\n\nWith such slippery flippers, he\n\ncan\n\n'\n\nt\n\ngrasp the wheel.\n\nThe taxi will slither and probably swerve,\n\nthen throw everyone out at the very next curve.\n\nA centipede on roller skates is rather bizarre . . .\n\nWith one hundred feet,\n\nhe\n\n'\n\nd\n\ngo fast and go far.\n\nBut to put on his boots would take him an\n\nage\n\n\u2013\n\nhe\n\n'\n\nd\n\nget in a temper,\n\nhe\n\n'\n\nd\n\nget in a rage.\n\nAnd don't put a camel in a sailing boat . . .\n\nIt\n\n'\n\ns\n\nfar too tricky to keep afloat.\n\nHis hump and his feet would, I think,\n\ncapsize the vessel\n\nand\n\nmake it\n\nsink.\n\nA giraffe in an aeroplane\n\nwouldn\n\n'\n\nt\n\nbe right . . .\n\nThe roof of a plane just\n\nhasn\n\n'\n\nt\n\nthe height.\n\nWith legs and a neck so bony and long,\n\na giraffe on a plane would simply be wrong.\n\nAnd\n\ndon\n\n'\n\nt\n\nask a whale to ride a bike . . .\n\nJust imagine what it would be like -\n\nwithout a bottom to sit on the seat.\n\nAnd how would he pedal without any feet?\n\nA\n\npig\n\non a skateboard?\n\nAnother mistake . . .\n\nAnd I\n\nwouldn\n\n'\n\nt\n\nput a hippo in a hot air balloon . . .\n\nThe\n\nbasket\n\n'\n\ns\n\ntoo small, there\n\nwouldn\n\n'\n\nt\n\nbe room.\n\nAnd if it did fly, with\n\nhippo\n\n'\n\ns\n\ngreat weight,\n\nit would come crashing down in a terrible state.\n\nAnd never let a bear near an ice cream van . . .\n\nBears gobble up ice cream as fast as they can.\n\nAnd if\n\nthey\n\n'\n\nre\n\nstopped they get annoyed,\n\nand an angry bear is one best to avoid.\n\n\" Then how can we\n\ntravel?\"\n\nthe animals shout.\n\n\"How can we animals get carried about?\"\n\n\"What\n\n'\n\ns\n\nthe best vehicle?\n\nWe\n\nhaven\n\n'\n\nt\n\na\n\nclue.\n\n\"\n\nWell,\n\nI\n\n'\n\nve\n\ngot an idea . . .\n\nHow about you?\n\nYes, animals on rollercoasters are good for a laugh . . .\n\nThere\n\n'\n\ns\n\nroom here for EVERYONE \u2013 even giraffe!\n\nSo\n\nit\n\n'\n\ns\n\ngoodbye to skateboards, balloons and THAT bus,\n\nfor we now have a conveyance that suits ALL OF US!\n\nwhee\n\nTo Isabel, with love ~ PC-P\n\nFor Mum and Dad x ~ DT\n\nBloomsbury Publishing, London, New Delhi, New York and Sydney\n\nFirst published in Great Britain in 2015 by Bloomsbury Publishing Plc\n\n50 Bedford Square, London, WC1B 3DP\n\nThis eBook edition first published in Great Britain in 2015\n\nText copyright \u00a9 Patricia Cleveland-Peck 2015\n\nText copyright \u00a9 David Tazzyman 2015\n\nThe moral rights of the author and illustrator have been asserted\n\nAll rights reserved\n\nNo part of this publication may be reproduced or transmitted by any means,\n\nelectronic, mechanical, photocopying or otherwise, without the prior permission of\n\nthe publisher\n\nA CIP catalogue record for this book is available from the British Library\n\nISBN 978 1 4088 4980 4 (HB)\n\nISBN 978 1 4088 4982 8 (PB)\n\nISBN 978 1 4088 4981 1 (eBook)\n\nVisit www.bloomsbury.com to find out more about our authors and their books\n\nYou will find extracts, author interviews, author events and you can sign up for\n\nnewsletters to be the first to hear about our latest releases and special offers\n\nwww.bloomsbury.com\n\nBLOOMSBURY is a registered trademark of Bloomsbury Publishing Plc\n\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":" \nGerbail T. Krishnamurthy and Shakuntala KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7(C) Springer-Verlag Berlin Heidelberg 2009\n\nGerbail T. Krishnamurthy and Shakuntala Krishnamurthy\n\nNuclear HepatologyA Textbook of Hepatobiliary Diseases\n\nGerbail T. Krishnamurthy\n\nTuality Community Hospital, Hillsboro, 97123, OR, USA\n\nShakuntala Krishnamurthy\n\nTuality Community Hospital, Hillsboro, 97123, OR, USA\n\nISBN 978-3-642-00647-0e-ISBN 978-3-642-00648-7\n\nSpringer Dordrecht Heidelberg London New York\n\nLibrary of Congress Control Number: 2009926189\n\n(C) Springer-Verlag Berlin Heidelberg 2009\n\nThis work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law.\n\nThe use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.\n\nProduct liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature.\n\nCover design: eStudioCalamar, Figueres Berlin\n\nPrinted on acid-free paper\n\nSpringer is part of Springer Science+Business Media (www.springer.com)\n\nDedicated with love and affection to our grandson Sachin Thomas Wheatley\n\nPreface to the Second Edition\n\nSince the publication of the first edition of Nuclear Hepatology almost 10 years ago, new advances have taken place, both in our understanding of liver pathophysiology and various imaging modalities. A unique feature of imaging of physiology is that it enables quantification. Since liver physiology is complex, quantification has been a challenge. Many publications in the past have often included quantification based on home-made software not available for others. Thus, the comparison of results from one center to another becomes difficult, if not impossible. The second edition of Nuclear Hepatology addresses these issues. Sophisticated software for liver and gallbladder function has been tested and validated through many of our previous publications. Now that software is FDA approved and available for others through a commercial company, it is hoped that future publications of imaging of liver and gallbladder physiology would routinely include quantification.\n\nAlthough the function of the hepatocyte is complex, it can be broadly divided into two main categories, substrate uptake at the basolateral border and intracellular transit prior to excretion into the canaliculi. The earliest manifestation of hepatocellular injury occurs in the form of prolongation of the intracellular transit time, which occurs long before the disruption of the basolateral border with subsequent rupture and death. The liver enzymes are released into circulation after the death of the hepatocyte. Hepatocyte function can be restored completely by treating the patient as soon as the intracellular transit is altered, but not after the rupture of the basolateral border (cell death). Measurement of intracellular transit time from a Tc-99m HIDA study enables early detection of the hepatocyte injury and early therapeutic intervention.\n\nMost of the chapters include updated information. The second chapter describes the latest information related to liver physiology and Chap. 5 provides sophisticated software quantification of pathophysiology. Cholescintigraphic images are correlated with morphologic images obtained with ultrasound, CT or MRI. Since PET\/CT imaging has currently become a standard in the care of the cancer patient, a detailed description is provided in Chap. 12. Latest information on biliary dyskinesia in adults and neonatal hepatitis in infants is updated. It is our firm belief that physicians, surgeons, and pediatricians caring for patients with liver and gallbladder disease would become more familiar with the latest advances in imaging technology and provide the best care for their patients, based on evidence from objective parameters.\n\nContents\n\n1 Morphology and Microstructure of the Hepatobiliary System1\n\n1.1 Morphology1\n\nReferences17\n\n1.2 Microstructure19\n\nReferences25\n\n2 Liver and Spleen Function27\n\n2.1 Liver Function27\n\nReferences44\n\n2.2 Spleen Function45\n\nReferences47\n\n3 Imaging Agents49\n\n3.1 Morphology and Physiology Imaging Agents49\n\nReferences67\n\n3.2 Radiolabeling of Red Blood Cells and Leucocytes70\n\nReferences73\n\n3.3 Gallium-67 Citrate73\n\nReferences74\n\n3.4 Somatostatin Receptor Imaging Agent75\n\nReferences76\n\n3.5 Fluorine18, 2-Flouro-2-deoxy-D-glucose (18F-FDG)77\n\nReferences82\n\n4 Imaging of Liver and Spleen Morphology85\n\n4.1 Imaging with Radiocolloid85\n\nReferences98\n\n4.2 Adenoma and Focal Nodular Hyperplasia99\n\nReferences105\n\n4.3 Hemangioma106\n\nReferences113\n\n4.4 Somatostatin Receptor Scintigraphy114\n\nReferences122\n\n5 Imaging and Quantification of Hepatobiliary Function125\n\n5.1 Hepatobiliary Imaging125\n\nReferences152\n\n5.2 Measurement of Hepatic Arterial vs. Portal Venous Blood Flow153\n\nReferences160\n\n5.3 Hepatopulmonary Syndrome160\n\nReferences165\n\n5.4 Duodenogastric Bile Reflux166\n\nReferences170\n\n5.5 Imaging and Quantification of Hepatocyte Asialoglycoprotein Receptors with Tc-99m Galactosyl Human Serum Albumin171\n\nReferences172\n\n6 Gallbladder, Sphincter of Oddi, Cholecystokinin, and Opioid Relation175\n\n6.1 Effect of Cholecystokinin on the Gallbladder and Sphincter of Oddi175\n\nReferences187\n\n6.2 Opioids190\n\nReferences194\n\n7 Intrahepatic Cholestasis197\n\n7.1 Imaging with Tc-99m HIDA197\n\nReferences205\n\n7.2 Imaging with Tc-99m Galactosyl Human Serum Albumin207\n\nReferences209\n\n8 Extrahepatic Cholestasis211\n\n8.1 Intraluminal Causes211\n\nReferences223\n\n8.2 Wall Thickening224\n\nReferences233\n\n8.3 Combined Intrahepatic and Extrahepatic Cholestasis (Sclerosing Cholangitis)235\n\nReferences239\n\n8.4 Extrinsic Compression239\n\nReferences241\n\n9 Diseases of the Gallbladder243\n\n9.1 Chronic Calculous Cholecystitis246\n\nReferences254\n\n9.2 Chronic Acalculous Cholecystitis257\n\nReferences270\n\n9.3 Acute Cholecystitis272\n\nReferences287\n\n9.4 Management of Gallbladder Disease290\n\nReferences296\n\n10 Biliary Dyskinesia299\n\nReferences315\n\n11 Pediatric Nuclear Hepatology319\n\n11.1 Congenital Biliary Atresia vs. Neonatal Hepatitis319\n\nReferences331\n\n11.2 Cystic Diseases of the Hepatobiliary System332\n\nReferences339\n\n12 Malignant Liver Lesions341\n\n12.1 Management346\n\nReferences346\n\n13 Liver Transplantation347\n\n13.1 Types of Liver Transplantation347\n\n13.2 Normal Functioning Liver Transplant351\n\nReferences360\n\nIndex363\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_1(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 1. Morphology and Microstructure of the Hepatobiliary System\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nLiver and gallbladder disease is a common entity around the world and according to the World Health Organization estimation accounts for 46.1% of global disease [1]. Liver transplantation for end-stage liver disease, segmental resection for tumor, and therapeutic interventional maneuvers has made it necessary to have thorough knowledge of the morphology of the liver and biliary system in much greater detail than ever before [2]. With the widespread application of segmental liver resection for living donor liver transplantation or radioablation of liver tumors, thorough knowledge of internal structures is critical for radiologists, nuclear medicine physicians, and surgeons. Since the publication of the first edition of our book in 2000, many advances in liver disease therapy have taken place, making it necessary to provide more detailed anatomic and histopathological information. Anatomical details of the vascular and ductal structures are well depicted on a multi-detector computer tomography (MDCT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), enabling identification of the third or fourth order branches on the images. Such detailed structural information is necessary for surgeons for segmental resection of the liver.\n\n## 1.1 Morphology\n\nLiver and gallbladder disease is a common entity around the world and according to the World Health Organization estimation accounts for 46.1% of global disease [1]. Liver transplantation for end-stage liver disease, segmental resection for tumor, and therapeutic interventional maneuvers has made it necessary to have thorough knowledge of the morphology of the liver and biliary system in much greater detail than ever before [2]. With the widespread application of segmental liver resection for living donor liver transplantation or radioablation of liver tumors, thorough knowledge of internal structures is critical for radiologists, nuclear medicine physicians, and surgeons. Since the publication of the first edition of our book in 2000, many advances in liver disease therapy have taken place, making it necessary to provide more detailed anatomic and histopathological information. Anatomical details of the vascular and ductal structures are well depicted on a multi-detector computer tomography (MDCT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), enabling identification of the third or fourth order branches on the images. Such detailed structural information is necessary for surgeons for segmental resection of the liver.\n\n### 1.1.1 Embryology\n\nThe liver and biliary systems develop from an endodermal bud that arises during the 5th week of intrauterine life when the embryo is about 3 mm in length [3]. The bud originates from the ventral surface at the junction of the foregut with the midgut, and soon divides into cranial (pars hepatica) and caudal (pars cystica) branches. The ventral pancreas sprouts near the caudal bud, and the dorsal pancreas arises on the opposite side at the foregut-midgut junction (Fig. 1.1.1). When the embryo is about 5 mm in length, the cranial and caudal branches become further connected by a common stalk, which later becomes the common bile duct. By the time the embryo is about 7 mm in length, the cranial branch (pars hepatica) divides into two cellular columns, which later become the physiologic right and left hepatic lobes [4]. The gallbladder develops from the caudal branch (pars cystica) and continues its connection with the common stalk through a channel, which later becomes the cystic duct. Canalization takes place to form a patent biliary tree (gallbladder, cystic duct, right and left hepatic duct, common hepatic duct, and the common bile duct). When the embryo is about 10 mm in length, the gut begins to make a 90\u00b0 clockwise rotation and completes it by the time it is 12 mm in length, which brings the ventral pancreas in close contact with the dorsal pancreas, facilitating their fusion into a single pancreas before birth [5]. This rotation brings the common bile duct posterior to the duodenum. Many congenital abnormalities around this region are secondary to mal-rotation at this junction. The caudate lobe arises separately close to the inferior vena cava, independent of the right and left hepatic lobes. The liver begins bile secretion by the 12th intrauterine week, thus completing the formation of the hepatobiliary system, the most complex metabolic factory in the human body. In adults, the liver weighs about 1,500-1,800 g and forms about 1\/50 of the body weight. In children, however, it forms a relatively much larger fraction (1\/20) of the total body weight.\n\nFig. 1.1.1\n\nEmbryology of the hepatobiliary system. The hepatic bud arises from the endoderm of the primitive foregut at its junction with the midgut when the embryo is about 3 mm in length. The hepatic bud divides into cranial (pars hepatica) and caudal (pars cystica) branches when the embryo reaches 5 mm size. The ventral pancreas arises from the pars cystica, which later gives rise to the biliary system. After a 90\u00b0 clockwise rotation (10 mm embryo), the ventral pancreas fuses with the dorsal pancreas. This rotation brings the common bile duct posterior to the duodenum (12 mm). The common bile duct opens into the duodenum at the postero-medial wall at an elevation called the papilla\n\n### 1.1.2 Liver Lobes and Surfaces\n\nMost of the liver is situated in the right upper quadrant of the abdomen underneath the right hemi-diaphragm, with the superior border situated at the level of the right fifth intercostal space. Liver consists of five surfaces: anterior, posterior, right lateral, superior, and inferior. The anterior, right lateral, and posterior surfaces are smooth, and superior and inferior surfaces are rough with grooves and fissures for entry and exit of the vascular and biliary structures (Fig. 1.1.2). The liver is divided into right and left lobes on the basis of either anatomic or physiologic markers. Anatomically, the liver is divided into right and left lobes on the basis of the line of attachment of the falciform ligament. The anatomic division serves no useful purpose in the management of liver disease and hence has been given less importance in recent years. The physiologic division, on the other hand, has gained much more popularity as it follows embryologic development and delineates functional lobes and segments, whose line of demarcation is used for liver resection during transplant or tumor surgery. The physiologic division into right and left lobes is indicated on the inferior surface by a deep fissure called the plane of Serege-Cantlie that passes from the gallbladder fossa along the inferior border to the inferior vena caval groove along the superior border [5].\n\nFig. 1.1.2\n\nSurfaces, segments, and lobes of the liver. The anatomic left lobe (divided by the falciform ligament) is much smaller than the anatomic right lobe, but the physiologic left lobe is much larger than the anatomic left lobe. The quadrate lobe, which forms a part of the anatomic right lobe, forms a part of the physiologic left lobe. Liver consists of three lobes (including the caudate lobe), four segments, and eight areas. HA hepatic artery, BD bile duct, PV portal vein, GB gallbladder\n\nThe falciform ligament, the marker of the anatomic right and left lobes, lies to the left of the deep fissure (Serege-Cantlie line) that divides the liver into physiologic right and left lobes. The caudate lobe situated posteriorly and quadrate lobe situated anteriorly form part of the anatomic right lobe, but both of these structures belong to the physiologic left lobe (Fig. 1.1.2). The anatomic right lobe is approximately six times larger (85%) than the anatomic left lobe (15%), whereas the physiologic right lobe is 70% and physiologic left lobe 30% in size. Thus, the physiologic left lobe is much larger than its anatomic counterpart. It is important, therefore, to be very specific while describing lobes of the liver, whether one is referring to the anatomic or to the physiologic division. Throughout this book, we will refer to the physiologic division unless otherwise mentioned.\n\n### 1.1.3 Segments and Areas\n\nThe liver is divided into lobes, segments, and areas. The division is made on the basis of either the vascular [6, 7] or the bile duct branches [8]. As both the vessels (hepatic artery and portal vein) and bile ducts travel together to every lobe, segment, and area of the liver, it usually makes no difference which structure is chosen as the reference point for the division. Segments are named by either numbers or given a directional nomenclature, similar to the division of the lungs into lobes and segments. Couinaud [6] and Bismuth [9] used numbers, whereas Healey and Schroy [8] preferred directional nomenclature. The imaging technology (nuclear medicine, CT, MRI, and ultrasound) and surgeons prefer to use numerical segments for the division [10-16]. Table 1.1.1 shows names and numbers adopted by different authors. Starting from the caudate lobe (I), the numbers go clockwise covering the lateral (II, III) and medial (IVA, IVB) segments of the left lobe, and inferior (V, VI) and superior (VII, VIII) half of the right lobe. The directional nomenclature used by Healey and Schroy [8] is much easier to remember, whereas the numbers require memorization. Recent authors seem to prefer the numbers proposed by Couinaud and Bismuth [6, 9, 17].\n\nTable 1.1.1\n\nNomenclature for hepatic segments and lobes as adopted by different authors\n\nLiver lobes | Hjortsjo (5) | Healey and Schroy (8) | Couinaud (6) | Bismuth (9)\n\n---|---|---|---|---\n\nCaudate lobe | Dorsal segment | Lobus caudatus | I | I\n\nLeft lobe | Dorso-lateral segment Ventro-lateral segment Central segment Dorso-ventral segment | Lateral superior area Lateral inferior area Medial superior area Medial inferior area | II III IV IV | II III IVA IVB\n\nRight lobe | Ventro-caudal segment Dorso-caudal + intermedio-caudal Dorso-cranial + intermedio-cranial Ventro-cranial | Anterior-inferior area Posterior-inferior area Posterior-superior area Anterior-superior area | V VI VII VIII | V VI VII VIII\n\nThree major hepatic veins drain the liver blood into the inferior vena cava, left hepatic vein, middle hepatic vein, and right hepatic vein. The middle hepatic vein, which follows the direction of the Serege-Cantlie plane (from the gallbladder fossa below to the inferior vena caval groove above), divides the liver into physiologic right and left lobes. The right hepatic vein divides the right lobe into anterior (V and VIII) and posterior (VI and VII) segments. The left hepatic vein divides the left lobe into medial (IVA and IVB) and lateral (II and III) segments. The right and left branches of the portal vein, hepatic artery, or common hepatic duct divide the liver segments into superior and inferior areas. The liver, therefore, consists of two large lobes, four segments, and eight areas (Fig. 1.1.3). Recent studies, however, suggest that in the case of extended liver resection for malignancy, Hjortsjo's segmental division may provide better anatomic detail than Couinaud's classification [18]. The caudate lobe (I), despite being small in size, is considered as a separate lobe mainly because of its unique embryology and vasculature [19, 20]. It lies between the hilar structures and inferior vena cava and consists of three parts: Spiegel's lobe (left), the paracaval (middle) and caudate process (right).\n\nFig. 1.1.3\n\nHepatic and portal venous system. The left hepatic vein, carrying blood from the lateral segment of the left lobe, joins the middle hepatic vein, carrying blood from the medial segment of the left lobe and anterior segment of the right lobe, to form a single venous trunk before joining the inferior vena cava. The right hepatic vein carries blood mostly from the posterior segment of the right lobe and joins the inferior vena cava separately. The portal vein is formed by the union of the superior mesenteric vein and splenic veins. It divides into right and left portal branches that travel in opposite directions and enter the parenchyma in the middle, dividing the liver into superior and inferior areas. (CBD common bile duct, IVC inferior vena cava)\n\n### 1.1.4 Hepatic Artery\n\nAfter arising from the celiac axis, the hepatic artery runs between the two layers of the hepatogastric ligament (lesser omentum) and enters the liver at the hilum. It is situated anterior to the portal vein and on the left side of the common bile duct (Fig. 1.1.3). In 90% of patients, the hepatic artery divides into right and left branches before entering the hilum of the liver. In the remaining 10%, the hepatic artery divides into three terminal branches, with the third branch entering the quadrate lobe (IV) directly. Wide variability is seen in the branching of the hepatic artery, portal vein, and bile ducts, and their clear delineation by imaging procedures (MDCT, ERCP, MRCP) is essential prior to segmental liver resection [21]. The hepatic artery supplies about 400 ml of arterial blood per minute at 100 mmHg systolic pressure and accounts for 25% of the total liver blood flow [22].\n\nThe cystic artery to the gallbladder usually arises from the right hepatic artery in the triangle of Calot, which is bordered by the inferior liver surface above, common hepatic duct to the left, and the cystic duct to the right. Often the cystic artery may arise from the main hepatic artery, left hepatic artery, or the gastroduodenal artery. Soon after its origin, the cystic artery enters the gallbladder at its neck and divides immediately into a superficial and a deep branch, both of which were first identified by Vesalius in 1564 [5]. The superficial branch supplies blood mostly to the free inferior wall covered by the peritoneum, and the deep branch supplies blood to the superior wall, which lies in direct contact with the inferior liver surface.\n\n### 1.1.5 Portal Vein\n\nThe portal vein is formed by the union of the splenic and superior mesenteric veins and measures about 5.5-8 cm in length; it enters the liver at the porta hepatis (Fig. 1.1.4). It usually divides at a 180\u00b0 angle into the right and left portal vein branches, which enter the liver parenchyma in the middle, dividing the liver into superior and inferior areas. The right portal vein gives off anterior and posterior segmental branches, and the left portal vein gives off medial and lateral segmental branches (Fig. 1.1.5). At least one branch enters each area of the liver segment. On average, three small portal vein branches (varying from one to six) enter the caudate lobe. They may arise from the left, right, or portal vein bifurcation. The portal vein supplies about 1,200 ml blood per minute to the liver (75% of the total liver blood supply) at 7-10 mmHg systolic pressure [22].\n\nFig. 1.1.4\n\nPortal vein. Coronal section CT (with contrast agent) shows the formation of the portal vein (PV) by the union of the superior mesenteric vein (SMV) with splenic veins\n\nFig. 1.1.5\n\nPortal vein branches. Coronal section CT (with contrast agent) at the porta hepatis shows the branching of the portal vein (PV) into right portal vein (RPV) and left portal vein (LPV) at almost 90 \u00b0. Middle hepatic vein (MHV) is seen entering the inferior vena cava at the superior liver margin\n\n### 1.1.6 Hepatic Veins\n\nThere are three distinctly separate hepatic veins: right, middle, and left (Fig. 1.1.6). They interdigitate and overlap with the portal venous system. The left hepatic vein has two tributaries, the medial and lateral branches. The medial branch drains blood from segments IVA and IVB, and the lateral branch drains blood from segments II and III (Fig. 1.1.6). The middle hepatic vein runs along the gallbladder fossa-inferior vena cava plane (Serege-Cantlie) and divides the liver into physiologic right (V-VIII) and left lobes (I-IV). It receives blood from the superior (IVA) and inferior (IVB) areas of the medial segment of the left lobe, and the superior (VIII) and inferior (V) areas of the anterior segment of the right lobe. The middle and left hepatic veins unite to form a single trunk before joining the inferior vena cava (Fig. 1.1.6). The right hepatic vein is the largest of the three veins and drains blood mostly from the superior and inferior areas of the posterior segment (VI and VII) of the right lobe (Fig. 1.1.7). Small tributaries are also received from the anterior segment. The right hepatic vein joins the inferior vena cava directly as a separate branch.\n\nFig. 1.1.6\n\nHepatic veins. Axial CT (with the contrast agent) at the upper part of the liver shows three hepatic veins. Left hepatic vein (LHV) has a medial (MB) and lateral (LB) branch and unites with the middle hepatic vein (MHV) before joining the inferior vena cava (IVC) as single trunk. Right hepatic vein (RHV) joins the IVC directly\n\nFig. 1.1.7\n\nRight hepatic vein. A coronal section CT with contrast agent at the middle of the right lobe shows the right hepatic vein (RHV) draining blood from the posterior (VI and VII) segment\n\nThe major portion of the venous blood from the caudate lobe drains directly into the inferior vena cava through three short veins [19, 20]. Smaller veins also drain into the middle and left hepatic veins. Because of this separate venous pathway directly into the inferior vena cava, the caudate lobe often maintains normal function during thrombosis of the hepatic veins (Budd-Chiary syndrome). The patients with Budd-Chiary syndrome demonstrate a normal pattern of Tc-99m-sulfur colloid uptake by the caudate lobe, whereas the rest of the liver parenchyma may show marked reduction in radiocolloid uptake. The venous blood from the gallbladder drains directly into the inferior vena cava. As the major portion of the caudate lobe falls on the left side of the Serege-Cantlie plane, it is usually included with the physiologic left lobe.\n\n### 1.1.7 Bile Ducts\n\nThe biliary tree consists of a network of ductal systems progressively increasing in size and originating at the hepatocytes as the bile canaliculus (Fig. 1.1.8). Bile canaliculi from the adjoining hepatocytes unite to form the cholangioles (<20 \u00b5m), which in turn combine to form the interlobular ducts (20-100 \u00b5m) and later the area ducts (100-400 \u00b5m). Ducts from each area unite to form the segmental ducts (400-800 \u00b5m). The segments are positioned anterior and posterior in the right lobe, and medial and lateral in the left lobe [23]. The anterior segmental duct unites with the posterior segmental duct (72%) to form the right hepatic duct (Fig. 1.1.9). The right posterior segmental duct unites with the left hepatic duct directly in 22%, and in the remaining 6% of the cases, the right anterior segmental duct joins the left hepatic duct directly [8].\n\nFig. 1.1.8\n\nIntra- and extra-hepatic ducts and gallbladder. 1 Gallbladder, 2 common bile duct, 3 common hepatic duct, 4 right hepatic duct, 5 anterior segmental duct, 6 anterior superior area duct, 7 anterior inferior area duct, 8 posterior segmental duct, 9 posterior superior area duct, 10 posterior inferior area duct, 11 left hepatic duct, 12 medial segmental duct, 13 medial inferior area duct, 14 medial superior area duct, 15 lateral segmental duct, 16 lateral superior area duct, 17 lateral inferior area duct, 18 falciform ligament\n\nFig. 1.1.9\n\nVariations in bile drainage from the right lobe. The anterior segmental duct (ASD) usually joins with the posterior segmental duct (PSD) forming the right hepatic duct (RHD) in 72%. Sometimes either PSD (22%) or ASD (6%) may join the left hepatic duct directly. Both RHD and LHD unite to form the common hepatic duct\n\nIn the left lobe, the medial segmental duct usually unites with the lateral segmental duct (62%) to form the left hepatic duct. The left medial segmental duct joins the left inferior area duct in 25% of the cases. Other variations are less frequent (Fig. 1.1.10). It is rare for either the left medial or the left lateral segmental duct to join the right hepatic duct directly. The medial segmental duct drains bile from the quadrate lobe (IVA, IVB), and the lateral segmental duct drains bile from the entire anatomic left lobe (II, III). In a Tc-99m-HIDA study, the medial segmental duct and the lateral segmental duct appear as separate trunks in an anterior view image, but the anterior and posterior segmental ducts of the right hepatic lobe are superimposed on one another in the anterior or posterior view of the liver. A right lateral view, therefore, is necessary to the separate bile drainage pattern of the anterior segmental duct from the posterior segmental duct of the right lobe (Fig. 1.1.2).\n\nFig. 1.1.10\n\nVariations in drainage of bile from the left lobe. The medial segmental duct (MSD) usually unites with the lateral segmental duct (LSD) in 62%, forming the left hepatic duct (LHD), which later unites with the right hepatic duct (RHD), forming the common hepatic duct. In the remaining 38% of patients, the main difference in bile drainage pertains to variations in area ducts joining with each other. It is rare for either the left medial or the left lateral segmental duct from the left lobe to join directly with the right hepatic duct (RHD). (LSAD lateral superior area duct, LIAD lateral inferior area duct, MIAD medial inferior area duct, MSAD medial superior area duct, PSD posterior segmental duct, ASD anterior segmental duct)\n\nThe caudate lobe (I) is divided anatomically into three parts: (1) the caudate process (right), (2) the paracaval (middle), and (3) Spiegel's (left) lobe (Fig. 1.1.11). Ducts from the caudate process are small, difficult to identify, and drain bile mostly into the right posterior segmental duct or right hepatic duct, and less often into the left hepatic duct. The duct from Spiegel's lobe is much larger in size, easy to identify at surgery, and drains bile mostly into the left hepatic duct. Ducts from the paracaval portion are small and variable in course [19, 20]. Because bile drainage from the caudate lobe is very variable and can occur into the left hepatic duct, right hepatic duct, or bifurcation, cancer of the hilar region can spread directly into the main lobes through the caudate lobe. Because of this unique feature, the caudate lobe is usually resected with a major lobectomy for Klatskin's tumor [19].\n\nFig. 1.1.11\n\nCaudate lobe. Axial section CT with contrast shows the caudate lobe situated posteriorly, in between the inferior vena cava and vessels at the porta hepatis. The caudate lobe consists of three parts: (1) right (caudate process), (2) middle (paracaval), and (3) left (Spiegel's) lobe\n\n### 1.1.8 Lymphatics\n\nThe lymph vessels from the liver parenchyma generally follow the course of the blood vessels and bile ducts and join with the gallbladder lymph vessels at the porta hepatis, and later divide into two main lymph channels; one channel follows the course of the common bile duct, and the other follows the course of the hepatic artery. Both channels pass through several lymph nodes. The channel following the course of the hepatic artery drains lymph primarily into nodes around the celiac axis, and the other channel, which follows the course of the common bile duct, drains lymph into lymph nodes around the pancreas [5]. The lymph from the liver parenchyma and bile ducts ultimately reaches the cisterna chyli (Fig. 1.1.12). The location of the liver lymph nodes is highly variable with the exception of one node situated at the junction of the gallbladder neck with the cystic duct (node of Mascagni). Enlargement of the node of Mascagni may cause cystic duct obstruction and block bile entry into the gallbladder, mimicking acute cholecystitis. Small lymph vessels around the central vein accompany the hepatic veins and inferior vena cava and drain lymph directly into the thoracic duct [24].\n\nFig. 1.1.12\n\nNerve supply and lymphatic drainage of the hepatobiliary system. The vagus (parasympathetic) nerve from the medulla descends along each side of the neck and mediastinum and enters the abdomen. The left vagus gives off branches to the anterior gastric plexus (AGP), from whence the vagal branches reach the liver and gallbladder and intrahepatic ducts. The right vagus gives off branches to the posterior gastric plexus (PGP), from whence the vagal branches are given off mainly to the common bile duct and the sphincter of Oddi. The phrenic nerve from cervical 3-4 supplies the liver capsule and the peritoneum covering the liver and gallbladder. Sympathetic nerve fibers reach the biliary system via the splanchnic nerves (T7-11) after passing through the celiac ganglion. The lymph from the gallbladder is drained to a node near the neck (node of Mascagni) and then to the nodes along the common bile duct, which also receive lymph from the lower half of the liver. The liver and gallbladder lymph vessels enter the peripancreatic lymph nodes and ultimately drain lymph into the cisterna chili\n\n### 1.1.9 Nerves\n\nThe hepatobiliary system is supplied by both the somatic and autonomic nervous system. The somatic nerve supply comes from the lower thoracic intercostal nerves (T7-11) and the right phrenic nerve (C3, 4). The lower thoracic intercostal nerves supply the parietal peritoneum. The right phrenic nerve supplies the diaphragm and the peritoneum covering the liver and the gallbladder. The pain sensation due to distension of the liver capsule, gallbladder wall, and bile ducts is transmitted through these nerves (Fig. 1.1.12).\n\nThe autonomic nerve supply consists of both the sympathetic and parasympathetic nervous systems. The parasympathetic nerve fibers travel via the vagus, which arises from the medulla and traverses down on each side of the neck and mediastinum to reach the abdomen. Because of the clockwise rotation of the gut during early intrauterine life (Fig. 1.1.1), the left vagus nerve becomes the anterior and the right vagus the posterior trunk. Both of these nerve trunks were first identified and correctly described by Vesalius in 1543 [25]. The anterior trunk (left vagus) enters the anterior gastric plexus at the gastro-esophageal junction. A branch from the anterior gastric plexus, the anterior hepatic nerve, enters the porta hepatis and bifurcates; one branch supplies the intrahepatic and proximal extrahepatic bile ducts and blood vessels, and the other branch supplies the gallbladder. The posterior vagal trunk (right vagus) passes behind the stomach and enters the posterior gastric plexus. A few of its branches enter the celiac ganglion. From the posterior gastric plexus, the nerve fibers enter the distal common bile duct and the sphincter of Oddi (Fig. 1.1.12).\n\nThe parasympathetic nerve supply to the gallbladder comes primarily from the anterior trunk (left vagus). The distal common bile duct and the sphincter of Oddi receive their parasympathetic nerve supply primarily from the posterior trunk (right vagus). The parasympathetic motor function of the gallbladder, therefore, is controlled mainly through the anterior trunk (left vagus) and that of the sphincter of Oddi mainly through the posterior trunk (right vagus). An injury or section of the anterior trunk (left vagus) alone during vagotomy, therefore, has the same effect as complete vagotomy (cutting of both vagii) as far as the motor function of the gallbladder is concerned. Parasympathetic ablation enhances muscular relaxation and increases bile stasis within the gallbladder, promoting cholelithiasis [26-28]. Stimulation of the parasympathetic system, on the other hand, increases the tonicity of the gallbladder and promotes complete bile emptying.\n\nThe hepatobiliary system receives the sympathetic nerve supply via the greater splanchnic (T7-9) and lesser splanchnic nerves (T10-11). The axons from preganglionic sympathetic nerve cells in the lateral horn of the thoracic T7-11 segments travel via the greater and lesser splanchnic nerves and enter the celiac ganglion. The postganglionic sympathetic fibers from the celiac ganglion enter the liver, gallbladder, common bile duct, and the sphincter of Oddi. Sympathetic nerve stimulation relaxes the gallbladder wall. The hepatic artery and its branches are supplied by sympathetic nerves that control the vascular tone. The pain from the hepatobiliary system is carried to the central nervous system via both the splanchnic nerves and the branches of the right phrenic nerve (Fig. 1.1.12).\n\n### 1.1.10 Biliary Apparatus\n\n#### 1.1.10.1 Intrahepatic Ducts\n\nThe hepatobiliary system is analogous to a tree. The hepatocytes can be considered to represent the leaves and canaliculi the trunk; area and segmental ducts represent the branches of the tree. The common hepatic duct and the common bile duct represent the trunk and the sphincter of Oddi the roots of a tree. The gallbladder is akin to a fruit [29]. Bile canaliculi from the hepatocytes join to form the cholangioles, which unite to form the interlobular bile ducts and then into larger area ducts. Ducts from each area unite to form the segmental ducts. The anterior and posterior segmental ducts from the right lobe unite to form the right hepatic duct, and the medial and lateral segmental ducts from the left lobe unite to form the left hepatic duct (Fig. 1.1.7).\n\n#### 1.1.10.2 Extrahepatic Ducts\n\nThe right and left hepatic ducts leave the liver parenchyma and proceed inferiorly for a distance of 0.5-1.5 cm before joining to form the common hepatic duct [8]. The common hepatic duct is 2-7 cm in length and joins with the cystic duct to form the common bile duct.\n\n#### 1.1.10.3 Gallbladder\n\nThe gallbladder lies along the inferior liver border in a groove between the right lobe and the quadrate lobe (medial segment of the left lobe; IVA, IVB). It consists of a fundus, body, and neck (Fig. 1.1.13). The gallbladder measures about 7-10 cm in length, 3-5 cm in width, and 40-50 ml in volume [30]. The superior third of the wall is in direct contact with the liver and hence lacks the peritoneal covering. The rest of the gallbladder wall is covered with the visceral peritoneum. The gallbladder is a pear-shaped, single-chamber organ with the extension of the fundus below the inferior liver margin. The position of the fundus, on the body surface, corresponds to the point of intersection of the lateral margin of the right rectus muscle with the right costal margin. A line drawn between the left anterior superior iliac spine and umbilicus points to the fundus of the gallbladder when it is extended upwards to meet with the right costal margin. Gallstones often lodge in a pouch-like structure (Hartmann pouch) at the neck, initiating cystic duct obstruction and subsequent acute cholecystitis. The mucous membrane thrown into folds in the neck and cystic duct often acts as a valve (Heister valve) for bile entry into and exit out of the gallbladder. The cystic duct measures about 3-8 cm in length and less than 3 mm in diameter and joins the common hepatic duct at a 45\u00b0 angle (80%) to form the common bile duct. Sometimes, the cystic duct may directly join the right hepatic or the left hepatic duct. There are many variations in the way the cystic duct joins with the common hepatic duct, right hepatic, or left hepatic duct [31]. The artery to the gallbladder (cystic artery) usually arises from the right hepatic artery (72%) or from its accessory branches (13%), and less often directly from the hepatic artery (6%) or the gastroduodenal artery.\n\nFig. 1.1.13\n\nExtrahepatic biliary tract. The distal one-third of both right and left hepatic ducts, and the entire common hepatic and common bile ducts, are extrahepatic in location. The gallbladder consists of a fundus, body, neck, and cystic duct. The mucous membrane in the neck and cystic duct is thrown into folds, acting as a valve (Heister's valve) for bile entry and exit. Gallstones often lodge in a pouch near the neck (Hartmann's pouch). The sphincter of Oddi (enlarged) at the distal end of the common bile duct consists of three separate sphincters. The distal common bile duct is surrounded by the choledochal sphincter (sphincter of Boyden). The distal pancreatic duct (duct of Wirsung) is surrounded by a separate pancreatic sphincter. The common channel formed by the union of two ducts is surrounded by the ampullary sphincter. The common channel (ampulla of Vater) opens into the duodenum at an elevation called the papilla. The name sphincter of Oddi refers to all three sphincters\n\nThe gallbladder is supplied by both the sympathetic and parasympathetic nervous systems, which control its tone, contraction, and relaxation. Parasympathetic stimulation causes contraction and bile emptying, and sympathetic stimulation results in relaxation and bile stasis. The gallbladder lymph, after passing through a node at the neck (node of Mascagni), enters the hepatic plexus and ultimately reaches the cisterna chyli (Fig. 1.1.7). The gallbladder is absent in 1:1,600 live births, and in about 8% of cases, it is entirely intrahepatic in location [32]. The C loop of the duodenum and the hepatic flexure of the colon are in close proximity to the gallbladder.\n\n#### 1.1.10.4 Common Bile Duct\n\nThis duct is formed by the union of the common hepatic duct with the cystic duct. It varies in length from 7 to 17 cm, and the lumen is less than 8 mm in diameter (Fig 1.1.13). The common bile duct is divided into the supraduodenal, retroduodenal, intrapancreatic, and intraduodenal segments. The supraduodenal segment is the longest and measures 2-4 cm in length. The retroduodenal and intrapancreatic segments each measure about 2.5-3 cm in length. The intradoudenal segment is the narrowest part of the common bile duct. The retroduodenal segment lies behind the duodenal bulb and may be non-visualized in a Tc-99m HIDA study if there is fluid collection in the duodenal lumen. The common bile duct enters the postero-medial wall of the second part of the duodenum and unites with the pancreatic duct (duct of Wirsung), forming a common channel, the ampulla of Vater, which finally enters the duodenal lumen at an elevation called the \"papilla.\" The papilla lies about 8-10 cm away from the pylorus of the stomach. The common bile duct joins with the pancreatic duct, forming a common channel of 10-12 mm length in 86% of cases. The two ducts join together at the ampulla just before opening into the duodenum in 6% of cases, and in the remaining 8%, both ducts open separately into the duodenum [32].\n\n## 1.2 Microstructure\n\nThe liver is the largest organ in the body and consists of an intricate structure to carry out the complex exocrine (bile secretion) and endocrine (protein synthesis) functions efficiently. The organ shape and structure are well maintained despite the paucity of connective tissue.\n\nThe concept of the lobule as the basic micro-architectural unit of the liver prevailed for well over a century. A lobule is hexagonal in shape and consists of a tributary of the hepatic vein at the center surrounded by six portal triads (consisting of the terminal branch of the hepatic artery, portal vein, and bile duct) at the periphery, and the space in between is occupied by a single cell plate of hepatocytes and cells of the sinusoidal space. A new concept of an acinus as the basic liver unit was first proposed in 1958 and is now well accepted because it explains the function and regeneration of the liver in a much better way than the lobule model [1]. An acinus is diamond shaped with a portal triad at one corner and central vein (hepatic vein) at the other three corners. Hepatocytes are arranged in three zones. The cells in zone 1 towards the portal triad receive a much higher concentration of oxygen and other nutrients than cells in zone 3 towards the central vein. Zone 1 cells, therefore, can withstand hypoxia better and regenerate much faster than cells in zone 3. The liver consists of the polygonal cells (hepatocytes), sinosoidal cells, canalicular cells, and other supporting cells (Fig. 1.2.1). An adult liver consists of well over 250 billion cells, of which hepatocytes constitute 78% of the volume, non-hepatocytes 6.3% of the volume, 2.8% by endothelial cells, 2.1% by Kupffer cells, and 1.4% by stellate cells. The remaining 16% of liver volume is made up of extracellular space [2].\n\nFig. 1.2.1\n\nMicrostructure of the liver. The vascular space is divided into two compartments by the endothelial cells: (1) endothelial or sinusoidal space and (2) the perisinusoidal space of Disse. Kupffer cells are located in the sinusoidal space and stellate cells (Ito cells) in the perisinusoidal space of Disse. The basolateral border of the hepatocyte faces the space of Disse. Canaliculi are invaginations of the lateral wall of two adjacent hepatocytes. Canaliculi join to form the canal of Hering, which in turn unites with others to form the interlobular ducts. The portal triad consists of a branch of the bile duct, hepatic artery, and portal vein. Substrates move from the basolateral border to the canaliculi through the hepatocyte.SER smooth endoplasmic reticulum, RER rough endoplasmic reticulum\n\n### 1.2.1 Vascular Compartment\n\nThis compartment is situated between two single layer plates of hepatocytes and consists of two spaces: (1) the sinusoidal space and (2) the perisinusoidal space of Disse (Fig. 1.2.1). The sinusoidal space is the much larger of the two and accounts for 2\/3 of the vascular compartment. Four types of cells are found in the vascular space: (1) endothelial cells (sinusoidal lining cells), (2) Kupffer cells, (3) stellate cells (lipocyte or Ito cells), and (4) pit cells [3]. These four cells together constitute the functional unit of the hepatic sinusoid.\n\n### 1.2.2 Endothelial Cell\n\nThese are flat cells lining the vascular space and consist of numerous holes or fenestrae in between [4]. The fenestrae vary in size from 0.1 to 3 \u00b5m in diameter and selectively allow certain plasma constituents to pass through from the sinusoidal space to the perisinusoidal space of Disse. The number of fenestrae decreases and the diameter of the hole increases in patients with alcoholic liver disease and cirrhosis [5-7]. The main function of the fenestrae is to act as a selective filter, allowing only those constituents that need to enter the perisinusoidal space of Disse and excluding others from the entrance. Red blood cells and leucocytes are excluded, whereas the electrolytes, plasma proteins (albumin), vitamins, and other essential nutrients are allowed free entry into the perisinusoidal space of Disse.\n\n### 1.2.3 Kupffer Cell\n\nKupffer described two types of cells, one in 1876 [8] and the other in 1899 [9]. It was first thought that the cell described in 1876 was the reticuloendothelial cell bearing his name (Kupffer cell). However, in 1951, Ito showed that this cell is the fat-storing (lipocyte, Ito cell) cell situated in the perisinusoidal space of Disse, recognized now as the stellate cell [10]. The cell described by Kupffer in 1899 is now considered the Kupffer cell. The Kupffer cells are highly specialized macrophages distributed irregularly within the sinusoidal space. There is no direct connection between two adjacent Kupffer cells. Their surface is irregular with folds and ruffles. They are highly mobile scavenger cells often found within the space of Disse or may lie free within the sinusoidal space, unattached to the endothelial cell. The cytoplasm is rich in lysosomes, Golgi apparatus, and rough endoplasmic reticulum (Fig. 1.2.1). The Kupffer cells proliferate locally to maintain their population, but at times of greater need they increase their number by calling reinforcement from the bone marrow.\n\n### 1.2.4 Stellate Cell\n\nThese cells, \"the sternzellen of Von Kupffer,\" first described in 1876, are the resting fibroblasts in the perisinusoidal space of Disse that are now organized as the stellate cells [8]. They have been called by many names, such as lipocyte, hepatic pericyte, or Ito cells [10, 11]. For many years, it was thought that these star-shaped cells did not have any function in humans. Stellate cells are rich in vitamin A and are the storage site for retinoids. They become activated during liver injury and play a dominant role in angiogenesis, vascular remodeling, repair, and fibrosis [12]. The activation of stellate cells increases production of membrane metalloproteinase 1 and 2 (MMP-1 and MMP-2) and tissue inhibitors of metalloproteinases (TIMP). Metalloproteinases promote matrix degradation and subsequent replacement by interstitial collagen in the subendothelial space of Disse. Other accompanying effects include a reduction in the number of fenestrae and a loss of microvilli along the perisinusoidal surface of the hepatocytes, both of which result in decreasing the delivery of organic anions (including HIDA) into the perisinusoidal space of Disse.\n\n### 1.2.5 Pit Cell\n\nThese cells are large granular T lymphocytes or natural killer cells found within the sinusoidal space. They are highly mobile killer lymphocytes and contain organelles necessary for removal of tumor cells and virus-infected hepatocytes. Activated natural killer cells promote hepatocyte proliferation and regeneration of the liver [14].\n\n### 1.2.6 Hepatocyte\n\nThe hepatocyte is the largest cell in the liver and varies in size from 13 to 30 \u00b5m with an average diameter of 25 \u00b5m (Fig. 1.2.2). Each milligram of liver tissue consists of 202,000 cells. There are about 250 billion hepatocytes in an adult liver [15]. A hepatocyte is polyhedral, multifaceted (as many as eight surfaces), and measures about 11,000 cubic \u00b5m in volume. Because of their relatively larger size, hepatocytes account for 78% of the liver by volume. Sinusoidal cells account for 6%, and the extracellular space occupies the remaining 16% of the liver volume. On the basis of function, the hepatocyte plasma membrane is divided into three domains: (1) the basolateral domain, (2) contact or contiguous domain, and (3) canalicular domain.\n\nThe basolateral domain faces the perisinusoidal space of Disse and accounts for 70% of the cell wall. It consists of 30-50 microvilli, which increase the absorptive surface by six times [16]. The microvilli extend along the paracellular space until the two adjacent hepatocytes come in close contact at the point of the desmosome. This surface is bathed in plasma filtered through the fenestrae of the sieve plate of the endothelial cells and allows metabolic exchange between the plasma and the hepatocyte. Organic anions, including Tc-99m-HIDA, enter the hepatocyte along the basolateral domain.\n\nThe contact domain accounts for 15% of the plasma membrane and is placed between two adjacent hepatocytes. The tight junction situated near the canaliculus prevents plasma constituents from entering the canalicular space directly from the space of Disse. The gap junction can be located anywhere along the lateral border and provides direct communication between adjacent hepatocytes on a selective basis.\n\nThe canalicular domain accounts for the remaining 15% of the cell surface and is situated at the center of two adjacent hepatocytes. It represents a specialized part of the hepatocyte. The canalicular wall consists of microvilli that increase the functional surface.\n\nHepatocyte contains a nucleus and a nucleolus that are rich in deoxyribonucleic acid. The smooth endoplasmic reticulum (SER) is made up of tubular structures containing microsomes and carries out bilirubin conjugation and detoxification of drugs and other organic anions. SER is steroid sensitive and participates in enzyme induction when phenobarbital is administered. The rough endoplasmic reticulum (RER) contains ribosomes and is responsible for protein synthesis, including albumin [13]. Lysosomes are cytoplasmic particles close to bile canaliculi and contain hydrolytic enzymes, including acid phosphatase [16]. Lysosomes perform a scavenger function and remove from blood excess material, including ferritin, bile pigments, and metals such as copper. The Golgi apparatus consists of particulates and vesicles and lies close to the bile canaliculus. The lysosomes and Golgi apparatus together perform the tasks of storage, entrapment, and final excretion into bile of various non-essential body constituents. The mitochondria, which participate in oxidative phospharilation, heme synthesis, and citric acid cycle, are scattered throughout the cell. The hepatocytes and cells in the sinusoidal and canalicular space are supported by a cytoskeleton consisting of microtubules and micro filaments. The cells of the sinusoidal and perisinusoidal space of Disse are supported by collagen, laminin, protoglycon, fibrinonectin, and heparan sulphate [15, 16].\n\n### 1.2.7 Bile Canaliculus\n\nBile canaliculi are a simple convoluted border of the hepatocyte and account for 13% of the hepatocyte wall. The convolutions are microvilli that increase the surface area for bile secretion (Fig. 1.2.1). A canaliculus varies from 0.1 to 1 \u00b5m in diameter. At the periphery of a hepatic lobule several bile canaliculi join to form the canal of Hering, which acts as a transitional zone between intralobular and interlobular ductal systems. The interlobular ducts unite to form area ducts that drain bile from an area of the liver. Area ducts unite to form the segmental ducts, which in turn unite to form the lobar ducts. The cells lining the ducts (cholangioles) are cuboidal in shape and contain apical microvilli, which project into the duct lumen [17].\n\n### 1.2.8 Gallbladder and Cystic Duct\n\nThe gallbladder wall consists of three layers: (1) the serosal layer, (2) fibromuscular layer, and (3) mucosal layer. The serosal layer is the peritoneum, which covers about 2\/3 of the gallbladder wall with the exception of the superior 1\/3, which is in direct contact with the liver. The fibromuscular layer consists mostly of elastic fibrous tissue. The muscular layer is irregular and consists of longitudinal and circular muscle fibers, which are well developed around the fundus and infundibulum, and scanty over the body and neck of the gallbladder. The mucosa consists of a single layer of cells with three different cell types: columnar, pencil, and basal. The mucosal layer is thrown into folds that increase the surface area of the gallbladder. The columnar cells have microvilli, 0.7-0.8 \u00b5m in length, along the luminal surface. The intercellular space between two adjacent columnar cells is narrow at the luminal end, but is widely open towards the fibromuscular layer [18]. Water and electrolytes are continuously absorbed from the lumen, through these intercellular spaces, making room for entry of fresh hepatic bile into the gallbladder during fasting [19]. The wall is impermeable to bile acids, bilirubin, radiocontrast agents, and other organic anions, including Tc-99m-HIDA. The neck contains mucous-secreting cells. Pencil cells, which are long and narrow, are found mainly in the body and extend from the basement membrane to the lumen. Basal cells are small and are concentrated more towards the fibromuscular layer.\n\nThe water absorbed from the gallbladder lumen through the lateral intercellular spaces enters venous blood through several small veins that drain into the hepatic or portal veins. There is no one single large cystic vein. The venous blood from the free wall of the gallbladder drains into venous radicals, which eventually enter the portal venous system.\n\nThe cystic duct, common hepatic duct, and common bile duct possess a mucosa, submucosa, and muscularis. The mucosal cells are a continuation of the gallbladder mucosal cells and contain the columnar cells with a ciliated border. The walls of the common hepatic duct and common bile duct are composed of a thick layer of connective tissue interspersed with few muscle cells. This structural configuration is well suited for the bile ducts to participate in bile concentration and discharge.\n\n### 1.2.9 Sphincter of Oddi\n\nFor well over a century, the study of this small segment of the biliary tract has fascinated anatomists, physiologists, and microscopists [20]. More recently, it has gotten the attention of gastroenterologists, hepatologists, and electron microscopists. For many years it was believed that the sphincter was a mere extension of the smooth muscle from the duodenal wall. Boyden's detailed work in 1937 clearly established it as a true sphincter, separate from the duodenal wall musculature [21]. The common bile duct enters the postero-medial wall of the second part of the duodenum tangentially and traverses for about 2 cm before joining the pancreatic duct (duct of Wirsung) to form a common channel, the ampulla of Vater. The common channel travels for 10-15 mm before entering the duodenal lumen at an elevation, the papilla, which is about 7-10 cm from the pylorus of the stomach (Fig. 1.1.13). The circular and longitudinal muscle fibers form a sphincter called the sphincter choledochus (sphincter of Boyden) at the distal end of the common bile duct before it joins the pancreatic duct. The sphincter is about 10-15 mm in length and mostly intramuscular. The contractions of this sphincter prevent reflux of pancreatic secretions into the common bile duct. The distal pancreatic duct (duct of Wirsung) is also surrounded by a distinct sphincter called the pancreatic sphincter whose contractions prevent bile reflux into the pancreatic duct. The pancreatic sphincter is absent in about 20% of the subjects [22]. The common channel formed by the union of the common bile duct and the pancreatic duct is called the ampulla of Vater and is surrounded by a weak sphincter called the sphincter of ampulla (pylorus of Westpal). The name, \"sphincter of Oddi,\" commonly refers to the function of all three sphincters situated at the distal end of the common bile duct and the pancreatic duct. Variations in the length, its union with the pancreatic duct, and opening into the duodenum of the common bile duct are frequent and are related to embryologic development [23]. The common bile duct opens through the ampulla of Vater into the lumen of the second part of the duodenum in 82% of the cases. The opening is lower than usual in 5%, or opens at an angle in 7%, or opens into the transverse duodenum (third part) in the remaining 6% of the patients [24].\n\nTable 1.2.1\n\nFunction of various cells of the liver [15]\n\nHepatocyte | Endothelial cell | Kupffer cell | Stellate cell | Canalicular cell\n\n---|---|---|---|---\n\nBile secretion | Plasma filtration | Phagocytosis of colloids, bacteria, endotoxin, tumor cells | Storage of fats, vitamin A, and retinoid | Bile transit\n\nPhospharilation | Endocytosis | Receptor for Fc fraction, C3b complement | Collagen secretion | Water secretion\n\n|\n\nRemoval of collagen Fc fragment of IgG, C3b complement\n\n|  |  |\n\nHem synthesis\n\n|  |  |  |\n\nElectrolyte transfer\n\nProtein synthesis\n\n|  |  |  |\n\nBeta oxidation\n\n|  |  |  |   \n|  |\n\nSecretion of TNF-a\n\n|  |\n\nGlycogenesis\n\n|  |\n\nCollagenase\n\n|  |\n\nBilirubin conjugation\n\n|  |\n\nInterleukins\n\n|  |\n\nDrug detoxification\n\n|  |\n\nArachidonic acid\n\n|  |\n\nLipoprotein synthesis\n\n|  |\n\nErythroblastosis\n\n|  |\n\nStorage of ferritin, vit B-12\n\n|  |\n\nStorage of iron, ferritin, hemosiderin, immune complex\n\n|  |\n\nReferences\n\n1.\n\nWilliams R. Global challenges in liver disease. Hepatology 2006;44:521-526PubMedCrossRef\n\n2.\n\nStarzl TE. The saga of liver transplantation, with particular reference to the reciprocal influence of liver and kidney transplantation (1955-1967). J Am Coll Surg 2002;195:587-610PubMedCrossRef01498-9)\n\n3.\n\nLinder HH, Green RB. Embryology and surgical anatomy of the extra hepatic biliary tract. Surg Clin N Amer 1964;44:1273-1285\n\n4.\n\nNetter FH. CIBA collection of medical illustration, vol. lll, Digestive system, part lll. Liver, biliary tract, and pancreas. CIBA, Summit NJ, 1964\n\n5.\n\nHess W. Surgery of the biliary passages and the pancreas. D Von Nostrand Company Inc, Princeton NJ, 1965\n\n6.\n\nCouinaud C. Le foie etudes anatomiques et chirurgicales, Masson, Paris, 1957\n\n7.\n\nReifferscheid M. Chirurgie der leber. Georg Thieme Verlag, Stuttgart, 1957\n\n8.\n\nHaley JE, Schroy PC. Anatomy of the biliary ducts within the human liver. Analysis of the prevailing pattern of branchings and the major variations of the biliary ducts. Arch Surg 1953;66:599-616CrossRef\n\n9.\n\nBismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg 1982;6:3-9PubMedCrossRef\n\n10.\n\nGoldsmith MA, Woodburn RT. Surgical anatomy pertaining to liver resection. Surg Gynecol Obstet 1957;141:429-437\n\n11.\n\nSugarbaker PH. En bloc resection of hepatic segments 4B, 5 and 6 by transverse hepatectomy. Surg Gynecol Obstet 1990;170:250-252PubMed\n\n12.\n\nSugarbaker PH, Nelson RC, Murray DR, Chezmar JL, Barnardino MF. A segmental approach to computerized tomographic portography for hepatic resection. Surg Gynecol Obstet 1990;171:189-195PubMed\n\n13.\n\nNelson RC, Chezmar JL, Sugarbaker PH, Murray DR, Bernardino MF. Pre-operative localization of focal liver lesions to specific liver segments: utility of CT during arterial portography. Radiology 1991;181:443-448\n\n14.\n\nLaforture M, Madore F, Patriquin H, Breton G. Segmental anatomy of the liver: a sonographic approach to the Couinaud nomenclature. Radiology 1991;181:443-448\n\n15.\n\nSoyer P. Segmental anatomy of the liver: utility of a nomenclature accepted worldwide. AJR. Amer J Roentgenol 1993;161:572-573\n\n16.\n\nDodd GD III. An American's guide to Couinaud's numbering system. AJR. Amer J Roentgenol 1993;161:574-575\n\n17.\n\nSutherland S, Harris J. Claude Couinaud-A passion for the liver. Arch Surg 2002;137:1305-1310CrossRef\n\n18.\n\nKogure K, Kuwano H, Fujimaki N, Ishikawa H, Takada K. Reproposal for Hjortsjoo's segmental anatomy on the anterior segment in human liver. Arch Surg 2002;137:1118-1124PubMedCrossRef\n\n19.\n\nAbdalla EK, Vauthey J, Couinaud C. The caudate lobe of the liver. Implications of embryology and anatomy for surgery. Surg Oncol Clin N Am 2002;11:835-848PubMedCrossRef00035-2)\n\n20.\n\nKitagawa S, Murakami G, Hata F, Hirata K. Configuration of the right portion of the caudate lobe with special reference to identification of its right margin. Clinical Anat 2000;13:321-340CrossRef13%3A5<321%3A%3AAID-CA2>3.0.CO%3B2-R)\n\n21.\n\nVarotti G, Gondoles G, Goldman J, Wayne M, Florman SS, Schwartz ME, Miller MM, Emre S. Anatomic variations in right liver living donor. J Am Coll Surg 2004;198:577-582PubMedCrossRef\n\n22.\n\nSherlock S, Dooley J. Diseases of the liver and biliary system. 10th edition, Blackwell Science, Malden, MA, 1997\n\n23.\n\nRoberts SK, Ludwig J, LaRusso NF. The pathology of biliary epithelia. Gastroenterology 1997;112:269-279PubMedCrossRef70244-0)\n\n24.\n\nJones AL. The architecture of bile secretion. A morphological perspective of physiology. Dig Dis Sci 1980;25:609-629PubMedCrossRef\n\n25.\n\nHolle F. Historical outline. In: Holle F, Anderson S. eds. Vagotomy: latest advances. Springer, New York, 1974\n\n26.\n\nLaRusso D, Misciagno G, Noviello MR, Torantino S. Cholelithiasis after billroth ll gastric resection. Surgery 1988;103:579-583\n\n27.\n\nGriffiths JMT, Holmes G. Cholecystitis following gastric surgery. Lancet 1994;2:780-782\n\n28.\n\nTurunen M, Antila L. Gallbladder disease following gastrectomy. ACTA Chir Scand 1964;127:134-137PubMed\n\n29.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23(Suppl):35S-45S\n\n30.\n\nGunnarson E, Investigation of the distension capacity of the human gallbladder. ACTA Radiol (Stockh) 1961;56:161-165CrossRef\n\n31.\n\nGoor DA, Ebert PA. Anomalies of the biliary tree. Report of a repair of an accessory bile duct and review of the literature. Arch Surg 1972;104:302-309PubMedCrossRef\n\n32.\n\nBoyden EA. The accessory gallbladder-An embryological and comparative study of aberrant biliary vesicles in man and domestic mammals. Am J Anat 1926;38:177-231CrossRef\n\nReferences\n\n1.\n\nRapapport AM. The structural and functional unit in the human liver (liver acinus). Anat Rec 1958;130:673-689CrossRef\n\n2.\n\nBloulin A, Bolender RP, Weibel ER. Distribution of organelles and membranes between hepatocytes and non-hepatocytes in the rat liver parenchyma. A stereological study. J Cell Biol 1977;72:441-455CrossRef\n\n3.\n\nGendrault J, Montecino-Rodriguez, Cinqualbre J. Structure of the normal human liver sinusoid after perfusion fixation. In: Knook DL, Wisse E (eds). Liver sinusoidal cells. Elsevier Biomedical Press, Amsterdam, 1982;pp 93-100\n\n4.\n\nWisse E. An electron microscopic study of the fenestral endothelial lining of rat liver sinusoid. J Ultrastructure Research 1970;31:125-150CrossRef90150-4)\n\n5.\n\nToner PG, Carr KE. Ultrastructure of the liver and biliary apparatus. In: Marlow S, Sherlock S. Eds, Surgery of the gallbladder and bile ducts. Butterworth & Co Ltd, Boston, 1981, pp 19-65\n\n6.\n\nWisse E, DeZanger RB, Charles K, Van Der Smissen P, McCuskey RS. The liver sieve: considerations concerning the structure and function of endothelial fenestrae, the sinusoidal wall and the space of Disse. Hepatology 1985;5:683-692PubMedCrossRef\n\n7.\n\nHorn T, Christoffersen P, Henrikseen JH. Alcoholic liver injury: defenestration in non-cirrhotic livers. A scanning microscopic study. Hepatology 1987;7:77-82PubMedCrossRef\n\n8.\n\nKupffer C Von. Uber die Sternzallen der Leber. Arch Mikr Anat 1876;12:353-357CrossRef\n\n9.\n\nKupffer C Von. Uber die sogenanten Sternzellen der sangetheier Leber. Arch Mikr Anat 1899;54:254-260CrossRef\n\n10.\n\nIto T. Cytological studies on stellate cells of Kupffer and fat storing cells in the capillaries of the human liver. ACTA Anat Nippon 1951;26:42 (abstract)\n\n11.\n\nLee JS, Semela D, Iredale J, Shah VH. Sinusoidal remodeling and angiogenesis: a new function for the liver-specific pericyte? Hepatology 2007;45:817-825PubMedCrossRef\n\n12.\n\nFriedman SL, Rockey DC, Bissell M. Hepatic fibrosis 2006: report of the third AASLD single topic conference. Hepatology 2007;45:242-249PubMedCrossRef\n\n13.\n\nFriedman SL, Basal MB. Reversal of hepatic fibrosis-fact or fantasy? Hepatology 2006;43:S82-S88PubMedCrossRef\n\n14.\n\nNakashima SL, Inui T, Habu Y, Kinishita M, et al. Activation of mouse natural killer cells accelerates liver regeneration after partial hepatectomy. Gastroenterology 2006;131:1573-1583PubMedCrossRef\n\n15.\n\nSherlock S, Dooley J. Diseases of the liver and biliary system, 10th edn. Blackwell Science, Malden, MA, 1997\n\n16.\n\nFeldman G. The cytoskeleton of the hepatocyte. J Hepatology. 1989;8:380-384CrossRef90038-X)\n\n17.\n\nJones AL, Schmucker DL, Reston RH, Murakami T. The architecture of bile secretion. A morphological perspective of physiology. Dig Dis Sci 1980;25:609-629PubMedCrossRef\n\n18.\n\nEveff RD, Higgins JA, Brown AC. The fine structure of normal mucosa in human gallbladder. Gastroenterology 1964;47:49-60\n\n19.\n\nTormey JM, Diamond JM. Studies on the structural basis of water transport across epithelial membranes. Federation Proceedings 1966;25:692-707\n\n20.\n\nOddi R. D'une disposition a sphincter del'ouverture du canal cholique. Arch. Ital Biol 1887:8:317-322\n\n21.\n\nBoyden EA. The sphincter of Oddi in man and certain representative mammals. Surgery 1937;1:25-37\n\n22.\n\nBoyden EA. The anatomy of the choledochoduodenal junction in man. Surg Gynecol Obstet 1957;104:641-652PubMed\n\n23.\n\nLinder HH. Embryology and anatomy of the biliary tree. In: Way LW, Pelligrini CA. (Eds) Surgery of the gallbladder and bile ducts. WB Saunders Co, Philadelphia, 1987;pp 3-22\n\n24.\n\nLinder HH, Pena VA, Ruggieri RA. A clinical and anatomical study of anomalous termination of the common bile duct into the duodenum. Ann Surg 1976;184:626-632CrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_2(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 2. Liver and Spleen Function\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nThe liver is the largest organ and carries out the most complex biological functions in the body. It secretes bile, synthesizes proteins, metabolizes nutrients, hormones, and drugs, and detoxifies noxious endogenous and exogenous substrates. To accomplish all of these functions, the liver is located centrally in the body and endowed with well-designed architecture with a generous amount of blood supply. Secretion of bile is one of many important liver functions, and bile promotes digestion and absorption of essential nutrients; it also serves as a vehicle to get rid of biological waste products from the body. The biliary tree is designed not only for continuous bile secretion and flow, but also for periodic bile storage and discharge (gallbladder) at the time when food enters the small intestine. The spleen carries out many functions whose importance has been recognized only recently. This chapter will discuss the various functions of these two organs.\n\nThe liver is the largest organ and carries out the most complex biological functions in the body. It secretes bile, synthesizes proteins, metabolizes nutrients, hormones, and drugs, and detoxifies noxious endogenous and exogenous substrates. To accomplish all of these functions, the liver is located centrally in the body and endowed with well-designed architecture with a generous amount of blood supply. Secretion of bile is one of many important liver functions, and bile promotes digestion and absorption of essential nutrients; it also serves as a vehicle to get rid of biological waste products from the body. The biliary tree is designed not only for continuous bile secretion and flow, but also for periodic bile storage and discharge (gallbladder) at the time when food enters the small intestine. The spleen carries out many functions whose importance has been recognized only recently. This chapter will discuss the various functions of these two organs.\n\n## 2.1 Liver Function\n\nThe liver secretes about 600-800 ml of bile per day, at 25-33 ml h-1 or 0.42-55 ml min-1 [1]. Under normal hydration, osmolality of the hepatic bile is similar to that of plasma and ranges between 290-320 mOsm -l. Bile secretion is independent of hepatic perfusion pressure; thus, it differs from that of urine formation, which is very much dependent upon the glomerular filtration pressure in the kidneys [2]. The hepatic bile is composed of 98% water and 2% solutes, which include bile acids, phospholipids, cholesterol, conjugated bilirubin, electrolytes, and proteins (Table 2.1.1). Almost all of these functions are carried out mainly by the hepatocyte, which possesses all of the ingredients necessary for performing complex functions [3]. After extraction from blood in the space of Disse, some substrates are metabolized and transported through the hepatocyte to be secreted into canaliculi, while others may be secreted without any changes. All three domains of the hepatocyte plasma membrane participate in the uptake and excretion [4]. The uptake from the blood in the space of Disse takes place along the basolateral domain, which accounts for approximately 40% of the hepatocyte border. Bile secretion occurs at the canalicular domain, which constitutes 10% of the cell border. The lateral domain, the wall facing two adjacent hepatocytes, forms the remaining 50% of the cell border and plays a major role in water and solute transport and regulation of the total volume of bile secreted per day (Fig. 2.1.1).\n\nFig. 2.1.1\n\nMechanism of bile secretion. Uptake of solutes from the space of Disse occurs along the basolateral domain of the hepatocyte through many different pathways controlled by different transporter proteins. Four organic anion transporter proteins (OATPs) and organic anion transporter-2 (OAT2) and organic cation transporter proteins (OCT1) control uptake of anions and cations along the basolateral border (red). Sodium-dependent bile salt uptake occurs via sodium taurocholate protein (NTCP). Five multidrug resistance-associated proteins (MRPs) control secretion (reflux) from the hepatocyte back into space of Disse (blue). After intracellular transit, solute secretion into bile takes place along the canalicular domain through MRP2, multidrug- resistant-1 p-glycoprotein (MDR1 and MDR3), bile salt export pump (BSEP), breast cancer-resistance protein (BCRP), and flippases (ABCG5\/ABCG8). Chloride channel, glutathione (GSH) transporter, and chloride (Cl-)\/ bicarbonate (HCO3 -) exchange transporters also control excretion. Cholangioles absorb bile salts from the lumen through apical sodium-dependent bile salt transporter (ASBT) protein, and other anions are absorbed through OATP1A2. Exchange of Cl- for HCO3 - takes place. These substrates are secreted into the peribiliary plexus at the basolateral domain of the cholangiocytes mediated by MDR3, OST-1, and OST-2. Water enters the canalicular bile by three different routes: (1) transcellular, (2) paracellular, and (3) a combination of paracellular and transcellular\n\nTable 2.1.1\n\nComposition of human hepatic and gallbladder bile\n\nWater (g\/dl-1) | 98 | 92\n\n---|---|---\n\nNa+ (mEq\/l-1) | 150 | 130\n\nK+ (mEq\/l-1) | 5 | 10\n\nCa2 + (mEq\/l-1) | 5 | 23\n\nC1\u2212 (mEq\/l-1) | 100 | 25\n\nHCO3\u2212 (mEq\/l-1) | 28 | 10\n\nBile salts (g\/dl-1) | 1 | 6\n\nBilirubin (g\/dl-1) | 0.05 | 0.3\n\nCholesterol (g\/dl-1) | 0.1 | 0.6\n\nFatty acids (g\/dl-1) | 0.12 | 0.8\n\nLecithin (g\/dl-1) | 0.04 | 0.3\n\nBile formation in the hepatocyte can be divided into four major phases: phase I, uptake of substrates from blood (space of Disse) along the basolateral border; phase II, metabolism (hydroxylation); phase III, detoxification (conjugation); phaseIV, excretion into bile canaliculi along the canalicular border. Both phases II and III take place intracellularly within the hepatocyte. A disease process can affect one, two, three, or all four phases at a time. The entire metabolic process is controlled by genes mainly through their nuclear receptors.\n\n### 2.1.1 Basolateral (Sinusoidal) Domain\n\nIn the past decade, new knowledge has contributed to better understanding of the mechanisms involved in bile formation and flow. Basolateral and canalicular domains of the hepatocyte possess many polypeptide transporters that regulate the entrance and exit of substances across the plasma membrane (Fig. 2.1.1). Both sodium-dependent and sodium-independent pathways control the uptake of substrates along the basolateral border. The sodium-dependent pathway is regulated by sodium taurocholate cotransporting polypeptide (NTCP), which controls the majority of conjugated bile salts, a few sulfated steroids, and to a minor extent uptake of unconjugated bile salts. The sodium-dependent pathway also uses the Na+\/K+ ATPase pump, which enables net movement of three Na+ ions out of the hepatocyte for every two K+ ions moving into the hepatocyte from the space of Disse [5]. The net effect of these electrolyte exchanges results in a higher concentration of K+ inside than outside, and a higher concentration of Na+ outside than inside of the hepatocyte. Due to this ion imbalance, the inside of the hepatocyte carries a much higher negative charge (-35 mV) than its outside environment [6].\n\nSodium-independent pathways are represented by several members of the superfamily of organic anion-transporting polypeptides (OATPs). Four of the OATPs located along the basolateral border include OATP1B1 (formerly OATP-C), OATP1B3, OATP1A2, and OATP2B1 [7]. In humans, the highest concentration of OATP1B1 and OATP1B3 is found in the liver. Bilirubin uptake is controlled mainly by OATP2B1. Three of the OATPs (OATP1B1, OATP1B3, and OATP1A2) have overlapping functions for conjugated and unconjugated bile salts, bromosulphophtalein, sulfates, glucoronides, and selected organic anions and organic cations. OATPs control uptake of many drugs, including radiotracers (Tc-99m-HIDA). OATP2B1 also controls uptake of bromosulfaphtalein (possible Tc-99m HIDA) and steroid sulfates. Other sodium-independent uptake systems, separate from OATPs, are the organic anion transporter2\/organic cation transporter1 (OAT2\/OCT1) gene family members, and they control uptake of organic anions and organic cations, respectively.\n\nBesides the above group of uptake transporters, the basolateral domain has transporters that control excretion of substrates from the hepatocyte into blood (reflux) in the space of Disse (Fig. 2.1.1). These transporters belong to the adenosine triphosphate (ATP) binding cassette (ABC) family transporters called multidrug resistance-associated proteins (MRPs). Of the six known MRPs, five (MRP1, MRP3, MRP4, MRP5, and MRP6) are located along the basolateral border and play a role in the efflux of drugs and their metabolites (MRP4 and MRP5), drug conjugates (MRP1), and bile salts (MRP3) into the space of Disse. The sixth MRP (MRP2) is located along the canalicular border and controls excretion of bilirubin, bile salts, and other organic anions into the canaliculi.\n\n### 2.1.2 Nuclear Receptors\n\nOf the more than 100 nuclear receptor super-family members known in the mammalian cells, 49 have been identified in the human cell and are divided into four major classes [8]. Class I nuclear receptors are homodimers and include most steroid receptors (glucocorticoids, estrogens, androgens, mineralocorticoids, and progesterone). Class II receptors consist of eight heterodimer partners of RXR (retinoid X receptor) and include constitutive androstane receptor (CAR), farnesoid X receptor (FXR), liver X receptor (LXR), peroxisomal proliferator receptor (PPAR), pregnane X receptor\/steroid, and xenobiotic receptor (PXR\/SXR), retinoic acid receptor (RAR), thyroid hormone receptor (TR), and vitamin D receptor (VDR). Class II nuclear receptors play a major role in controlling the function of the hepatocyte. Class III nuclear receptors are orphan homodimers and include retinoid X receptor (RXR), chicken ovalbumin upstream promoter (COUP-TF), and hepatocyte nuclear factor 4 (HNF4), and class IV is monomers and includes liver receptor homologue1 (LRH1). The short heterodimer partner (SHP) is a nuclear receptor separate from the other class four types described (Table 2.1.2).\n\nTable 2.1.2\n\nNuclear receptors, ligands, and their target genes that influence uptake and excretion of organic anions by the hepatocyte\n\nNuclear receptor | Ligand (s) | Major target gene\n\n---|---|---\n\nRXR partners (class II receptors)\n\nFXR (farsenoid X receptor) | Bile acids, bilirubin | BSEP, SHP, UGTs, SULTS, MRP2, MDR3\n\nPXR (pregnane X receptor) | Xenobiotics, UDC | CYP3A, OATP1B1, MRP2, MRP4, GST\n\nCAR (constitutive  X receptor) | Xenobiotics, phenobarb | CYP3A, OATP1B1, MRP2, MRP4, UGT, SULTs, GSTs\n\nLXR (liver X receptor) | Oxysterols (metabolites of cholesterol) | CYP7A, CYP8B, ABCG5\/8\n\nRAR (retinoic acid receptor) | All-trans retinoic acid | NTCP, MRP2\n\nPPAR (peroxisomal  proliferators receptor)\n\nOthers\n\nSHP-1 (short heterodimer partner) | None | Inhibits NTCP, CYP7A, CYP8B.\n\nHNF-\u03b1 (hepatocyte nuclear factor \u03b1) | None | NTCP, CYP7A.\n\nModified from Boyer [9]\n\nA typical nuclear receptor consists of five functional domains (Fig. 2.1.2). At the aminoterminal (N) end is the activation function 1 (AF1) region, which is responsible for ligand-independent transcriptional activation and coordination. DNA-binding domain (DBD) controls high affinity recognition with specific response. The hinge region in the middle facilitates coordination of multiple domains. Ligand-binding domain (LBD) determines specificity and affinity and is responsible for manifesting species variability. The C-terminal end contains activation function 2 (AF2), acts as a control switch, and maintains ligand-dependent transcriptional function [8].\n\nFig. 2.1.2\n\nStructure of class II nuclear receptors. A nuclear receptor consists of five functional domains. The aminoterminal (N) end is the activation function 1 (AF1) region, which controls the ligand-independent transcriptional activation and coordination. The DNA-binding domain (DBD) controls high-affinity recognition with a specific response. The middle region (HINGE) facilitates coordination of multiple domains. The ligand-binding domain (LBD) determines specificity, affinity, and species variability. The C-terminal end contains activation function 2 (AF2) and acts as a control switch to maintain ligand-dependent transcriptional function\n\n### 2.1.3 Regulation of Basolateral Transporters\n\nClass II nuclear receptors control many of the functions of the hepatocyte. By definition, class II nuclear receptors cannot act alone or as homodimers. They act by forming a heterodimer partner with retinoid X receptor (RXR). After complexing with RXR, class II receptors acquire DNA-binding capacity and regulation of transcriptional activity. Five (FXR, CAR, PXR, LXR, and RAR) of eight class II nuclear receptors play major roles in influencing hepatic uptake and excretion of organic anions (Table 2.1.2).\n\nCholestasis suppresses sodium taurocholate-cotransporting polypeptide (NTCP) through FXR (farnesoid X receptor)-mediated induction of short heterodimeric partner 1 (SHP1), which prevents further uptake of bile salts that may otherwise reach toxic levels. Cholestasis also downregulates OATP1B1 through bile acid-mediated activation of SHP1, which decreases hepatocyte nuclear factor \u03b1 (HNF\u03b1). HNF\u03b1 is one of the major activators of OATP1B1. Although cholestasis in general downregulates nuclear receptors, it stimulates OATP1B3 via activation of FXR, and thus provides an escape mechanism for clearance of xenobiotics from the body (Fig. 2.1.2). After the uptake, intracellular transit of both sodium-dependent and sodium-independent substrates is regulated by the cyclic adenosine monophosphate-mediated dephosphorylation process, which is controlled by protein kinase B. Uptake of toxins like phalloidin and microcystin is mediated by OATP1B1 and OATP1B3, whereas the uptake of the most toxic natural substance known, amanitin, is controlled solely by OATP1B3 [7].\n\n### 2.1.4 Transport Through the Hepatocyte\n\nAfter uptake along the basolateral border facilitated by NTCP, bile acids are hydroxylated and transported through the hepatocyte via a 33-kDa cytosolic protein, 3-\u03b1-hydroxysteroid dehydrogenase in phase II (Fig. 2.1.3.). After its uptake, bilirubin binds to glutathione-S-transferase and undergoes conjugation (phase III) by hepatic microsomal enzyme uridine-diphosphonate glucoronyl transferase (UGT) to form monoglucoronide and then diglucoronide [9]. The conjugation process converts hydrophobic salts into hydrophilic salts, which facilitates rapid excretion into bile canaliculi. Many organic anions (including Tc-99m-HIDA) are transported through the hepatocyte by yet undefined mechanisms.\n\nFig. 2.1.3\n\nMicroenvironment and transporter proteins of the hepatocyte. Substrates are carried in blood loosely bound to albumin and delivered into the space of Disse. Basolateral domain of the hepatocyte has many transporter proteins that control uptake (red) and excretion (blue) of substrates from and into blood in the space of Disse. Uptake proteins (red) include four organic anion transporter proteins (OATPs), sodium taurocholate cotransporting peptide (NTCP), and sodium\/potassium ATPase. It has five multidrug resistance-associated proteins (MRPs) that control reflux of substrates from the cytoplasm into blood. After the uptake, substrates are metabolized (phase 2), conjugated (phase 3), and excreted (phase 4) unchanged into bile canaliculi. Excretion is controlled by canalicular domain proteins, such as multidrug resistant p-glycoproteins (MDR1, MDR2), MRP2, bile salt export protein (BSEP), breast cancer-resistant protein (BCRP), organic cation (OC), and flippases (ABCG5\/ABCG8), FIC1 protein\n\n### 2.1.5 Secretion into Bile Canaliculi\n\nThe quantity of solute transported across the canalicular membrane is the rate-limiting step in the volume of bile secreted per day. The canalicular membrane contains several ATP-dependent and ATP-independent transport proteins (pumps) to enable secretion of solutes from the hepatocyte into canaliculi [7, 10]. These pumps include ATP-dependent multidrug-resistance-1 p-glycoprotein (MDR1) and phospholipid transporter multidrug-resistance p-glycoprotein 3 (MDR3). The canalicular membrane also localizes multidrug resistance-associated protein 2 (MRP2), canalicular-bile-salt-export pump (BSEP or SGPG) and ABC half transporters, and breast cancer-resistance protein (BCRP), all of which facilitate excretion of bile salts and xenobiotics into bile canaliculi. Flippases (ABCG5 and ABCG8) control cholesterol metabolism and excretion both by hepatocytes and intestinal cells. The ATP-independent transport systems include a chloride channel, a chloride-bicarbonate-anion exchanger, and a glutathione (GSH) transporter (Fig. 2.1.1). Secretion of other organic anions, such as bilirubin, BSP, indocyanin green, and glutathione (Tc-99m-HIDA), is controlled mainly by MRP2. The secretion of organic cations (e.g., cancer chemotherapy agents, cyclosporin A, calcium channel blockers, and other drugs) is mediated by MDR1-a 170 gene product [11]. After passing through the tight junction, sodium and other cations enter the canaliculi through the space between the lateral domain of two adjacent hepatocytes, and the water then simply follows the electrolytes by passive diffusion.\n\n### 2.1.6 Regulation of Canalicular Membrane\n\nProduction of bile salt export protein (BSEP) and multidrug resistance glycoprotein 3 (MDR3) is controlled by a FXR-mediated process resulting in increased bile salt excretion into canaliculi, thereby facilitating formation of mixed micelles (Fig. 2.1.3). This action protects hepatocytes and cholangiocytes from toxic levels of bile salts. FXR also upregulates MRP2 and increases bile salt excretion into canaliculi. PXR (pregnane X receptor) upregulates MDR1, which is a key transporter protein in cellular excretion of many drugs and xenobiotics. LXR (liver X receptors \u03b1 and \u03b2) controls flippases, ABCG5 and ABCG8, and transport proteins [9].\n\nCholangiocytes along the bile ducts further modify bile composition by selective absorption or secretion of bile solutes and water. Cholangiocytes absorb bile salts through apical sodium-dependent bile salt transporter (ASBT) and OATP1A2. After their uptake, bile salts are excreted through the basolateral membrane (via MRP3) into the peribiliary plexus where they reach the portal circulation. Bile acids and sterols also use organic solute transporters (OST\u03b1\/OST\u03b2) to be secreted into the peribiliary plexus through the basolateral domain. Unlike the basolateral border of the hepatocyte, which lacks MRP2, the basolateral border of the cholangiocyte contains MRP2 that controls excretion of organic anions into peribiliary plexus (Fig. 2.1.1).\n\n### 2.1.7 Aquaporins\n\nOf the daily total bile volume of 600 ml, 450 ml (75%) is secreted by hepatocytes, and 150 ml (25%) is added by the cells lining the canaliculi (cholangioles or cholangiocytes). Of a total of 450 ml hepatocellular bile, 225 ml (50%) is bile salt dependent, and the remaining 225 ml (50%) is bile salt independent (Fig. 2.1.1). Although the cholangiocytes account for only 3 to 5% of liver volume, they play a major role controlling daily bile volume mainly by secretion or absorption of water by either direct passive membrane passage or through special water-channel proteins called aquaporins (AQPs) located within the hepatocytes and cholangiocytes. AQPs are small (25-34 kDa) hydrophobic protein molecules consisting of 263-323 amino acids. Both amino and carboxy terminals are located intracellularly within the cytoplasm (Fig. 2.1.4). Each AQP monomer has six \u03b1 helical transmembrane domains connected by five loops, A-E (Fig. 2.1.4A). Three of the connecting loops (A, C, E) are extracellular, and two (B, E) are intracellular [12]. When one intracellular and one extracellular loop, each containing Asp-Pro-Ala (NPA) amino acids, are juxtaposed to within the plasma membrane, AQP forms a tetramer containing four single water channels and allows molecules of 3 \u00c5 size or less to pass through (Fig. 2.1.4B). This enables water molecules (2\u00c5) to pass through the tight junction readily. Figure 2.1.5 summarizes the mechanisms and carrier proteins that play a major part in the transport of water from blood into the hepatocyte and finally into bile canaliculi.\n\nFig. 2.1.4\n\nStructure of aquaporins. Aquaporins are membrane proteins that regulate water movement. Each aquaporin has six alpha helical transmembrane domains connected by five loops, A-E E (top). Three of the connecting loops (A, C, E) are extracellular and two (B, E) are intracellular. Each aquaporin forms a tetramer (four single water channels) when one intracellular and one extracellular loop, each containing Asp-Pro-Ala (NPA) amino acids, are juxtaposed within the plasma membrane and allows molecules of 3 \u00c5 size or less to pass through (bottom). This enables water molecules (2\u00c5) to pass through the tight junction readily\n\nFig. 2.1.5\n\nWater movement within the hepatocytes and cholangiocytes. In the basal state, aquaporin 8 and aquaporin 1 are distributed free within the cytoplasm of the hepatocytes and cholangiocytes, respectively. Water passes passively through the lipid plasma membrane, facilitated by AQP9 and AQP4 water channels located on the membrane, respectively. When stimulated by cholecystokinin or secretin, hepatocyte AQP8 translocates to the canalicular border, and cholangiocyte AQP1 translocates to the apical border, promoting rapid passage of water from the cell into the bile duct lumen. In the stimulated state, each AQP channel can increase its water passage by more than ten times at its basal state\n\nWater can pass either through the cell (transcellular) or between two adjacent (paracellular) cells. When electrolytes, bile salts, and other organic anions are transported from the basolateral to the canalicular border through the hepatocyte, and secreted into canaliculi, water follows passively through the cell via both channel-mediated and non-channel-mediated pathways. Of the 13 AQPs that have been identified in the mammalian cells, seven (AQP0, AQP1, AQP4, AQP5, AQP8, AQP9, AQP11) are found within the hepatobiliary system [13]. Three of the AQPs (AQP0, AQP8, AQP9) are found in the hepatocytes, and two (AQP1, AQP4) are localized in the cholangiocytes. Four of them (AQP1, AQP4, AQP8, AQP9) play a major role in controlling water transport in the hepatobiliary tree. In the basal state, AQP8 and AQP1 are distributed free within the cytoplasm of the hepatocytes and cholangiocytes, respectively, and water diffuses passively through the lipid plasma membrane, facilitated by AQP9 and AQP4 water channels on the membrane (Fig. 2.1.5). In the stimulated state (CCK or secretin), hepatocyte AQP8 translocates to the canalicular border, and cholangiocytes AQP1 translocates to the apical border, allowing rapid passage of water from the cell into the bile duct lumen. Each AQP maintains its own rate of water transport; AQP0 is the slowest, while AQP1 and AQP4 allow 50-80 times more rapid flow of water. In the stimulated state, each AQP channel can increase its water transport ten times more rapidly than at the basal state.\n\n### 2.1.8 Protein Secretion\n\nLiver is the main source of plasma proteins, albumin, and globulins. Serum albumin synthesized entirely by the hepatocytes accounts for 60% of plasma proteins, is composed of 585 amino acids, and does not contain any carbohydrate moiety. In addition to controlling osmotic pressure, albumin functions as a carrier protein for drugs, metals, vitamins, amino acids, steroid, fatty acids, and Tc-99m-HIDA. Other proteins secreted by hepatocytes include \u03b1-1 anti trypsin, \u03b1-fetoprotein, \u03b1-2 macroglobulin, antithrombin lll, ceruloplasmin, C-reactive protein, fibrinogen, haptoglobin, hemopexin, and transferrin (Table 2.1.2). Most of these proteins are composed of a carbohydrate moiety and hence are called glycoproteins [14]. Hepatic bile is relatively more dilute (contains fewer bile salts, bilirubin, chloride, and bicarbonate per liter) than the gallbladder bile (Table 2.1.3).\n\nTable 2.1.3\n\nPlasma proteins secreted by hepatocytes [11]\n\nProtein | Molecular weight (kDa) | Function | Ligand binding | Plasma conc.  (mg dl-1)\n\n---|---|---|---|---\n\nAlbumin | 66 | Osmotic pressure | Hormones amino acids fatty acids, vitamins | 4,500-5,000\n\n|\n\nCarrier protein\n\n|\n\nAlpha-1 anti-trypsin | 54 | Trypsin and general | Present in serum & tissue secretions | 1.3-1.4\n\n|\n\nProtease inhibitor\n\n|\n\nAlpha Feto adults protein | 72 | Osmotic regulation | Hormones | Undetectable in adults\n\n|\n\nCarrier protein | Amino acids | Present in fetal blood\n\nAntithrombin lll | 65 | Protease inhibitor | Binding to Protease | 15-60\n\nCeruloplasmin | 134 | Copper transport | 6 copper atoms per mol | 15-60\n\nC-reactive protein | 105 | Tissue inflammation | Complement C1q | Increased in inflammation\n\nFibrinogen | 340 | Fibrin precursor during hemostasis.\n\n|  |\n\n200-450\n\nTransferrin | 80 | Iron transport | Two iron atoms per mol | 3-6.5\n\nHaptoglobin | 100 | Transport of hemoglobin | Hemoglobin | 40-180\n\nProthrombin | 72 | Hemostasis | Calcium chelation | 10.0\n\n### 2.1.9 Cell Death: Apopstosis or Necrosis\n\nLiver, being metabolically very active, has mechanisms to increase or decrease the number of cells needed to carry out complex biological functions. It can get rid of unwanted cells through cell death or recruit new cells through regeneration. Liver can regenerate to its original size within a few weeks after resection of 60-70% of its volume. Cell death is a common phenomena associated with varieties of liver diseases, including viral hepatitis, cholestasis, ischemia\/reperfusion injury, and hepatotoxins. Cell death occurs in one of two forms: necrosis or apopstosis. Both forms utilize a common pathway, but with different end results (Fig. 2.1.6). They involve participation of the plasma membrane, mitochondria, nucleus, endoplasmic reticulum, and lisosomes [15]. Necrosis is an acute process involving contiguous liver cells and takes place rapidly within a few minutes. Cells swell, forming blebs along the plasma membrane, disrupting its permeability, which ultimately results in its rupture with the release of cytosolic proteins, such as aspartate aminotransfarase (AST), alanine aminotransfarase (ALT), alkaline phosphatase (Alk.Phos), and lactic dehydrogenase (LDH), into blood. Necrosis is associated with acute inflammatory cell infiltration. Apoptosis, on the other hand, is a programmed cell death that occurs at a relatively a slow pace, requiring ATP. It affects cells at discontinuous locations, and death is characterized by chromatin condensation, DNA degradation, and shrinkage of cells with very little acute inflammatory cell infiltration [16]. Cytochrome c plays a central role in both processes (Fig. 2.1.6).\n\nFig. 2.1.6\n\nCell death through apoptosis or necrosis. Both forms utilize a common pathway, but with different end results. The process is initiated by interaction of death ligands with its corresponding receptor, which converts procaspase 8 to caspase 8. Caspase 8 can release caspase 3 directly in the type 1 mechanism. In the type 2 mechanism, caspase 8 converts Bid to tBid, which acts on the mitochondrial membrane, which releases cytochrome c. In the absence of ATP, necrosis sets in, involving contiguous liver cells, and takes place rapidly within a few minutes. Cells swell, forming blebs along the plasma membrane, disrupting its permeability, resulting in a rupture with the release of cytosolic proteins into the blood stream. Necrosis is followed by acute inflammatory cell infiltration. Apoptosis, on the other hand, is a programmed cell death that requires the presence of ATP and occurs at a relatively a slow pace. It affects cells at discontinuous locations, and death is characterized by chromatin condensation, DNA degradation, and shrinkage of cells with very little acute inflammatory cell infiltration (adopted from [16])\n\nHepatocytes, cholangiocytes, sinusoidal endothelial cells, stellate cells, and Kupffer cells express death receptors, such as tumor necrosis factor-alpha receptor 1 (TNF\u03b1-R1). The plasma membrane receives death signals through injury by toxins, ischemia\/reperfusion injury, or toxic biological waste products. Death ligand and receptor interactions release adaptor proteins, TRADD and FADD, which in turn lead to activation of caspase 8 ( cysteine-asp artate proteases ). Caspase 8 can directly release the end product in the form of caspase 3 (type 1 signaling), which induces apoptosis (Fig. 2.1.7). Activated caspase 8 converts cytosolic inactive protein Bid to its active form, tBid, which translocates to the mitochondria and releases cytochrome c through activation of Bak and Bax, two members of the Bcl2 family (type 2 signaling). Type 2 signaling leads to opening of membrane permeability transition (MPT) pores in the inner membrane of the mitochondria. Opening of MPT starts the process of cell death, either through necrosis or apoptosis, depending upon the next sequence of events that follows [17]. If the MPT opening is sudden due hepatotoxins, ischemia\/reperfusion injury, or calcium overload, all of which lead to ATP depletion, the process leads to mitochondrial depolarization, disruption of oxidative phosphorylation, and mitochondrial swelling, rupture of the outer membrane, and necrosis [18]. In the presence of an adequate amount of ATP, cytochrome c releases caspase 9, which in turn releases caspase 3, which promotes apoptosis (Fig. 2.1.6).\n\nFig. 2.1.7\n\nDeath ligand and receptor interaction. Plasma membrane receives death signals through injury by toxins, ischemia\/reperfusion injury, or toxic biological waste products. Death ligand and receptor interactions release adaptor proteins, TRADD and FADD, which in turn lead to activation of procaspase 8 (cysteine-aspartate proteases) to caspase 8. Caspase 8 can directly release the end product caspase 3 (type 1 signaling) that induces apoptosis. Activated caspase 8 converts cytosolic inactive protein, Bid, to its active form, tBid, which translocates to the mitochondria and releases cytochrome c through activation of Bak and Bax (type 2 signaling). Type 2 signaling leads to opening of membrane permeability transition (MPT) pores in the inner membrane of the mitochondria. Opening of MPT starts the process of cell death, either through necrosis or apoptosis, depending upon the next sequence of events that follows. If the MPT opening is sudden due to death receptor-ligand interaction, which leads to ATP depletion and rupture of the outer membrane, necrosis is the outcome. Nuclear factor k beta in the genes controls cell death. In the presence of adequate amounts of ATP, cytochrome c releases caspase 9, which in turn releases caspase 3, which promotes apoptosis\n\n### 2.1.10 Bile Entry, Storage, and Concentration by the Gallbladder\n\nHepatic bile that enters the gallbladder is of much lower osmolality than the bile that leaves the gallbladder after a meal (Table 2.1.1). A major portion (60-70%) of the hepatic bile secreted during fasting enters the gallbladder, and a minor fraction enters the duodenum directly, depending upon the tonus of the sphincter of Oddi (Fig. 2.1.8). During a period of 10 h in the night, the liver produces about 250 ml of bile (25 ml h-1 or 0.42 ml h-1), of which 175 ml (70%) enters the gallbladder (17.5 ml h-1 or 0.3 ml min-1). An empty gallbladder can fill to its maximum capacity of 50 ml during a period of 6 h. A fully filled gallbladder continues to receive hepatic bile secreted during fasting by absorbing 0.3 ml of water per minute. This is accomplished primarily by absorption of water and electrolytes through the gallbladder wall. As much as 90% of water can be absorbed through the gallbladder wall during a 6-h period. Dietschy demonstrated that 100 ml of hepatic bile placed inside the gallbladder reduces to less than 10 ml in 6 h mainly through absorption of water (Fig. 2.1.9). As a consequence of this selective water absorption, the concentration of solutes increases in the gallbladder bile [19]. This process of selective absorption of water resulting in higher concentration of bile salts, bilirubin, cholesterol, fatty acids, and lecithin in the gallbladder bile than hepatic bile is called the concentration function of the gallbladder [20, 21]. A normal gallbladder can sequester all of 3-6 g total body bile salts within it after an overnight fast. Fresh hepatic bile enters the gallbladder along its central long axis and moves laterally to reach the wall as the space is made available through removal of water. It takes nearly 30 min for the fresh hepatic bile to reach the wall from the central long axis [21].\n\nFig. 2.1.8\n\nBile entry mechanism into the gallbladder. A higher mean (range) pressure at the sphincter of Oddi (15 cm of H2O) than the pressure inside the gallbladder lumen and absorption of water through the wall during fasting facilitate constant hepatic bile inflow into the gallbladder\n\nFig. 2.1.9\n\nBile concentration. Mainly through different rates of absorption, gallbladder (rabbit) increases the concentration of sodium and bile salts and decreases the concentration of chloride and bicarbonate when compared to hepatic bile. Gallbladder bile volume decreases by 90% of its basal volume to achieve these concentrations [20]\n\nThe volume of hepatic bile that enters the gallbladder during fasting is controlled by two mechanisms, the tonus of the sphincter of Oddi and absorption of water through the gallbladder wall (Fig. 2.1.10). Under basal conditions, the mean pressure in the sphincter of Oddi is 15 cm of water, in the common bile duct, 12 cm of water, and in the gallbladder, 10 cm of water. By choosing the path of least resistance, the hepatic bile enters the gallbladder. The tonus of the sphincter of Oddi is dependent upon the frequency and amplitude of phasic wave contractions. The phasic wave frequency ranges from 1 to 13 per minute with an average of six contractions per minute [22]. High frequency contractions (> 8 min-1) are relatively rare (14%). Sphincter of Oddi phasic wave contractions occur in conjunction with phase III of the migrating motor complex, which begins in the stomach and traverses through the duodenum and jejunum [23].\n\nFig. 2.1.10\n\nAbsorption of water through the gallbladder epithelium. Lateral intercellular channels between the columnar epithelial cells are widely open during fasting, allowing free passage of water from the lumen into the connective space. Water absorption creates space for constant entry of hepatic bile into the gallbladder during fasting [20]\n\nThe second mechanism that promotes hepatic bile entry into the gallbladder is the rate of absorption of water through the gallbladder wall. During fasting, the lateral intercellular channels between the columnar epithelial cells are widely opened, allowing the passage of sodium and water from the gallbladder lumen into the interstitial spaces and then the hepatic venous blood (Fig. 2.1.4). Constant removal of water allows steady entry of hepatic bile into the gallbladder (Fig. 2.1.11). These lateral intercellular spaces collapse when the gallbladder wall contracts following ingestion of a meal or injection of cholecystokinin. Quabain inhibits water transport across most epithelial membranes, including the gallbladder [20]. Spontaneous gallbladder emptying and refilling play a minor role in making room for the fresh hepatic bile. In large number of normal subjects monitored continuously for 2 h with Tc-99m-HIDA by the authors, spontaneous gallbladder emptying to the extent of 5-10% was noticed in less than 2% of the subjects. The bile that enters the duodenum during fasting normally moves antegrade towards the jejunum. Normally, there is no bile reflux from the duodenum into the stomach in the basal state.\n\n### 2.1.11 Gallbladder Emptying\n\nEmptying of the gallbladder is under both hormonal and nervous control, with hormonal control playing the major role. Nervous control is exerted through both the sympathetic and parasympathetic system as shown in Fig. 1.1.12 of Chap. 1. The cholinergic parasympathetic nerve fibers to the gallbladder come primarily from the anterior gastric plexus (left vagus) and control its contraction and emptying. The gallbladder response to sham feeding is mediated through these cholinergic nerve fibers and can be blocked with atropine or after vagotomy [24]. The parasympathetic cholinergic nerve fibers to the sphincter of Oddi come mainly from the posterior gastric plexus (right vagus). Sympathetic post-ganglionic nerve fibers from the celiac ganglion reach the gallbladder and the sphincter of Oddi. Sympathetic nerve stimulation relaxes the gallbladder wall and promotes hepatic bile entry.\n\nThe hormone-induced contraction and emptying of the gallbladder occur mainly through endogenous release of cholecystokinin (CCK), demonstrated first in 1928 by Ivy and Oldberg [25]. Cholecystokinin, a linear 33 or 39 amino acid polypeptide, is produced from a large precursor protein with 114 amino acids. Most of the biological functions of the hormone are confined to the last four carboxy terminal amino acids. A much shorter cholecystokinin with only eight carboxy terminal amino acids (CCK-8) carries out most of the biological functions of the parent molecule with 33 amino acids [26]. The contraction and emptying of the gallbladder begin within 2-3 min after an intravenous administration of CCK-8, but it may take as long as 10-20 min to begin emptying following a meal [27]. This time delay in gallbladder emptying after a meal is due to a combination of time taken for the meal to pass from the stomach into the duodenum and the time taken for the CCK-secreting cells in the duodenal mucosa to release enough hormones into the blood stream. Cerulein, motilin, and other gastrointestinal hormones with an identical carboxy terminal tetrapeptide also induce gallbladder contraction and emptying [28].\n\nFig. 2.1.11\n\nPattern of bile transit within the gallbladder. Fresh hepatic bile enters the gallbladder along its central long axis and moves laterally to reach the wall as water is removed by the lateral intercellular channels. It takes about 30 min for the fresh hepatic bile to reach the wall from the central long axis. Fully filled gallbladder outline is superimposed onto early frames to show how radiolabeled fresh bile moves inside. Radiolabed bile first enters at 12 min and reaches the wall at 48 min [21]\n\n#### 2.1.11.1 Spleen Function\n\nThe spleen is composed mostly of reticuloendothelial cells and lymphoid tissue. The spleen is usually seen during radionuclide imaging with radiocolloids and radiolabeled red blood cells, leucocytes, monoclonal antibodies, or peptides (somatostatin). As the spleen does not concentrate Tc-99m-HIDA, it is not seen during functional hepatobiliary imaging.\n\nA normal spleen weighs between 80-200 gm with an average of 150 gm [1]. In the posterior view of a radiocolloid scan, the spleen normally measures 10.5 cm along the oblique axis. The spleen has to enlarge more than 2.5 times its normal size before it is palpable in the left upper quadrant during a routine physical examination. Most of the palpable spleens are enlarged, but not all non-palpable spleens are normal in size.\n\nThe spleen carries out many important functions (Table 2.2.1) that include: (1) hemopoiesis, (2) destruction of senescent red blood cells, leucocytes, and platelets, (3) culling and pitting, (4) phagocytosis, (5) reservoir function, and (6) immunologic function [2].\n\nTable 2.2.1\n\nFunctions of the spleen\n\n(1) Hemopoiesis\n\n---\n\n(2) Destruction of senescent red blood cells, leucocytes and platelets\n\n(3) Culling and pitting\n\n(4) Phagocytosis\n\n(5) Reservoir function\n\n(6) Immunologic function\n\nDuring the first 6 months of intrauterine life, the spleen functions as a major hematopoietic organ, and this function normally disappears by birth. In thalassemia and myeloid metaplasia, the spleen is capable of resuming its intrauterine function in adult life to produce red blood cells. The normal function in adults is one of destruction of senescent red blood cells, leucocytes, and platelets. Excessive destruction of blood cells by the spleen results in anemia, leucopenia, or thrombocytopenia. The volume of red blood cells in the body and their destruction by the spleen are measured by labeling the cells with chromium-51 [3]. During labeling, hexavalent chromium-51 (Na2CrO4) crosses the red cell membrane and attaches to hemoglobin after reduction into a trivalent form [4]. The physical half life of Cr-51 is 27 days. Random labeling, elution of Cr-51 and death of senescent red cells all account for the mean RBC survival half-time of 35 days (normal life span of RBC is 120 days). Chromium-51 released after RBC death is taken up by the reticuloendothelial cells, and it does not label other red blood cells in blood; hence, it serves as an ideal marker for RBC survival studies.\n\nThe selective removal of abnormal red cells by the spleen is called culling, and removal of intra-erythrocytic inclusions without destroying the RBC is called pitting. Howell-Jolly bodies, remnant of RBC nucleus, are removed from the red blood cells by the spleen. The appearance of Howell-Jolly bodies in the peripheral blood, therefore, is an indication of either splenectomy or of a non-functioning spleen [5]. Hypersplenism is documented by showing increased spleen\/liver and increased spleen\/precordial count ratio in association with decreased RBC survival time. Return of splenic function after splenectomy is attributed to auto-transplantation (due to spillage) of the splenic tissue on the peritoneal surface or an accessory spleen [6]. Imaging of the spleen with radiocolloids, a popular modality in the 1970 and 1980s, is largely replaced today by computerized tomography and ultrasound. Radiocolloid spleen imaging is now obtained occasionally to clarify an abnormality that has already been detected with CT or ultrasound or to confirm splenomegaly in the diagnosis of polycythemia rubra vera [7].\n\nThe spleen capsule has a thin muscle layer whose contraction squeezes out the sequestered RBC, WBC, and platelets into peripheral circulation. Injection of epinephrine induces smooth muscle contraction with a subsequent rise in peripheral cell count [3]. The spleen plays a protective role on the lung tissue, and pulmonary hypertension is shown to develop after splenectomy in some patients [8]. The immunologic function of the spleen is carried out by the lymphocytes and reticuloendothelial cells (phagocytosis). The spleen produces antibodies against many microorganisms, especially polysaccharide-encapsulated bacteria, such as pneumococci. Overwhelming infection sometimes follows after splenectomy in children. Human splenic autotransplantation produces significant antipneumococcal antibody in response to administration of pneumococcal vaccine [9].\n\nReferences\n\n1.\n\nFitz JG. Cellular mechanism of bile secretion. In: Zakim D, Boyer TD, eds. Hepatology.  A textbook of liver disease. Philadelphia, WB Saunders, 1996, pp 362-376\n\n2.\n\nBrauer RW, Leong SF, Holloway RJ. Mechanism of secretion. Effect of perfusion pressure and temperature on bile flow and bile secretion pressure. Am. J Physiology 1954;177:103-106\n\n3.\n\nBoyer JL, Klatskin G. Canalicular bile flow and bile secretary pressure. Evidence for a non-bile salt dependent fraction in the isolated perfused rat liver. Gastroenterology 1970;59:853-859PubMed\n\n4.\n\nJones AL, Schmucker DL, Renston RH, Murakami T. The architecture of bile secretion. A morphological perspective of physiology. Dig Dis Sci 1980;25:609-629PubMedCrossRef\n\n5.\n\nSellinger M, Barrett C, Malle P, Gordon ER, Boyer JL. Cryptic Na+, K+-ATPase activity in the rat liver canalicular plasma membranes: evidence for its basolateral origin. Hepatology 1990;11:223-229PubMedCrossRef\n\n6.\n\nMeier PJ. Molecular mechanisms of hepatic bile salt transport from sinusoidal blood into bile. Am J Physiol 1995;269:G801-G812PubMed\n\n7.\n\nPauli-Magnus C, Meier PJ. Hepatobiliary transporters and drud-induced cholestasis. Hepatology 2006;44:778-787PubMedCrossRef\n\n8.\n\nKarpen SJ. Nuclear receptor regulation of hepatic function. J Hepatology 2002;36:832-850CrossRef00129-0)\n\n9.\n\nBoyer JL. Nuclear receptor ligands: rational and effective therapy for chronic cholestatic liver disease. Gastroenterology 2005;129:735-740PubMed\n\n10.\n\nTrauner M, Meier PJ, Boyer JL. Molecular pathogenesis of cholestasis. N Eng J Med 1998:339:1217-1227CrossRef\n\n11.\n\nKamimato Y, Gatmaitan Z, Hsu J, Arias IM. The function of Gp 170, the multidrug resistance gene product, in rat liver canalicular membrane vesicles. J Biol Chem 1989;264:11693-11698\n\n12.\n\nMasyuk AI, Marinelli RA, LaRusso NF. Water transport by epithelia of the digestive tract. Gastroenterology 2002;122:545-562PubMedCrossRef\n\n13.\n\nMasyuk AI, LaRusso NF. Aquaporins in the hepatobiliary system. Hepatology 2006;43:S75-S81PubMedCrossRef\n\n14.\n\nDonohue TM Jr., Tuma DJ, Sorrell MF. Plasma proteins metabolism. In: Zakim D, Boyer TD. Hepatology. A text book of liver disease, 3rd edn. Philadelphia, WB Saunders, 1996, pp 130-148\n\n15.\n\nLemasters JJ. Necrapopstosis and the mitochondrial permeability transition: shared pathways to necrosis and apoptosis. Am J Physiol 1999;276:G1-G6PubMed\n\n16.\n\nLemasters JJ. Dying of a thousand deaths: redundant pathways from different organells to apoptosis and necrosis. Gastroenterology 2005;129:351-360PubMedCrossRef\n\n17.\n\nMalhi H, Gres GJ, Lamaster JJ. Apoptosis and necrosis in the liver: a tale of two deaths? Hepatology 2006;43:S31-S44PubMedCrossRef\n\n18.\n\nKrishnamurthy G, Krishnamurthy S. Cholescintigraphic measurement of liver function: how is it different from other methods? Eur J Nucl Med Mol Imaging 2006;33:1103-1106PubMedCrossRef\n\n19.\n\nDietschy JM. Water and solute movement across the wall of the everted rabbit gallbladder. Gastroenterology 1964;47:395-408PubMed\n\n20.\n\nWheeler HO. Concentrating function of the gallbladder. Am J Med 1971;51:588-595PubMedCrossRef90283-X)\n\n21.\n\nKrishnamurthy S, Krishnamurthy GT. Hepatic bile entry into and transit pattern within the gallbladder lumen: a new technique quantitative cholescintigraphic technique for measurement of its concentration function. J Nucl Med 2002;43:901-908PubMed\n\n22.\n\nThune A, Scicchitano J, Roberts-Thompson I, Toouli J. Reproducibility of endoscopic sphincter of Oddi manometry. Dig Dis Sci 1991;36:1401-1405PubMedCrossRef\n\n23.\n\nLee SK, Kim MH, Seo DW, Yoo BM, Lee MH, Myung SJ, Min YI. Frequency of phasic wave contraction is variable during long-term sphincter of Oddi manometry. Am J Gastroenterol 1996;91:2395-2398PubMed\n\n24.\n\nFisher RS, Rock E, Malmud LS. Gallbladder emptying response to sham feeding in humans. Gastroenterology 1986;90:1854-1857PubMed\n\n25.\n\nIvy AC, Oldberg E. A hormone mechanism of gallbladder contraction and evacuation. Am  J Physiology 1928;86:599-613\n\n26.\n\nMutt V. Cholecystokinin: isolation, structure, and function. In: Jerzy Glass GB. ed. Gastrointestinal hormones. New York, Raven, 1980, pp 169-221\n\n27.\n\nBobba VR, Krishnamurthy GT, Kingston E, Turner FE, Brown PH, Langrell K. Gallbladder dynamics induced by a fatty meal in normal subjects and patients with gallstones: Concise communication. J Nucl Med 1984;25:21-24PubMed\n\n28.\n\nBloom SR, Adrian TE, Mitchenere P, et al. Motilin induced gallbladder contraction. A new mechanism. Gastroenterology 1981;80:1113\n\nReferences\n\n1.\n\n1. Mattsson O. Scintigraphic spleen volume calculation. Acta Radiol [Diagn] (Stockh) 1982;23:471-477\n\n2.\n\nSpencer RP, Pearson HA. The spleen as a hematological organ. Semin Nucl Med 1975;5:95-102PubMedCrossRef80007-9)\n\n3.\n\nGray SJ, Sterling K. The tagging of red blood cells and plasma proteins with radioactive chromium. J Clin Invest 1950;29:1604-1613PubMedCrossRef\n\n4.\n\nPollycove M, Tono M. Blood volume. In: Sandler MP, Patton JH, Coleman RE, Gottschalk A, Wackers FJTh, Hopper PB. Diagnostic nuclear medicine, 3rd edn. Williams and Wilkins, Baltimore, 1996, pp 827-834\n\n5.\n\nCrosby WH. Normal functions of the spleen relative to red blood cells. A review. Blood 1959;14:399-408\n\n6.\n\nPearson HA, Johnston D, Smith KA, Touloukian RJ. The born-again spleen. Return of splenic function after splenectomy for trauma. New Eng J Med 1978;298:1389-1392PubMedCrossRef\n\n7.\n\nSpencer RP. Spleen imaging. In: Sandler MP, Patton JH, Coleman RE, Gottschalk A, Wackers FJT, Hopper PB. Diagnostic nuclear medicine, 3rd edn. Williams and Wilkins, Baltimore, 1996, pp 865-874\n\n8.\n\nHoeper MM, Niedermeyer J, Hoffmeyer F, Flemming P, Fabel H. Pulmonary hypertension after splenectomy? Ann Intern Med 1999;130:506-509PubMed\n\n9.\n\nLeemans R, Manson W, Snijder JAM, Smit JW, Klasen HJ, The TH, Timens W. Immune response capacity after human splenic autotransplantation. Restoration of response to individual pneumococcal vaccine subtypes. Ann Surg 1999;229:279-285PubMedCrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_3(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 3. Imaging Agents\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nHistorical evolution The introduction of radiocolloids in the 1940s, whose rate of clearance from the circulation was used as an indicator of liver function, gave birth to nuclear hepatology [1]. Imaging of the liver morphology began in 1954 with gold-198 colloid using an automated rectilinear scanner developed by Cassen [2, 3]. Imaging of morphology was supplanted by imaging of liver physiology with the introduction of I-131 rose bengal in 1955 by Taplin et al. [4]. Morphology imaging gained wide clinical popularity after the introduction of technetium-99m colloid in 1965 [5], and a rapid leap in imaging of physiology occurred with the introduction of technetium-99m-HIDA agents in 1976 [6].\n\nHistorical evolution The introduction of radiocolloids in the 1940s, whose rate of clearance from the circulation was used as an indicator of liver function, gave birth to nuclear hepatology [1]. Imaging of the liver morphology began in 1954 with gold-198 colloid using an automated rectilinear scanner developed by Cassen [2, 3]. Imaging of morphology was supplanted by imaging of liver physiology with the introduction of I-131 rose bengal in 1955 by Taplin et al. [4]. Morphology imaging gained wide clinical popularity after the introduction of technetium-99m colloid in 1965 [5], and a rapid leap in imaging of physiology occurred with the introduction of technetium-99m-HIDA agents in 1976 [6].\n\n## 3.1 Morphology and Physiology Imaging Agents\n\nThe liver carries out the most complex biological functions through the hepatocytes, Kupffer cells, endothelial cells, fat cells (Ito cells), blood vessels and biliary epithelial cells. The liver imaging agents are classified broadly into two groups: (1) those that identify pathology mainly through detection of changes in liver morphology and (2) those that identify pathology by identifying changes in liver physiology (Table 3.1.1). A wide variety of imaging agents now available enable the study of specific cell functions (Table 3.1.2). Radiocolloids are the most common agents for imaging morphology, and Tc-99m-HIDA compounds are the most preferred agents for physiology. Since liver morphology imaging is now carried out mostly with CT or ultrasound, imaging of physiology is currently the most common diagnostic procedure in nuclear hepatology. Since the publication of the first edition of our book, fluorine-18-labeled 2-fluoro-2-deoxyglucose (18-FDG) has become a major factor in the assessment of primary and metastatic lesions of the liver and is included in the current edition.\n\nTable 3.1.1\n\nClassification of liver imaging agents\n\n(1) Morphology imaging agents | Radiocolloids (gold-198, Tc-99m-S colloid) gallium-67 citrate\n\n---|---\n\n(2) Physiology imaging agents | These agents can be further divided into four subgroups based on specific function\n\n(a) Hepatobiliary agents | Tc-99m-HIDA, Tc-99m-PG, I-131 rose bengal, etc.\n\n(b) Blood pool agents | Tc-99m-RBC, Tc-99m-albumin\n\n(c) Receptor-specific agents | Tc-99m-GSA, In-lll octreotide, In-lll monoclonal antibody, Tc-99m-monoclonal antibodies\n\n(d) Miscellaneous agents | Indium -lll WBC, Tc-99m-WBC(HMPAO), fluorine-18 2-fluoro-2-deoxyglucose (18FDG) and other agents that are used primarily for imaging of other organs, but pass through the liver during their elimination, enabling imaging of the hepatobiliary system, e.g., Tc-99m-sestamibi, Tc-99m-tetrofosmin, Tc-99m-HMPAO, etc.\n\nTable 3.1.2\n\nThe cell, mechanism of uptake, disposition and dose of radiolabeled agents for imaging of the liver and spleen\n\nAgent | Uptake by | Mechanism of uptake | Excretion into bile | Dose\n\n---|---|---|---|---\n\nTc-99-S colloid | Kupffer cell | Phagocytosis | No | 2-5 mCi\n\nTc-99m-GSA | Hepatocyte | ASGP receptor | No | 2-8 mCi\n\nTc-99m-HIDA | Hepatocyte | RME | Yes | 2-8 mCi\n\nTc-99m-RBC | Hemangioma | Blood pool | No | 10-20 mCi\n\nTc-99m HMPAO | Infection | Chemotaxis | No | 10-20 mCi\n\nIn-111 WBC(oxine) | Infection | Chemotaxis | No | 0.5-1.0 mCi\n\nIn-111 Octreotide | Somatostatin- | Receptor-ligand receptor | No interaction | 3-8 mCi\n\nIn-111 MOAB | TAG-72 | Antigen-antibody Interaction | No | 2-5 mCi\n\nGa-67 citrate | Hepatocyte | Unknown | No | 2-10 mCi\n\nF-18 FDG | Hepatocyte | Glucose receptor | No | 10-15 mCi\n\nASGP Asialoglycoprotein, GSA, galactosyl human serum albumin, HIDA hepatic iminodiacetic acid, RME receptor-mediated endocytosis.\n\n### 3.1.1 Radiocolloids\n\nRadiocolloids are small particles, 5-1 \u00b5m size, that are removed from circulation by the reticuloendothelial cells of the liver, spleen and bone marrow. They carry a negative charge of -30 mV and do not pass through the dialysis membrane, which is permeable to ions. However, they readily pass through an ion-exchange column and show no movement on paper chromatography [7]. Although Au-198 is no longer used for imaging, thorough understanding of its pharmacokinetics provides a sound basis for understanding the biokinetics of Tc-99m-S colloid and is described briefly below.\n\n### 3.1.2 Gold-198 Colloid\n\nGold (Au)-198 colloid is one of the smallest radiocolloid particles known to nuclear medicine. The particles vary in size from 5 to 50 m\u00b5, with an average size of 30 m\u00b5, and clear from blood with a T \u00bd of 3 min. Gold-198 has a physical half life of 2.7 days, decays by a beta minus emission and emits a monoenergetic gamma photon of 411 keV for imaging. The adult dose ranges from 100 to 150 \u03bcCi in 25 \u03bcg to 2.5 mg gold. The three organs concentrating Au-198 colloid are the liver, spleen and bone marrow, with the smallest particles preferentially taken up by the bone marrow and the largest particles by the spleen [9]. The percent dose localized in each organ depends upon its function and size, and the size and electrochemical character of the radiocolloid particles. Normally, the liver weighs about 1,500-1,800 g, the spleen 150-200 g and the bone marrow \u223c1,500 g (Table 3.1.3). Normally, about 90% of the Au-198 colloid dose is taken up by the liver, 7% by the reticuloendothelial (RE) cells of the bone marrow and 3% by the spleen [10]. In moderate hepatocellular disease, the liver mass increases (2,400 g) because of fatty infiltration, and the mass of the spleen increases (250 g) because of portal hypertension. In advanced cirrhosis, the liver actually shrinks in size (1,400 g) because of fibrosis, whereas the spleen continues to increase in size (400 g) because of the increase in portal hypertension. The mass of reticuloendothelial cells in the bone marrow does not change. In moderate liver disease, the uptake by the liver decreases to 70%. In advanced cirrhosis when the liver shrinks in size, the radiocolloid uptake may fall below 35%. As the uptake of radiocolloid by the liver decreases, the uptake by the spleen and bone marrow increases in direct proportion to the degree of portal hypertension.\n\nTable 3.1.3\n\nLiver, spleen and bone marrow mass in normal subjects and patients with liver disease [10]\n\nClinical status | Mass of the organ in grams\n\n---|---\n\nLiver | Spleen | Bone marrow\n\nNormal | 1,807 | 174 | 1,500\n\nEarly to intermediate liver disease | 2,400 | 250 | 1,500\n\nIntermediate to advanced liver disease | 1,400 | 400 | 1,500\n\n### 3.1.3 Technetium-99m-Sulfur Colloid\n\nTechnetium-99m-sulfur colloid particles are much larger, with a wider variation in size than Au-198 colloid particles, with an average size of about 300 m\u00b5 (Table 3.1.4). The usual dose for planar imaging in adults is 2-5 mCi. Liver perfusion and SPECT studies require a much larger dose, in the range of 5-10 mCi. Technetium-99m has a physical half life of 6 h and emits a gamma photon of 140 keV energy, which makes it ideal for imaging. Intravenously injected particles clear from blood with a T \u00bd of 2.5 min.\n\nTable 3.1.4\n\nCharacteristics of Tc-99m-S colloid\n\nParameter\n\n|   \n---|---\n\nHalf life | 6.03 h\n\nBlood clearance T\u00bd | 2.5 min\n\nParticle size range (\u03bcm) | 100-1,000\n\nParticle mean size (\u03bcm) | 300\n\nDecay constant | 0.1149 h-1\n\nMean disintegration | 87%\n\nG-rad \u03bcci-1 h-1 | 0.0369\n\nAdult dose | 2-8 mCi\n\nDose to liver from a study | 0.68-2.72 rads\n\nNormally, about 85% of the injected dose of Tc-99m-S colloid is taken up by the liver, 7% by the spleen, 5% by the bone marrow and the remaining 3% by other organs, such as the lungs, stomach, etc. [11]. In moderate parenchymal liver disease, the radiocolloid uptake by the liver decreases, and the uptake by the spleen and bone marrow increases. In severe parenchymal liver disease (cirrhosis), when the liver shrinks in size, \u223c30% of the dose is taken up by the liver, and as much as 30% by the spleen, 25% by the red marrow and the remaining 13% of the dose by other organs, including the lungs, kidney and stomach (Table 3.1.5). As most of liver morphology imaging is currently obtained with CT, MRI or ultrasound, radiocolloid imaging is chosen primarily for delineating the functional characteristics of the lesion that have already been detected with one of the other imaging modalities. Radiocolloid spleen imaging is often obtained for accurate measurement of spleen size in the diagnosis of polycythemia rubra vera and other myeloproliferative disorders. Technetium-99m-S colloid preparations are also used in the measurement of gastric emptying time, evaluation of shunt (LeVeen) patency and for the detection of acute GI bleeding, gastro-esophageal reflux or pulmonary aspiration of gastric contents, etc.\n\nTable 3.1.5\n\nRelative distribution of Tc-99m-sulfur colloid (% injected dose) in normal subjects and patients with liver disease [11] | Liver | Spleen | Marrow | Other\n\n---|---|---|---|---  \n|  |  |\n\nClinical status\n\nNormal | 85 | 7 | 5 | 3\n\n|\n\nMild to moderate liver disease | 67 | 13 | 12 | 8\n\n|\n\nModerate to severe liver disease | 32 | 30 | 25 | 13\n\n|\n\nThe radiocolloid dose is used within 6 h of its preparation, and the particles are shaken vigorously just prior to injection to prevent settlement at the bottom of the vial. As free Tc-99m pertechnetate appears in breast milk, mothers are instructed not to feed their infants with breast milk for the next 24 h and to use formula milk instead. The breast milk expressed prior to radiocolloid injection and stored is preferable to formula milk. The usual pediatric dose is 15-75 \u03bcCi kg-1 (0.56-2.78 MBq kg-1). For bone marrow imaging in pediatrics, the dose is 30-150 \u03bcCi kg-1 (1.1-5.6 MBq kg-1). The minimum dose per study is 600 \u03bcCi (22.2 MBq). For gastroesophageal reflux and pulmonary aspiration studies, the Tc-99m-S colloid dose is given orally, mixed with a liquid or a semisolid meal.\n\n### 3.1.4 Mechanism of Radiocolloid Uptake\n\nMetchnikoff in 1884 first observed a process where highly mobile polymorphonuclear leucocytes ingested (phagocytosis) foreign particles, microorganisms and cellular debris, removing them from the circulation. Similar phenomena were observed in the cells lining the liver sinusoids [12]. Kupffer in 1899 described the nature of these cells in the hepatic sinusoids which today bear his name, the Kupffer cells [13]. Aschoff in 1924 introduced the concept of the reticuloendothelial system consisting of the mesenchymal cells distributed throughout the body [14]. Radiocolloid uptake is seen primarily in three organs in the body: the liver, spleen and bone marrow. Lung and other organ uptake normally is not high enough to be seen on the images.\n\nThe uptake of radiocolloids by the RE system cells is dependent upon various factors, including particle size, charge, dose, chemical composition and other factors. The maximum phagocytic capacity in humans is 1.07 mg min-1 kg-1 body weight [15]. The RE system acts as a biological filter by removing effete cells and foreign material from blood and thus restricting the general toxic effect on the body. The filtering mechanism becomes increasingly efficient in the spleen as the particle size increases. The smallest particles are removed preferentially by the bone marrow, medium-size particles by the liver and the largest particles by the spleen. As the Au-198 colloid particles are the smallest (30 \u03bcm), most of them are taken up by the liver and bone marrow, and very few particles by the spleen, explaining the reason why the spleen is usually not visualized well in the scans obtained with gold-198.\n\nUpon intravenous injection, radiocolloid particles are coated by plasma opsonins, making them susceptible to phagocytosis. Radiocolloid-opsonin complex attaches to the RE cell membrane and initiates phagocytosis (Fig. 3.1.1). The cytoplasm of the RE cell flows around the opsonized radiocolloid particles as pseudopods, encircles the particle and ultimately incorporates into the cytoplasm, forming a phagosome [16, 17]. The ultimate fate of the radiocolloid in the phagosome depends upon its nature. The phagosome is either destroyed and the contents stored in the cytosol or the phagosome is destroyed, digested and its contents released back into circulation. Gold-198 radiocolloids are stored intracellularly, whereas the Tc-99m-S colloids are digested and released into the circulation [18].\n\nFig. 3.1.1\n\nMechanism of radiocolloid uptake. After intravenous injection, radiocolloid comes in contact with plasma proteins forming a radiocolloid-opsonin complex. The complex is encircled by pseudopodes of the Kupffer cells in the liver and reticuloendothelial (RE) cells in the spleen and bone marrow. After complete engulfment, the radiocolloid forms a phagosome within the cytosol\n\n### 3.1.5 Dosimetry of Radiocolloids\n\nThe liver is the critical organ for radiocolloids and receives 39 rads mCi-1 of Au 198 and 0.34 rad mCi-1 of technetium-99m-S colloid (Table 3.1.6). From one imaging study, the liver receives 5.8 rads from Au-198 (200 \u03bcCi dose) and 0.68 rads from Tc-99m-S colloid (2-mCi dose). Radiation to the liver decreases as the severity of liver disease increases. The total body receives 1.4 rads mCi-1 with Au-198 and 0.019 rads mCi-1 with Tc-99m-S colloid. Introduction of Tc-99m-sulfur colloid in 1965 was a major breakthrough that revolutionized liver morphology imaging in the late 1970s and through the early 1980s.\n\nTable 3.1.6\n\nAbsorbed dose (rads mCi-1) from Tc-99m-sulfur colloid in normal subjects and patients with liver disease [11] | Normal | Moderate disease | Severe disease\n\n---|---|---|---\n\nOrganLiver | 0.34 | 0.21 | 0.16\n\nSpleen | 0.21 | 0.28 | 0.42\n\nRed marrow | 0.02 | 0.04 | 0.07\n\nOvaries | 0.005 | 0.008 | 0.012\n\nTestes | 0.001 | 0.002 | 0.003\n\nTotal body | 0.019 | 0.019 | 0.019\n\n### 3.1.6 Technetium-99m HIDA Agents\n\nFunctional imaging nuclear hepatology took a quantum leap with the introduction of Tc-99m-HIDA agents by Loberg et al. in 1976 [6]. Hepatobiliary diseases are quite common, and they often present clinically with dramatic suddenness requiring immediate diagnosis and therapy (acute cholecystitis). Technetium-99m HIDA agents fulfill the requirement for a rapid diagnosis.\n\n### 3.1.7 Labeling\n\nTechnetium-99m-HIDA agents are lidocaine analogues. Lidocaine has been used in clinical practice for many years, and its pharmacokinetics are well understood. Liver is the primary site of uptake and metabolism of lidocaine and indocyanin green [19-21]. Lidocaine (C14H22N2O) has a molecular weight of 270.80 and clears from blood in a biexponential fashion; the fast component has a T\u00bd of 7 min, and the slow component a T \u00bd of 108 min. Lidocaine shows a high first-pass extraction by the liver. About 90% of extracted lidocaine is metabolized into monoethylglycylxylidine, and the remaining 10% is excreted in urine unchanged. Age does not affect the biokinetic behavior of lidocaine.\n\nBased upon its wide clinical application in cardiology and with the knowledge that lidocaine is metabolized primarily in the liver, it was hypothesized that a technetium-99m-labeled lidocaine or its analogues could find potential imaging application in either cardiology or hepatology. Since technetium-99m could not be attached to lidocaine directly, iminodiacetic acid (IDA) was chosen as a bifunctional chelate to carry the ligand (lidocaine) at one end and the radiotracer (Tc-99m) at the other end [6]. Each molecule of labeled Tc-99m-HIDA complex, therefore, consists of two molecules each of the ligand and the chelate and an atom of technetium-99m in the middle (Fig. 3.1.2). When Tc-99m-HIDA was injected into mice and gamma camera imaging began, the investigators were startled not to find any myocardial uptake, but were immensely pleased to see radioactivity first in the hepatocytes and later throughout the biliary system [22]. For lack of any other better terminology, the investigators settled on a new name, Hepatic IminoDiacetic Acid, or HIDA. Thus, the major portion of the name (HIDA) reflects the chelate (IDA) more than it does the ligand (lidocaine), which provides the most critical functional information.\n\nFig. 3.1.2\n\nMolecular structure and hepatobiliary transit of Tc-99m-HIDA. Lidocaine (green) is the ligand with the biologic function, technetium-99m (black) is the radiotracer, and iminodiacetic acid (IDA) is the chelate (red) that binds them together. A labeled whole complex consists of an atom of Tc-99m, two molecules of lidocaine and two molecules of IDA. Albumin delivers the radiotracer to the space of Disse where the dissociation takes place. Tc-99m HIDA is taken up by the hepatocyte and secreted into bile canaliculi in free form where it mixes with the hepatic bile and serves as an ideal in vivo tracer for imaging of the entire hepatobiliary tree [27]\n\nRadiolabeling with technetium-99m does not affect the blood clearance or the hepatic uptake of lidocaine, but it alters the intrahepatic transit. Unlike lidocaine, Tc-99m-HIDA is not metabolized during its transit through the hepatocyte. It is secreted as native Tc-99m-HIDA into the bile canaliculi. This feature is readily demonstrated by re-injection of radiolabeled gallbladder bile intravenously into the same animal where the exact kinetics of the original injection are reproduced. Lidocaine forms a dimer with technetium-99m, which increases the molecular weight from 270.8 for lidocaine to 833 for Tc-99m-HIDA complex (Fig. 3.1.2). Increase in molecular weight enhances hepatocyte uptake and excretion. Labeling with technetium-99m imparts hepatic specificity. Lidocaine labeled with C14 or Tin (Sn)-113m, however, does not show hepatic uptake and excretion; instead, it is excreted mostly through urine [6].\n\n### 3.1.8 Structure-Function Relationship\n\nThe basic configuration of all Tc-99m-HIDA agents is very similar (Fig. 3.1.3). The bifunctional chelate, IDA, attaches to a molecule of lidocaine at one end and to an atom of technetium-99m at the other. Technetium-99m is the radiotracer, and the biological function resides with lidocaine. The biokinetic behavior of the labeled complex can be altered by making substitutions in the benzene ring at positions 2,4,6 (ortho), 4 (para) or 5 (meta) with a methyl, ethyl, isopropyl or isobutyl group. A halogen is attached in the meta position (mebrofenin). More than 30 new compounds were created by making various substitutions at different positions [23, 24, 25]. Six of the compounds have undergone critical clinical trials, and three have been approved for routine use by the United State's Food and Drug Administration.\n\nFig. 3.1.3\n\nMolecular configuration of six Tc-99m HIDA agents. Biological function is altered (varying liver T 1\/2 ) by making different chemical substitutions at positions 2,4,6 of the benzene ring. Mebrofenin (TMB) has a bromine at position 5, which makes it highly resistant to displacement by bilirubin [26]\n\nHepatic uptake of Tc-99m-HIDA agents varies from a low of 82.5-98.1% [26]. Hepatic uptake of Tc-99m-disofenin is 89% and mebrofenin 98% (Table 3.1.7). The uptake and excretion of Tc-99m-HIDA agents are dependent upon various factors, of which molecular structure, weight, lipid solubility and protein binding are important parameters. Radiolabeled complexes with a molecular weight between 300 and 1,000 are preferentially taken up by the hepatocytes and rapidly secreted into bile. An isopropyl substitution at 2 and 6 positions (disofenin) makes it a better agent than a dimethyl or diethyl substitution at the same locations, or an isopropyl substitution at the para position (PIPIDA). A methyl substitution at positions 2, 4, and 6 and a bromine atom at 5 (mebrofenin) result in creating the best agent of all. Tc-99m-mebrofenin shows the highest liver uptake (98%) and strongly resists displacement by a high bilirubin level. Both agents are secreted from the liver rapidly into bile with a mean excretion half time of 17 min with mebrofenin and 19 min with disofenin. The dose not taken up by the liver is excreted through the kidneys. Urinary excretion of mebrofenin is 2% and disofenin 11% of the dose injected.\n\nTable 3.1.7\n\nBiokinetic features of Tc-99m mebrofenin and Tc-99m disofenin\n\nAgent | Liver uptake (% dose) | Urine excretion (% dose) | Liver excretion (T\u00bd, min) | Radiation (mrad) to\n\n---|---|---|---|---\n\nLiver | Gallbladder\n\nTc-99m-Mebrofenin (Choletec) | 98 | 2. | 17 | 70 | 410\n\nTc-99m-Disofenin (Hepatolite) | 89 | 11 | 19 | 75 | 370\n\n### 3.1.9 Biokinetics of Tc-99m-HIDA Agents\n\nBiokinetic behavior of Tc-99m-HIDA agents can be divided into six functional phases: (1) blood transport, (2) uptake by the hepatocyte, (3) transit through the hepatocyte and secretion into bile canaliculi, (4) flow through the intrahepatic and extrahepatic ducts, (5) entry into the gallbladder and (6) final discharge into the small intestine [26, 27]. The dose not taken up by the liver is excreted in urine.\n\n### 3.1.10 Blood Transport\n\nTc-99m-HIDA agents are transported in blood bound to serum albumin, forming an albumin-Tc-99-HIDA complex [26]. Protein binding enhances hepatic delivery and hepatocyte uptake and decreases renal excretion. The agents clear from the blood at variable rates (Fig. 3.1.4). Hypoalbuminemia decreases hepatic delivery and increases renal excretion. The affinity of Tc-99m-HIDA to bind with albumin is much lower than that of bromsulfalein and bilirubin [28]. A substitution at the para position improves both albumin binding and lipid solubility. Methyl substitution at positions 2, 4 and 6 and a bromine at position 5 (mebrofenin) increase both hepatic delivery and hepatocyte uptake, and markedly reduce renal excretion. A butyl substitution at the para position has a similar effect on the uptake [25]. Albumin-bound Tc-99m-HIDA leaves the sinusoidal space through the fenestrae of the endothelial cells and enters the perisinusoidal space of Disse, a space unique for liver capillaries. Disassociation between albumin-Tc-99m-HIDA takes place in the space of Disse very close to the basolateral border of the hepatocyte (Fig. 3.1.2). Only Tc-99m-HIDA enters the hepatocyte, leaving albumin behind in the blood. This mechanism is common for most organic anions [28].\n\nFig. 3.1.4\n\nBlood clearance of six Tc-99m HIDA agents. Note the fastest blood clearance with mebrofenin, TMB [26]\n\n### 3.1.11 Hepatocyte Uptake\n\nThe mechanism of uptake of Tc-99m-HIDA by the hepatocyte is similar to those of other organic anions [30]. Liver concentrates three types of organic anions, including bile acids, free fatty acids and non-bile acid cholephils (bromsulfalein, bilirubin, rose bengal, indocyanin green and Tc-99m-HIDA). Non-bile acid cholephils are taken up by the hepatocyte by a mechanism called receptor-mediated endocytosis (RME). RME has been well documented for low density lipoprotein, IgA, insulin, transferrin, asiologlycoprotein and cholesterol [31]. It is believed that Tc-99m-HIDA compounds follow the RME pathway, followed by bilirubin and other organic anions. By subjecting cultured rat hepatocytes to different in vitro experimental conditions, Okuda et al. and Lan et al. have demonstrated three possible pathways for uptake of Tc-99m-HIDA: (1) organic anion pathway probably through RME, (2) bile acid (bile salt) pathway and (3) free fatty acid pathway [28, 32, 33].\n\n### 3.1.12 Receptor-Mediated Endocytosis\n\nAfter dissociation from albumin in the space of Disse, Tc-99m-HIDA attaches to its specific receptors through receptor protein (ligandin). These receptors are located along the basolateral border and along the walls of the coated pits, which are mere invaginations of the basolateral membrane into hepatocyte cytosol [31, 34]. The ligand (Tc-99-HIDA) and the receptor protein (ligandin) cluster in the coated pit (Fig. 3.1.5). This collection is one of the primary requirements for RME to progress [34]. After separation from the surface membrane the coated pit forms a coated vesicle, and Tc-99m-HIDA gets internalized within the hepatocyte. After losing the protein covering, the vesicle becomes an endosome. In the case of LDL, IgA, insulin and transferrin, the protein coating the vesicle is clathrin. Co-transport through bile acids and free fatty acids occurs simultaneously with RME.\n\nFig. 3.1.5\n\nSchematic representation of receptor-mediated endocytosis for uptake and excretion of Tc-99m HIDA by the hepatocyte. Primary uptake occurs via receptor-mediated endocytosis (RME). After detaching from albumin in the space of Disse, the radiotracer attaches to the ligand in receptors within the coated pits [1], which are invaginations of the basolateral border of the hepatocyte. A coated vesicle [2] is formed when it separates from the surface membrane. The coated vesicle rapidly loses its clathrin coat, forming an endosome [3]. Two endosomes combine together to form a fused endosome [4]. Hydrogen is pumped into the fused intra-vesicular space, initiating uncoupling of the receptor and ligand (CURL). Ligand enters the bile canaliculi, and the receptor moves to the surface for recycling. Tc-99m HIDA in addition uses free fatty acid (FFA) and bile acid (BA) pathways for uptake and excretion in free form into bile canaliculi (modified from Steer [31])\n\nDespite sharing a common mechanism of uptake, there are a few differences in hepatocyte uptake between Tc-99m-mebrofenin and Tc-99m disofenin. In cultured rat hepatocytes, bilirubin reduces the uptake of disofenin much more profoundly than that of mebrofenin. At 20 \u03bcM bilirubin in the culture medium, the hepatocyte uptake of Tc-99m disofenin reduces to 34% from a basal value of 100% without bilirubin in the culture medium. In contrast, the uptake Tc-99m mebrofenin remains at 70% of the basal value under identical experimental conditions. Both disofenin and mebrofenin show a reduction in hepatocyte uptake when bile acids or free fatty acids are added to the culture medium, suggesting the existence of other uptake pathways. These results indicate that Tc-99m-HIDA agents share a common pathway with organic anions (bilirubin), free fatty acid and bile acids. Bromsulfalein (BSP) inhibits uptake by the hepatocyte of Tc-99m disofenin much more profoundly than Tc-99m mebrofenin (Table 3.1.8).\n\nTable 3.1.8\n\nEffect of 20\u03bcM of various organic anions on the uptake (%) of Tc-99m disofenin and Tc-99 mebrofenin by cultured rat hepatocytes [32]\n\nAgent | Basal uptake | BSP | Bili | Tauro cholate | Glyco cholate | Cholate | Deoxy cholate | Chenodeoxy cholate\n\n---|---|---|---|---|---|---|---|---\n\nTc-99m-Disofenin | 100 | 59 | 34 | 61 | 59 | 66 | 42 | 42\n\nTc-99m-Mebrofenin | 100 | 107 | 70 | 69 | 85 | 80 | 62 | 71\n\n### 3.1.13 Transit Through the Hepatocyte and Secretion into Bile Canaliculi\n\nUnlike bilirubin and other organic anions, Tc-99m-HIDA agents are secreted into bile canaliculi in their native state, without undergoing any conjugation during their transit through the hepatocyte [6]. The mechanisms by which Tc-99m-HIDA is transported through the hepatocyte and then secreted into the bile canalicular lumen are not clear. The general belief is that the mechanism is similar to those of non-cholephil organic anions, free fatty acids and bile acids. Vesicular transport and receptor-ligandin transport are thought to be involved. After losing the clathrin coat, the vesicle forms an endosome. Two endosomes together form a fused endosome. At this point the ligand (Tc-99m-HIDA) and the receptor (ligandin) separate and start moving in two different directions. The ligand (Tc-99m-HIDA) enters the bile canaliculi, and the ligandin moves to the hepatocyte surface for recycling [35]. Rough endoplasmic reticulum and the Golgi complex are known to synthesize the receptor. After entering the canaliculi, Tc-99m-HIDA mixes thoroughly with the hepatic bile, and from then on it serves as an ideal in vivo tracer for delineation of the entire hepatobiliary tree (Fig. 3.1.2). The curves generated over the liver provide a measure of the rapidity of uptake and excretion of Tc-99m HIDA (Fig. 3.1.6). The dose not taken up by the liver is excreted through urine (Fig. 3.1.7).\n\nFig. 3.1.6\n\nHepatic uptake and excretion of six Tc-99m HIDA agents. Fastest uptake and excretion are noted with disofenin (DISIDA) and mebrofenin (TMB)\n\nFig. 3.1.7\n\nUrinary excretion of six Tc-99m HIDA agents. Less than 2% of the injected dose of mebrofenin (TMB) is excreted in 24-h urine. Other agents show an increasing amount of urinary excretion [26]\n\nCurrently, Tc-99m-disofenin and Tc-99m-mebrofenin are the most popular agents (Fig. 3.1.8). Tc-99m mebrofenin, which has bromine at position 5 (meta), clears from the liver much more rapidly than Tc-99m disofenin (Fig. 3.1.9).\n\nFig. 3.1.8\n\nMolecular structure of Tc-99m-disofenin and Tc-99m-mebrofenin. An atom of bromine at 5 and three methyl groups at 2, 4, 6 positions in mebrofenin change its biological behavior from that of disofenin with an isopropyl group at 2 and 6 positions\n\nFig. 3.1.9\n\nHepatic uptake and excretion of Tc-99m disofenin and Tc-99m mebrofenin. The uptake and excretion by the liver of Tc-99m mebrofenin are significantly faster when compared to Tc-99m disofenin\n\n### 3.1.14 Flow Through Intrahepatic and Extrahepatic Ducts\n\nThe hepatic bile is radiolabeled instantly, as soon as Tc-99m-HIDA secreted by the hepatocyte enters the bile canaliculi. In vivo bile radiolabeling under total basal conditions allows delineation of the entire intrahepatic and extrahepatic bile ducts. Of the 600 ml total bile produced per day, 450 ml is secreted by the hepatocytes and 150 ml by canalicular cells [36]. The bile within the ducts is radiolabeled as the hepatic bile passes through the ducts.\n\n### 3.1.15 Gallbladder Storage\n\nAbout 70% of the hepatic bile secreted during fasting hours enters the gallbladder (0.3 ml min-1), and the rest enters the duodenum directly [37]. A fully filled normal gallbladder can accommodate up to 50 ml of bile. It would, therefore, take approximately 180 min (6 h) for a completely emptied gallbladder to refill to its full capacity. Having the ability to accommodate a constant inflow of 0.3 ml bile min-1, the hepatic bile during fasting is made possible by absorption of an equal volume of water through the gallbladder wall (about 0.3 ml min-1). The gallbladder wall absorbs water, chloride and bicarbonates at a much faster rate than sodium, bile salts and cholesterol from hepatic bile. By this selective absorption, the gallbladder can sequester all of the total body bile salts within it during 10-12 h of fasting. This selective process of solute concentration is called the concentration function of the gallbladder.\n\nHighly concentrated gallbladder bile is discharged into the duodenum upon the arrival of food into the small intestine, where bile salts facilitate digestion and absorption of nutrients into the blood stream. There is a rapid rise in Tc-99m-HIDA counts when radiolabeled hepatic bile enters the gallbladder. Accumulation of a very high specific activity bile in a relatively small volume (50 ml) accounts for the gallbladder being the critical organ in a Tc-99m-HIDA study [38], receiving about 908 mrad mCi-1. The upper large intestine, lower large intestine and small intestine receive decreasing doses (Table 3.1.9). Radiation to the gastrointestinal tract decreases in liver failure when kidneys become the preferential route of excretion for Tc-99m-HIDA.\n\nTable 3.1.9\n\nRadiation-absorbed dose (mrad mCi-1) to various organs from Tc-99m-HIDA in normal subjects and patients with increasing severity of liver disease [38]\n\nBilirubin level | Normal | Patients with increasing serum bilirubin level\n\n---|---|---  \n|\n\n<1 mg dl-1 | < 1 mg dl-1 | 1-5 mg dl-1 | 5-10 mg dl-1 | >10 mg dl-1\n\nOrgan\n\n|\n\nGallbladder | 908 | 728 | 617 | 309 | 101\n\nUpper colon | 302 | 235 | 198 | 100 | 36\n\nLower colon | 199 | 154 | 131 | 68 | 27\n\nSmall intestine | 189 | 147 | 125 | 65 | 25\n\nLiver | 76 | 91 | 90 | 47 | 18\n\nOvaries | 62 | 50 | 43 | 25 | 13\n\nKidneys | 43 | 58 | 67 | 105 | 132\n\nU. Bladder | 35 | 46 | 53 | 87 | 111\n\nBone marrow | 24 | 21 | 19 | 13 | 9\n\nSpleen | 9 | 8 | 7 | 5 | 3\n\nTestes | 4 | 4 | 4 | 4 | 5\n\nTotal body | 16 | 15 | 14 | 9 | 6\n\n### 3.1.16 Final Discharge into the Duodenum\n\nWhen the food leaves the stomach and enters the duodenum, it stimulates CCK-secreting cells in the mucosa of the duodenum and jejunum to release endogenous cholecystokinin into the circulation. It usually takes about 6-26 min (mean 16 min) after a meal for serum CCK levels to rise above the threshold to induce contraction and emptying of the gallbladder [39]. Once the gallbladder contraction is initiated, bile emptying is maintained for 1-2 h post-meal. In addition to initiating gallbladder contraction and emptying, cholecystokinin stimulates water secretion by cholangiocytes lining the bile ducts and hastens bile flow by directly stimulating smooth muscle of the bile ducts [40]. Cholecystokinin also increases intestinal peristalsis and facilitates movement of bile emptied from the gallbladder antegrade towards the jejunum and ileum. By inducing contraction of the pylorus of the stomach, it prevents duodeno-gastric bile reflux.\n\n### 3.1.17 Other Tc-99m-Labeled Hepatobiliary Agents\n\nMany Tc-99m-labeled potential hepatobiliary agents have not been approved by the United States Food and Drug Administration for routine clinical use. Some are approved in other countries. These agents include Tc-99m-labeled penicillamine [41, 42], dihydrothiooctic acid [43], tetracycline [44] and pyridoxylidineglutamate [45]. Tc-99m-Pyridoxylidineglutamate has been used extensively in Australia, Japan and other Asian countries [46]. Some of the agents used for imaging of other organs pass through the liver and are secreted into bile, and often they provide information about the hepatobiliary function (Fig. 3.1.10). The myocardial perfusion imaging agent, Tc-99m-sestamibi, is taken up by hepatocytes and secreted into bile, and it provides an opportunity to measure the gallbladder ejection fraction with cholecystokinin in those rare patients where acalculous chronic cholecystitis (cystic duct syndrome) mimics an anginal type of pain.\n\nFig. 3.1.10\n\nSecretion of technetium-99m sestamibi into bile. Myocardial (H) perfusion imaging agent shows accumulation in the liver (L), bile ducts and gallbladder (GB). CBD common bile duct, INT intestine\n\n### 3.1.18 Technetium-99m-DTPA Galactosyl-Human Serum Albumin\n\nThe basolateral and lateral (not canalicular) border of the plasma membrane of the hepatocyte is rich in asialoglycoprotein (ASGP) receptors, which serve as a binding site for Tc-99m DTPA-galactosyl human serum albumin (Tc-99m GSA). These receptors specific for the hepatocytes are not found in any other cells in the body [31]. After an intravenous injection, Tc-99m GSA circulates in the blood, is extracted by the hepatocyte plasma membrane and is transferred to the lysosomes through receptor-mediated endocytosis. Blood disappearance parallels the clearance of indocyanin green, considered a gold standard agent for hepatocyte function [47]. Studies in Japan have shown a great potential for the measurement of the hepatic reserve prior to resection of the liver in patients with hepatocellular carcinoma, cholangiocarcinoma, cirrhosis and metastatic disease. Rapid sequence SPECT imaging allows quantitative measurement of functional reserve and enables prediction of prognosis [48-50].\n\n### 3.1.19 New SI Units for Measurement of Radiation\n\nThe International Commission on Radiation Units and Measurements recommended in 1974 that new SI (system international) units replace old CGS units for all scientific work after 1984. The old and new units of measurement and their relationship are shown in Tables 3.1.10-3.1.12 [51].\n\nTable 3.1.10\n\nOld CGS and new SI units for measurement of radioactivity [51]\n\nOld units curie | New SI units. Becquerel | Disintegrations per second (dps)\n\n---|---|---\n\nMegacurie (MCi) | 37 PBq | 3.7 \u00d7 1016\n\nKilocurie (KCi) | 37 TBq | 3.7 \u00d7 1013\n\nCurie (Ci) | 37 GBq | 3.7 \u00d7 1010\n\nMillicurie (mCi) | 37 MBq | 3.7 \u00d7 107\n\nMicrocurie (\u03bcCi) | 37 kBq | 3.7 \u00d7 104\n\nNanocurie (nCi) | 37 Bq | 3.7 \u00d7 10\n\nPicocurie (pCi) | 37 mBq | 3.7 \u00d7 10-2\n\nTable 3.1.11\n\nRelationship between new Becquerel and old Curie units [51]\n\n1 Becquerel (Bq) = 1 dis sec-1 = 27.03 \u00d7 10-12 Ci = 27.03 pCi\n\n---\n\n1 Kilobecquerel (kbq) = 103 Bq = 27.03 nCi\n\n1 Megabecquerel (MBq) = 106 Bq = 27.03 \u03bcCi\n\n1 Gigabecquerel (GBq) = 109 Bq = 27.03 mCi\n\nTable 3.1.12\n\nRelationship between old and new SI units for measurement of radiation [51]\n\nParameter | Old unit | New SI unit | Conversion factor\n\n---|---|---|---\n\nRadioactivity | Curie (Ci) = 3.7 \u00d7 1010 dps | Becquerel (Bq) = 1 dps | 1 Ci = 3.7 \u00d7 1010 Bq\n\n1 Bq = 2.7 \u00d7 10-11 Ci\n\nRadiation exposure | Roentgen (R) = 2.58 \u00d7 10-4 C kg-1 | Coulomb kg-1 C kg-1 | 1 R = 2.58 \u00d7 10-4 C kg-1\n\n1C kg-1 = 3.88 \u00d7 103 R\n\nRadiation absorbed dose | rad = 100 erg g-1 | Gray(Gy) = 1 J kg-1 | 1 rad = 0.01 Gy\n\n1 Gy = 100 rad\n\nRadiation dose equivalent | rem = QF \u00d7 rad | Sievert (Sv) = QF \u00d7 Gy | 1 rem = 0.01 Sv\n\n1 Sv = 100 rem\n\n## 3.2 Radiolabeling of Red Blood Cells and Leucocytes\n\nRadiolabeled red blood cells are used in nuclear medicine mainly for the assessment of vascular spaces, measurement of left ventricular volume and ejection fraction, and for localization of bleeding sites. Radiolabeled leucocytes are used primarily for the detection and localization of abscesses and delineation of sites of diffuse or focal infection. Major applications in nuclear hepatology include differentiation of hemangiomas from other focal liver lesions with Tc-99m-labeled red blood cells and differentiation of abscess from other cystic liver lesions with indium-111 oxine or Tc-99m-HMPAO labeled leucocytes.\n\n### 3.2.1 Red Blood Cell Labeling with Tc-99m\n\nTechnetium-99m red blood cells (RBC) are used for blood pool imaging in the separation of vascular malformation (hemangiomas) from other non-vascular liver lesions. Radiolabeling of RBCs with chromium-51 was first accomplished by Gray and Sterling in 1950 for the main purpose of measuring their survival in the diagnosis of hemolytic anemias [1]. Technetium-99m-labeled RBCs are used primarily for blood pool imaging, and survival studies cannot be carried out due to the short physical half life of Tc-99m of only 6 h [2]. Three methods of RBC labeling are available: the in vivo method, in vitro method and combined in vivo and in vitro method. The in vivo method is technically simple, but results in a slightly higher background radiation. The in vitro method, on the other hand, is technically more involved, but gives excellent lesion to non-lesion contrast because of low background radiation.\n\n### 3.2.2 In Vitro Method (Ultratag Kit made by Mallincrodt, St. Louis, MO)\n\nAbout 1 ml of patient blood is drawn into a heparinized syringe and added to the mixing vial, which contains 50 \u03bcg stannous chloride, 3.7 mg sodium citrate, 5.5 mg dextrose and 0.11 mg sodium chloride. Stannous (2+) chloride readily crosses the red cell membrane and attaches to the heme component of the hemoglobin molecule, ready to do its job of reducing valence of Tc-99m-pertechnetate from 7+ to 4+. About 0.6 ml of 0.1% sodium hypochlorite is added later as an oxidizing agent that converts all excess stannous chloride (2+) into stannic (4+) state in plasma, but not inside the red blood cell because of its inability to cross the intact red cell membrane. About 20-30 mCi of 99m-TcO4 (pertechnetate) is added to the reaction vial. Tc-99m-pertechnetate readily crosses the red cell membrane and attaches to the globin molecule after it gets reduced from 7+ to 4\\+ valence by the waiting stannous (2+) chloride on the heme fraction of the hemoglobin molecule. Once Tc-99m is reduced from the 7+ to 4\\+ valence state, it does not come out of the hemoglobin molecule. The entry of Tc-99m through the red cell membrane thus becomes one-way traffic. After 15-20 min of gentle incubation at room temperature, most of the Tc-99m is trapped inside the red blood cell [2]. The in vitro method is a very efficient labeling technique and does not necessitate blood centrifugation to remove plasma, because 97% of technetium-99m is associated with the red blood cell and less than 3% remains in plasma. Hemoglobin contains 95% of the total red cell radioactivity, of which 77% is associated with globin and the rest with the heme fraction of the hemoglobin molecule [3].\n\n### 3.2.3 In Vivo Method\n\nStannous chloride (10-20 \u03bcg kg-1) from a commercial pyrophosphate kit is injected intravenously. Tin (2+) enters the red cell membrane and attaches to hemoglobin to be ready to act as a reducing agent when Tc-99m-pertechnetate enters the cell. About 30 min later, 20-30 mCi Tc-99m-pertechnetate in saline is injected intravenously. Tc-99m-pertechnetate crosses the red cell membrane, gets reduced by stannous chloride and later binds firmly to hemoglobin.\n\n### 3.2.4 Combined In Vivo and In Vitro Method\n\nPre-tinning is accomplished first by intravenous injection of cold stannous pyrophosphate made for bone scanning. Fifteen to 20 min later, about 3-4 ml patient blood is drawn into a 50-ml-volume syringe, and 20-30 mCi Tc-99m-pertechnetate is added to the syringe, shaken gently for 10 min and re-injected through the same catheter. Because of the higher efficiency of labeling and lower background, the in vitro method may be preferred over the in vivo method in the detection of hepatic hemangiomas (blood pool) and gastrointestinal bleeding [4, 5].\n\n### 3.2.5 Leukocyte Labeling\n\nLeukocytes labeled with either In-111 oxine or Tc-99m-HMPAO are used in nuclear hepatology for the diagnosis of liver abscess, empyema or acute cholecystitis [6, 7].\n\n### 3.2.6 Indium-111 Oxine\n\nAbout 50-60 ml of patient blood is drawn into a heparinized syringe, and 10 ml of 0.9% sodium chloride containing 6% hetastarch is added to blood and mixed thoroughly [8]. The mixture is allowed to form sediment for 40 min. After the sedimentation, leukocyte-rich plasma is collected, diluted with saline in a ratio of 2:1 and centrifuged at 150 g for 10 min. The leukocyte-rich pellet is washed twice with 10 ml saline and centrifuged each time for 10 min at 150 g after washing. Washed cells are then resuspended in 4.5 ml saline. About 0.3-0.5 ml of indium-111 oxine containing 0.4-0.5 mCi (14.8-18.5 MBq) In-111 is added to the reaction vial and incubated gently for 15 min at room temperature. Indium-111 oxine penetrates the leukocyte membrane, and once inside the cell, indium-111 and oxine dissociate. Oxine diffuses out of the cell into the labeling medium, leaving indium-111 behind trapped inside the cell [6]. The suspension is then centrifuged for 8 min at 90 g, and the supernatant is discarded and the pellet containing labeled leukocytes is resuspended in platelet-poor plasma. About 6 ml of the suspension containing 0.3-0.4 mCi of In-111 leukocytes is injected intravenously. Indium-111-labeled leucocytes clear from blood with a T 1\/2 of 6 h, which is very close to the value of 7 h for cells labeled with the gold standard P-32, di-isopropylfluorophosphate. After labeling, each leukocyte receives approximately 1,480 rad (14.8 Gy) radiation from Auger electrons of 0.6-25.4 keV energy from In-111. This amount of radiation from its own source does not affect its function [8].\n\nThe major advantage of In-111 oxine-labeled leukocytes over Ga-67 citrate or Tc-99m-HMPAO WBCs for imaging abscesses is that the entire abdomen, with the exception of the liver and spleen, remains free of any secreted radioactivity into the bowel [9]. Abdominal infection is diagnosed by taking early images at 2-10 min and repeat images within 30-60 min after injection. Delayed images at 24 h may be needed in some patients. In the case of chest infection, the earliest images that will provide any useful information are taken at 3-4 h after injection. Due to usual margination of leucocytes in the lungs, early chest images are usually not diagnostic [10].\n\n### 3.2.7 Tc-99m-HMPAO\n\nThe blood separation step for leucocyte labeling with Tc-99m HMPAO remains identical to that of labeling with In-111 oxine described above. After separation, leukocytes are resuspended in 20% plasma\/ACD solution. About 20-25 mCi of Tc-99m-HMPAO is added to the reaction vial and incubated gently for 10 min at room temperature, washed with plasma and resuspended in plasma and reinjected. The labeling yield is between 50 and 60% with 80% activity bound to granulocytes [11]. The labeled leukocytes clear from blood with a T \u00bd of 4 h, which is slightly shorter than for In-111-labeled granulocytes. The main advantage of Tc-99m HMPAO is that a much larger dose can be given, yet the total body and organ radiation dose is much less. The agent is easily available at all times of need at a very reasonable cost. The main disadvantage is that free Tc-99m-HMPAO, not bound to leucocytes, is taken up by the hepatocytes and secreted into bile. Intestinal luminal activity interferes with the diagnosis in images taken beyond 30 min after injection. A negative scan rules out abdominal infection. Increasing numbers of studies in recent years have been being done with Tc-99m-HMPHO [11]. Interference from secreted bile radioactivity is avoided by taking abdominal images early, within 10-20 min after injection. The absorbed radiation dose from labeled red blood cells and leucocytes is shown in Table 3.2.1.\n\nTable 3.2.1\n\nRadiation absorbed dose from Tc-99m-labeled RBC and WBC and indium-111-labeled WBC\n\nOrgan | Tc-99-m-RBC | Tc-99m-WBC (HMPAO) | In-111 WBC\n\n---|---|---|---\n\nrad mCi-1 (Gy\/37 MBq) | rad mCi-1 (Gy\/37 MBq) | rads mCi-1 (Gy\/37 MBq)\n\nLiver | 0.07 | 0.15 | 5.0\n\nSpleen | 0.05 | 0.22 | 40.0\n\nLungs | 0.06 | - | -\n\nKidneys | 0.05 | - | -\n\nOvaries | - | 0.03 | 0.4\n\nTestes | - | 0.19 | 0.02\n\nBone marrow | 0.03 | 0.16 | 4.0\n\nWhole body | 0.02 | 0.03 | -\n\n## 3.3 Gallium-67 Citrate\n\nThe tumor detection capability of gallium-67 citrate was described first by Edwards and Hays in 1969 [1]. Very soon it was recognized that in addition to the detection of varieties of tumors (lymphomas, hepatomas, malignant melanoma and squamous cell carcinomas), Ga-67 was also taken up in high concentration by infectious lesions and abscesses. Benign conditions, such as pseudonodules of cirrhosis and other non-specific inflammations, do not concentrate the agent [2]. This differential uptake by benign versus malignant lesions and the ability to detect infection led to widespread clinical application of Ga-67 citrate imaging in the 1970s and 1980s, before CT and ultrasound became popular imaging techniques for detection of focal hepatic lesions. Gallium-67 imaging is reemerging primarily for determining therapeutic response to various chemotherapeutic agents in various malignancies.\n\n### 3.3.1 Pharmacokinetics\n\nGallium-67 is produced in an accelerator by bombarding zinc target with protons as represented by the equation [67Zn (p, n) 67Ga]. It has a physical half life of 78.3 h and decays by electron capture to stable zinc. It has three principle gamma photons with the mean energy of 93.7 keV (36%), 185 keV (20%) and 300 keV (16.0%). Upon intravenous injection, Ga-67 citrate is transported in blood bound to plasma proteins, mainly transferrin, and to a minor extent to lactoferrin and ferritin. Two different mechanisms are involved with reference to cellular uptake: normal soft tissues concentrate Ga-67 bound to transferrin, whereas tumors concentrate the fraction that is either free or bound loosely to other proteins [3]. In the hepatocytes, Ga-67 uptake is seen mostly in association with lysosomes and mitochondria and to a lesser extent in the cytosol. The nucleus concentrates less than 10% of the total hepatocyte uptake. The exchange of Ga-67 takes place between the lysosomes and the cytosol. After intravenous injection, blood pool activity remains high for up to 24 h [4]. Beyond 48 h, most of Ga-67 is cell bound. About 10% of injected activity is excreted in stool during the first week.\n\nIncreased capillary permeability facilitates Ga-67 entry into the site of acute inflammation, abscess or tumor. In the case of an abscess, Ga-67 is found in association with the leukocytes, siderophores and bacteria. Staphyllococcus aurius, E. coli and other microorganisms are shown to ingest Ga-67, accounting for high uptake by the abscess [5, 6]\n\nBecause of normal uptake by bone, and slow excretion by mucosa into the colon, the bone and lower large bowel receive the largest radiation dose from Ga-67: 18 mGy\/37 MBq to bone marrow and 8.4 mGy\/37 MBQ to the lower large bowel (Table 3.3.1). Currently, Ga-67 citrate imaging has re-emerged in the evaluation of chemotherapy for lymphomas.\n\nTable 3.3.1\n\nRadiation absorbed dose from gallium-67 citrate\n\nOrgan | mGy\/37 MBQ | rads mCi-1\n\n---|---|---\n\nMarrow | 18 | 1.8\n\nLower colon | 8.4 | 0.84\n\nSpleen | 7.0 | 0.70\n\nLiver | 6.3 | 0.63\n\nUpper colon | 5.5 | 0.55\n\nKidneys | 5.4 | 0.54\n\nOvaries | 3.0 | 0.30\n\nTestes | 2.5 | 0.25\n\nWhole body | 2.6 | 0.26\n\nModified from MIRD pamphlet no. 11, 1975\n\n## 3.4 Somatostatin Receptor Imaging Agent\n\nSomatostatin is a small peptide found in many normal tissues and in benign and malignant tumors. It was originally thought to regulate primarily the release of growth hormone [1]. Now it is evident that in addition to influencing growth hormone release, somatostatin regulates the release of cyclic neuropeptides and inhibits release of thyrotropin, insulin, glucagon, gastrin, secretin and cholecystokinin [2]. The somatostatin receptors are present in the brain, thyroid, lung, gastrointestinal tract, liver, gallbladder, pancreas, adrenals and activated leukocytes [3]. Two molecular forms of somatostatin have been identified: one consists of 14 (Fig. 3.4.1) and the other 28 amino acids in the molecule. The longer one with 28 amino acids is a dimer formed by the union of two shorter molecules. The serum half life of somatostatin is less than 3 min. Five subtypes of somatostatin receptors (SSTR 1-5) are recognized in the body. Both somatostatin 14 and 28 attach to all five subtypes with equal affinity. Octreotide is an analog of somatostatin with eight amino acids (octapeptide). It binds mainly to somatostatin receptor subtypes 2, 3 and 5, but not to subtypes 1 and 4 [3, 4].\n\nFig. 3.4.1\n\nMolecular structure of somatostatin and its radiolabeled analogues. Somatostatin consists of 14 amino acids. The receptor-binding sites are located on four sequentially arranged amino acids. In labeled octreotide, radioiodine, I-123, attaches directly to tyrosine (Tyr), whereas indium-111 requires DTPA as chelate for its attachment\n\n### 3.4.1 Indium-111 Pentetreotide (OctreoScan)\n\nRadiolabeled octreotide binds to somastostatin receptors on the surface of tumors, enabling their detection [5]. Radiolabeling is achieved with either iodine I-123 or indium-111. When I-123 is chosen, the amino acid tyrosine, a normal component of the molecule, is radiolabeled [6]. In the case of indium-111, a bifunctional chelate, diethylenetriaminepentaacetic acid (DTPA), is required for radiolabeling (Fig. 3.4.1). As a bifunctional chelate, DTPA attaches to indium-111 (radiotracer) with one arm and to the amino acid, d-phenylalanine of somatostatin analogue (ligand), with the other arm. Four amino acids (phenylalanine, tryptophan, lysine and threonine) arranged in a sequence provide the binding site for the radiolabeled analogue [7]. It binds with high affinity to SSTR2 and with lower affinity to SSTR3\/5.\n\nFollowing intravenous administration, In-111 pentetreotide clears from blood rapidly. About 33% of the administered dose remains in circulation at the end of 10 min. Kidneys are the major route of excretion. About 50% of the injected dose is excreted in urine in 6 h, 85% in 24 h and 90% in 48 h. Less than 2% of the dose is excreted in feces in 3 days. Stool radioactivity mostly represents biliary excretion. Kidneys are the target organs for radiation. About 7% of the dose accumulates in the kidneys by 4 h [8]. The recommended dose for scanning is 3 mCi for planar and 6 mCi for SPECT study. Clinical studies usually require a SPECT study necessitating a 6-mCi (222 MBq) dose [9]. Radiation to various organs from a diagnostic dose depends both upon the age and dose. The kidneys, spleen and urinary bladder receive the most radiation [10].\n\n### 3.4.2 Technetium-99m Depreotide\n\nTc-99m depreotide is a somatostatin analogue with a molecular formula of C65H95N16O12S2 and structure of R-Tyr-(D-Trp)-Lys-Val-R-(\u03b2-Dap)Lys-amide [11]. This agent is not superior to In-111 octreoscan, but due to its higher affinity for SSTR3 may be useful in those patients who show less or no uptake of In-111 octreoscan. In one study, 8 of 25 (32%) patients with negative In-111 octreoscan showed positive uptake with Tc-99m depreotide [12].\n\n## 3.5 Fluorine18, 2-Flouro-2-deoxy-d-glucose (18F-FDG)\n\nGlucose is the primary source of energy for most living cells in the body, especially for the neurons of the central nervous system. Carbohydrates in the diet are the main source of glucose. Each glucose molecule has 6 carbon (hexose), 6 oxygen and 12 hydrogen atoms and can be shown in the form of either a stick or ring diagram (Fig. 3.5.1). After intravenous administration, glucose diffuses readily out of the intravascular space through the capillary membrane and enters the interstitial space from where it enters cells either through active or passive diffusion. Its uptake is controlled by many transporter proteins on the plasma membrane and uses both sodium-dependent glucose transporter (SGLT) and facilitative sodium-independent glucose transporter pathways [1]. Once inside the cell, glucose is subjected to a ten-step metabolic process (glycolysis) that yields the end product (Fig. 3.5.2). Glucose is converted first into glucose-6-phosphate (G-6-P) by adding a phosphate group to the sixth carbon atom mediated by the enzyme glucokinase (hexokinase). Isomarase enzyme converts it into fructose-6-phosphate, which in turn is converted into fructose 1-6-diphosphate by the addition of another phosphate group at the carbon 1 position. Through the interaction with other enzymes, pyruvate is released, which may enter into the citric acid cycle or be converted into lactic acid. The final products are water and carbon dioxide. Most of these reactions take place rapidly within the cell. By reversing the metabolic process, glucose is re-synthesized (gluconeogenesis). In the reverse process, G-6-P is converted into glucose by the enzyme glucose-6-phosphatase (G-6-Ptase).\n\nFig. 3.5.1\n\nStructure. Molecular structure of glucose is shown in stick and ring forms\n\nFig. 3.5.2\n\nGlycolysis. Glucose breaks down into carbon dioxide and water through various intermediary steps (modified from [3])\n\n### 3.5.1 Structure\n\nRemoval of one oxygen atom of the hydroxyl group at the second carbon position converts glucose into 2-deoxyglucose (2DG), a glucose analogue (Fig. 3.5.3), which goes through an initial metabolic process similar to that of glucose. By replacing hydrogen with the fluorine (F-18) atom at the second carbon position of 2DG, a new compound, 2-fluoro-2-deoxyglucose (F-18 FDG), is created that behaves quite differently from glucose while going through the rest of the metabolic process [2]. The first metabolic step, however, remains intact, with 2-fluoro-2-deoxyglucose behaving like glucose with the conversion into 2DG-6-P (Fig. 3.5.4). Labeling with fluorine-18 enables the new compound (F18-FDG) for use in positron emission tomography (PET).\n\nFig. 3.5.3\n\nGlucose analogues. Removal of oxygen atom from C-2 position of glucose creates 2-deoxyglucose (2DG), which enables labeling with fluorine-18 relatively simple at the C-2 position, resulting in 2-fluoro-2-deoxyglucose (F-18 FDG)\n\nFig. 3.5.4\n\nMechanism of glucose and F-18 FDG transfer across the cell. Both leave the intravascular space readily and enter the cell. Through the enzyme hexokinase, both get converted into their respective 6-phosphate form. Unlike glucose, F-18 FDG does not undergo any further metabolic process enabling imaging. Glucose is converted into either glycogen or CO2 \\+ H2O, depending upon the body's needs\n\n### 3.5.2 Biodistribution\n\nImmediately after intravenous injection, F-18 FDG distributes throughout the body and readily crosses the blood-brain barrier. It diffuses out of the intravascular space into the interstitial space rapidly and enters the cell. Initial entry is directly proportional to organ blood flow. Many glucose transporter proteins on the plasma membrane control its entrance. Sodium-dependent glucose transporter (SGLT) proteins use the Na + K + ATPase pump. The sodium-independent pathway uses facilitative transporter (GLUT) proteins. Of the 13 known GLUT proteins, liver cells have four: GLUT2, GLUT7, GLUT9 and GLUT10 [3, 4]. Although initial uptake reflects organ blood flow, retention depends upon a subsequent metabolic pathway used by each organ. Organs with high hexokinase content show much higher F-18 FDG uptake than those with low hexokinase activity. The hexokinase content of organs is as follows: brain > heart > kidney > lung > liver [1]. The brain concentrates 6.9%, liver 4.4% and heart 3.3% of the injected dose (Fig. 3.5.5). Organs with high glucose-6-phosphatase enzyme activity show more rapid clearance than those with low enzyme activity. Brain and heart with high hexokinase content show increasing uptake during the first hour, whereas other organs with high G-6-Ptase show declining activity [5]. Increasing uptake by brain and heart is due to rapid conversion of F-18 FDG into F-18 DG-6-P mediated by the enzyme glucokinase (hexokinase). Compared to brain and heart, liver has much less hexokinase activity and more G-6-Ptase activity; both acting together contribute to rapid clearance of F-18 FDG from the liver. In the liver cell, G-6-Ptase converts F-18 FDG-6-P back into F-18 FDG, which diffuses back into blood [1]. Neither F18-FDG nor F-18 FDG-6-P enters the bile. This is evident from the fact that bile ducts and gallbladder are not seen in whole body PET study.\n\nFig. 3.5.5\n\nUptake and retention of F-18 FDG by various organs. Brain and heart show continuous uptake for 1 h, whereas other organs begin to show rapid clearance\n\nIn humans, the brain shows the highest uptake of F-18 FDG, followed by the liver, heart, red bone marrow, etc., as shown in Table 3.5.1. Kidneys excrete 20% of the injected dose in urine in 1 h and 21% in 2 h [5]. The initial uptake continues to increase in the brain and heart during the first hour, whereas it begins to decrease in the liver, kidney, spleen, pancreas and lung (Fig. 3.5.5). Continued uptake by the brain and heart reflects their high hexokinase activity relative to other organs, which begin to show a decrease. Once F-18 FDG is converted into 2DG-6-P, it is trapped inside the cell without much clearance by the heart and brain. The trapping rate is much less in the liver, kidney, spleen, pancreas and lung. Most of the radiotracer cleared from these organs is excreted in urine in its original form as F-18-FDG. Normally, glucose filtered by glomeruli is completely reabsorbed by the tubules. This shows that replacement of one hydroxyl group at the C-2 position in the glucose molecule by one atom of F-18 in FDG changes the biological behavior of the radiotracer to a great extent.\n\nTable 3.5.1\n\nOrgan uptake and radiation dose from F-18 FDG in human organs\n\nOrgan | Uptake [5] | Radiation dose [4]\n\n---|---|---\n\n(% Injected dose) | (mGy\/185 MBq) | (rad 5mCi-1)\n\nBrain | 6.9 | 4.81 | 0.48\n\nLiver | 4.4 | 2.22 | 0.22\n\nHeart | 3.3 | 12.03 | 1.20\n\nRed marrow | 1.7 | 2.04 | 0.20\n\nKidneys | 1.3 | 3.88 | 0.39\n\nLungs | 0.9 | 2.04 | 0.20\n\nSpleen | 0.4 | 2.22 | 0.22\n\nPancreas | 0.3 | 2.22 | 0.22\n\nTestes | 0.04 | 2.78 | 0.28\n\nOvary | 0.01 | 2.78 | 0.28\n\nBladder wall | 6.3 | 31.45 | 3.15\n\nRest of the body | 74.4 | -\n\n|\n\nTotal body | 99.95 | -\n\n|\n\nFrom Mejia [5]\n\n### 3.5.3 Radiation Dose\n\nOn a per organ basis, the urinary bladder wall receives the largest dose (0.091mGy\/MBq), followed by the heart, brain, kidneys, liver and other organs, as shown in Table 3.5.1. Dose to the bladder depends upon its initial volume prior to F-18 FDG injection. A completely filled bladder receives much less than an empty bladder [6]. Although a full bladder may receive much less radiation, patients are encouraged to empty prior to imaging to facilitate better visualization of other pelvic organs, especially the ovaries, uterus and pelvic floor lymph nodes.\n\nReferences\n\n1.\n\nSheppard CW, Wells EB, Hahn PF, Goodell JBP. Studies of the distribution of intravenously administered colloidal sol of manganese dioxide and gold in human beings and dogs using radioactive isotopes. J Lab Clin Med 1947;32:274-277PubMed\n\n2.\n\nStirret LA, Yuhl ET, Cassen B. Clinical application of hepatic radioactive surveys. Am J Gastroenterol 1954;21:310-317\n\n3.\n\nStirret LA, Yuhl ET, Libby RL. A new technique for diagnosis of carcinoma metastatic to the liver. Surg Gynecol Obstet 1953;96:210-215\n\n4.\n\nTaplin GV, Meredith OM Jr, Kade H. Radioactive (I-131 tagged) rose bengal uptake-excretion test for liver function using external gamma ray scintillation counting technique. J Lab Clin Med 1955;45:665-678PubMed\n\n5.\n\nHarper PV, Lathrop KA, Jimiriez F, Fink R, Gottschalk A. Technetium-99m as a scanning agent. Radiology 1965;85:101-103PubMed\n\n6.\n\nLoberg MD, Cooper M, Harvey E, Callery P, Faith W. Development of new radiopharmaceuticals based on N-substitution of iminodiacetic acid. J Nucl Med 1976;17:633-638PubMed\n\n7.\n\nMcAfee JG, Subramanian G. Radioactive agents for imaging. In: Freeman LM, Johnson PM (eds) Clinical radionuclide imaging. Grune and Stratton Inc, Orlando, 1984, vol. 1\n\n8.\n\nIya VK, Gopal GS, Chaudhuri SY. Colloidal gold. Preparation and particle size determination by electron microscope. Indian J Chem 1965;3:317-320\n\n9.\n\nDobson EL, Jones HB. The behavior of intravenously injected particulate material; its rate of disappearance from blood as a measure of liver blood flow. Acta Med Scand 1952;273:1-50 (suppl 144)\n\n10.\n\nCloutier RJ, Freeman LM, McAfee JG, McCormick KR, Patton DD, Rosenthal L, Smith EM. MIRD: Dose estimates report number 4. Summary of current radiation dose estimates to humans with various liver conditions from Au-198 colloidal gold. J Nucl Med 1975;16:173-174\n\n11.\n\nAtkins HL, Cloutier RJ, Lathrop KA, Freeman LM, McAfee JG, Nelp WB, Patton DD, Smith EM. MIRD: Dose estimates report number 3. Summary of current radiation dose estimates to humans with various liver conditions from Tc-99m sulfur colloid. J Nucl Med 1975;16:108A-108B\n\n12.\n\nMetchnikoff E. In Immunite dans les maladies infectieuses. Masson, Paris, 1901\n\n13.\n\nvon Kupffer C. Uberdie sogenanuten sternzellen der saugentheirer leber. Arch Microsk Anat 1899;26:1\n\n14.\n\nAshoff I. Das reticulo-endotheliale system. Ergebn Inn Med Kinderheilk 1924;26:1\n\n15.\n\nIio M, Wagner HN Jr, Scheffel U, Jabbour B. Studies of the reticulo-endothelial system (RES) 1. Measurement of the phagocytic capacity of the RES in man and dog. J Clin Invest 1963;42:417-416PubMedCrossRef\n\n16.\n\nSaba TM. Physiology and physiopathology of the reticuloendothelial system. Arch Intern Med 1970;126:1031-1052PubMedCrossRef\n\n17.\n\nStossel TP. How do phagocytes eat?. Ann Intern Med 1978;89:398-402PubMed\n\n18.\n\nKitani K, Taplin GV. Biliary excretion of 99m Tc- albumin microaggregate degradation products (a method for measuring Kupffer cell digestive function)?. J Nucl Med 1972;13:260-265PubMed\n\n19.\n\nBeckett AH, Boyes RN, Appleton PJ. The metabolism and excretion of lignocaine in man. J Pharm Pharmacol 1966;18:76-81 (suppl)CrossRef\n\n20.\n\nRowland M, Thomson PD, Guichard A, Melmon KL. Disposition kinetics of lidocaine in normal subjects. Ann N Y Acad Sci 1971;179:383-398CrossRef\n\n21.\n\nZito RA, Reid PR. Lidocaine kinetics predicted by indocyanin green clearance. New Engl J Med 1978;298:1160-1163PubMedCrossRef\n\n22.\n\nRyan J, Cooper M, Loberg MD, et al Technetium 99m labeled N-(2,6 dimethylphenyl carbomoylmethyl) iminodiacetic acid(Tc-99m-HIDA). A new radiopharmaceutical for hepatobiliary imaging studies. J Nucl Med 1977;18:997-1004PubMed\n\n23.\n\nNunn AD, Loberg MD, Conley RA. A structure-distribution-relationship approach leading to the development of Tc-99m mebrofenin: an improved cholescintigraphic agent. J Nucl Med 1983;24:423-430PubMed\n\n24.\n\nWistow BW, Subramanian G, Van Heertum RL, Henderson RW, Gagne GM, Hall RC, McAfee JG. An evaluation of Tc-99m labeled hepatobiliary agents. J Nucl Med 1977;18:455-461PubMed\n\n25.\n\nSubramanian G, McAfee JG, Henderson R, et al A new bifunctional chelate for designing Tc-99m labeled radiopharmaceuticals. In: Murry IP, Hoschl R (eds). Proceedings of first Asia and Oceania congress of nuclear medicine, 1976. Sidney, Australia. Pink Panther Printers, pp 144-149\n\n26.\n\nKrishnamurthy S, Krishnamurthy GT. Technetium-99m iminodiacetic acid organic anions: review of biokinetics and clinical application in hepatology. Hepatology 1989;9:139-153PubMedCrossRef\n\n27.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23:35S-45S (suppl)\n\n28.\n\nOkada H, Nunes R, Vallabhajosula S, Strashun A, Goldsmith SJ, Berk PD. Studies of the hepatocellular uptake of the hepatobiliary scintiscanning agent Tc-99m-DISIDA. J Hepatol 1986;3:251-259CrossRef80035-6)\n\n29.\n\nBerk PD, Stremmel W. Hepatocellular uptake of organic anions. In: H Popper, Schaffner F (eds) Progress in liver disease. Grune and Stratton, New York, 1988, pp 125-143, vol. 3\n\n30.\n\nChervu LR, Nunn AD, Loberg MD. Radiopharmaceuticals for hepatobiliary imaging. Semin Nucl Med 1982;12:5-17PubMedCrossRef80025-1)\n\n31.\n\nStreer CJ. Receptor-mediated endocytosis: mechanisms, biologic function and molecular properties. In: Zakim D, Boyer TD (eds) Hepatology, a text book of liver disease. WB Saunders, Philadelphia, 1996, pp 149-214\n\n32.\n\nLan JA, Chervu LR, Johansen KL, Wolkoff AW. Uptake of Technetium-99m Hepatobiliary agents by cultured rat hepatocyte. Gastroenterology 1988;95:1625-1631PubMed\n\n33.\n\nRoy-Chowdhury J, Jansen PLM. Bilirubin metabolism and its disorders. In: Zakim D, Boyer TD (eds) Hepatology, a text book of liver disease. WB Saunders, Philadelphia, 1996, pp 323-361\n\n34.\n\nGoldstein JL, Anderson RG, Brown MS. Coated pits, coated vesicles, and receptor-mediated endocytosis. Nature 1979;279:679-685PubMedCrossRef\n\n35.\n\nPearse BM, Bretscher MS. Membrane recycling by coated vesicles. Ann Rev Biochem 1981;50:85-101PubMedCrossRef\n\n36.\n\nSherlock S, Dooley J. Cholestasis. In: Sherlock S, Dooley J (eds) Diseases of the liver and biliary system. Blackwell Scientific Publication, Boston, 1993, pp 214-235\n\n37.\n\nKrishnamurthy GT, Bobba VR, McConnell D, Turner F, Mesgardeh M, Kingston E. Quantitative biliary dynamics: introduction of a new non-invasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n38.\n\nBrown PH, Krishnamurthy GT, Bobba VR, Kingston E. Radiation dose calculation for Tc-99m-HIDA in health and disease. J Nucl Med 1981;22:177-183PubMed\n\n39.\n\nBobba VR, Krishnamurthy GT, Kingston E, Turner FE, Brown PH, Langrell K. Gallbladder dynamics induced by a fatty meal in normal subjects and patients with gallstones: concise communication. J Nucl Med 1984;25:21-24PubMed\n\n40.\n\nMutt V. Cholecystokinin: isolation, structure, and function. In: Jerzy Glass GB (ed) Gastrointestinal hormones. Raven Press, New York, 1980, pp 169-221\n\n41.\n\nKrishnamurthy GT, Tubis M, Endow JS, Blahd WH. Technetium-99m-penicillamine. A new agent for cholescintigraphy. J Nucl Med 1972;13:418 (abstract)\n\n42.\n\nTubis M, Krishnamurthy GT, Endow JS, Blahd WH. 99m Tc-penicillamine, a new cholescintigraphic agent. Comparison with oral cholecystography. J Nucl Med 1972;13:652-654PubMed\n\n43.\n\nTonkin AK, DeLand FH. Tc-99m-Dihydrothioctic acid. A new polygonal cell imaging agent. J Nucl Med 1974;15:539\n\n44.\n\nFliegel CP, Dewanjee MK, Holman LB, Davis MA, Treves S. 99mTc-Tetracycline as a kidney and gallbladder imaging agent. Radiology 1974;110:407-412PubMed\n\n45.\n\nBaker RJ, Bellen JC, Ronai PM. Tc-99m-pyridoxylidineglutamate: a new hepatobiliary radiopharmaceutical. 1. Experimental aspects. J Nucl Med 1975;16:720-727PubMed\n\n46.\n\nRonai PM, Baker RJ, Bellen JC, Collins PJ, Lander H. Technetium-99m-pyridoxylidineglutamate: a new hepatobiliary radiopharmaceutical. ll. Clinical aspects. J Nucl Med 1975;16:728-737PubMed\n\n47.\n\nHwang E, Taki J, Shuke N, Nakajima K, Kinuya S, Konishi S, Michigishi T, Aburano T, Tonami N. Preoperative assessment of residual hepatic functional reserve using Tc-99m-DTPA-galactosyl human serum albumin dynamic SPECT. 1999;40:1644-1651\n\n48.\n\nSasaki N, Shiomi S, Iwata Y, Nishiguchi S, Kuroki T, Kawabe J, Ochi H. Clinical usefulness of scintigraphy with Tc-99m-galactosyl human serum albumin for prognosis of cirrhosis of the liver 1999;40:1652-1656\n\n49.\n\nUetake M, Koizumi K, Yagawa A, Nogata H, Tezuka T, Kono H, Ozawa T, Kusano T, Miyabukuro M, Hosaka M. Use of Tc-99m DTPA galactosyl human serum albumin to predict postoperative residual liver function. Clin Nucl Med 1999;24:428-434PubMedCrossRef\n\n50.\n\nAkaki S, Mitsumori A, Kanazawa S, Togami I, Takeda Y, Hiraki Y. Lobar decrease in 99m-Tc-GSA accumulation in hilar cholangiocarcinoma. J Nucl Med 1999;40:394-398PubMed\n\n51.\n\nBrown PH. Mathematics and statistics. In: Bernier DR, Christian PE, Langan JK (eds) Nuclear medicine, technology and techniques. Mosby, St Louis, 4th edition, 1997, pp 1-35\n\nReferences\n\n1.\n\nGray SJ, Sterling K. The tagging of red blood cells and plasma proteins with radioactive chromium. J Clin Invest 1950;29:1604-1610PubMedCrossRef\n\n2.\n\nSrivastava SC, Chervu LR. Radionuclide-labeled red blood cells: current status and future prospects. Semin Nucl Med 1984;14:68-82PubMedCrossRef80022-7)\n\n3.\n\nSrivastava SC, Strau RF. Blood cell labeling with 99mTc: progress and perspectives. Semin Nucl Med 1990;20:41-51PubMedCrossRef80175-8)\n\n4.\n\nFront D, Isreal O, Groshar D, Weininger J. Technetium-99m labeled red blood cell imaging. Semin Nucl Med 1984;14:226-250PubMedCrossRef80017-3)\n\n5.\n\nBirnbaum BA, Weinreb JC, Megibow AT, Sanger JJ, Lubat E, Kanamuller H, Noz ME, Bosniak MA. Definitive diagnosis of hepatic hemangioma: MR imaging VS Tc-99m-labeled red blood cell SPECT. Radiology 1990;176:95-101PubMed\n\n6.\n\nThakur ML, Segal AW, Louis L, Welch MJ, Peters TJ. Indium-111-labeled cellular blood components: mechanism of labeling, and intracellular location in human neutrophills. J Nucl Med 1977;18:1022-1026PubMed\n\n7.\n\nLantto EH, Lantto TJ, Vorne M. Fast diagnosis of abdominal infections and inflammations with technetium-99m -HMPAO labeled leukocytes. J Nucl Med 1991;32:2029-2034PubMed\n\n8.\n\nDatz FL. In-111-labeled leukocytes for the detection of infection: current status. Semin Nucl Med 1994;24:92-109PubMedCrossRef80225-9)\n\n9.\n\nLeddin DJ, Paterson WG, DaCosta LR, Dinda PK, Depew WT, Markotich J, McKaigney JP, Groll A, Beck IT. In-111 labeled autologous leukocyte imaging and fecal excretion. Comparison with conventional methods of assessment of inflammatory bowel disease. Dig Dis Sci 1987;32:377-387PubMedCrossRef\n\n10.\n\nMcAfee JG. Editorial: what is the best method for imaging focal infections? J Nucl Med 1989;31:413-416\n\n11.\n\nAllan RA, Sladen GE, Bassingham S, Lazarus C, Clarke SE, Fogelman I. Comparison of simultaneous 99mTc-HMPAO and 111-In oxine labeled white cell scans in the assessment of inflammatory bowel disease. Eur J Nucl Med 1993;20:195-200PubMedCrossRef\n\nReferences\n\n1.\n\nEdward CL, Hayes RL. Tumor scanning with 67 Ga citrate. J Nucl Med 1969;10:103-105\n\n2.\n\nLomas F, Dibos PE, Wagner HN Jr. Increased specificity of liver scanning with the use of 67-gallium citrate. New Engl J Med 1972;286:1323-1329PubMedCrossRef\n\n3.\n\nTsan MF. Mechanism of gallium-67 accumulation in inflammatory lesions. J Nucl Med 1985;26:88-92PubMed\n\n4.\n\nAulbert E, Gebherdt A, Schutz E, Haubold U. Mechanism of gallium-67 accumulation in normal rat liver lysosomes. Nuklearmedizin (Stuttg) 1976;15:185-194\n\n5.\n\nHammersley PA, Taylor DM, Cronshaw S. The mechanism of 67 Ga uptake in animal and human tumors. Eur J Nucl Med 1980;5:411-415PubMedCrossRef\n\n6.\n\nScheffel U, Wagner HN Jr, Klein JL, Tsan MF. Gallium-67 uptake by hepatoma: studies in cell cultures, perfused livers and intact rats. J Nucl Med 1985;26:1438-1444PubMed\n\nReferences\n\n1.\n\nKrulich L, Dhariwal AP, McCann SM. Stimulatory and inhibitory effects of purified hypothalamic extract on growth hormone release from rat pituitary in vitro. Endocrinology 1968;83:783-790PubMedCrossRef\n\n2.\n\nReichlin S. Somatostatin. New Engl J Med 1983;309:1495-1501PubMedCrossRef\n\n3.\n\n3. Reubi JC, Kvols LK, Krenning E, Lamberts SWJ. Distribution of somatostatin receptors in normal and tumor tissue. Metabolism 1990;39:78-81 (suppl 2)PubMedCrossRef90217-Z)\n\n4.\n\nLamberts SWJ, van der Lely AJ, deHerder WW, Hofland LJ. Octreotide. New Engl J Med 1996;334:246-254PubMedCrossRef\n\n5.\n\nKrenning EP, Bakker WH, Breeman WAP, Koper JW, Kooji PP, Ausema L, Lameris JS, Reubi JC, Lamberts SWJ. Localization of endocrine-related tumors with radioiodinated analog of somatostatin. Lancet 1989;1:242-244PubMedCrossRef91258-0)\n\n6.\n\nO'Connor ML, Kvols LK, Brown ML, Hung JC, Hayostek RJ, Cho DS, Vetter RJ. Dosimetry and biodistribution of an I-123-labeled somatostatin analog in patients with neuroendocrine tumors. J Nucl Med 1992;33:1613-1619PubMed\n\n7.\n\nKrenning EP, Bakker WH, Kooji PPM, Breeman WAP, Oei HY, deJong M, Reubi JC, Visser TJ, Bruns C, Kwekkeboom DJ, Reijs AEM, van Hagen PM, Koper JW, Lamberts SWJ. Somatostatin receptor scintigraphy with indium-111 DTPA-D-phe-1-octreotide in man: metabolism, dosimetry and comparison with iodine-123-Tyr-3 Octreotide. J Nucl Med 1992;33:652-658PubMed\n\n8.\n\nSomatostatin receptor imaging for neuroendocrine tumors. Product monograph. OctreoScan Mallinckrodt Medical Inc., St. Louis, MO, 1994\n\n9.\n\nJamar F, Fiasse R, Leners N, Pauwels S. Somastostatin receptor imaging with Indium-111-pentetreotide in gastroenteropancreatic neuroendocrine tumors: safety, efficacy, and impact on patient management. J Nucl Med 1995;36:542-549PubMed\n\n10.\n\nStabin MG, Kooji PPM, Bakker WH, Inoue T, Endo K, Coveney J, deJong R, Minegishi A. Radiation dosimetry for indium-111-pentetreotide. J Nucl Med 1997;38:1919-1922PubMed\n\n11.\n\nLebtahi R, LeCloirec J, Houzard C, Daou D, et al. Detection of neuroendocrine tumors: Tc-99m-P829 scintigraphy compared with In-111 pentetreotide scintigraphy. J Nucl Med 2002;43:889-895PubMed\n\n12.\n\nShah T, Kulakiene I, Quigley A, Warbey VS, Srirajaskanthan R, et al. The role of Tc-99m-depreotide in the management of neoroendocrine tumours. Nucl Med Commun 2008;29:436-440PubMedCrossRef\n\nReferences\n\n1.\n\nLong C. Studies involving enzymatic phosphorylation 1. The hexokinase activity of rat tissue. Biochem J 1952;50:407-415PubMed\n\n2.\n\nGallagher BM, Fowler JS, Gutterson NI, MacGregor RR, Wan C, Wolf AP. Metabolic trapping as a principle of radiopharmaceutical design: some factors responsible for the biodistribution of 18F] 2-deoxy-2-fluoro-D-glucose. J Nucl Med 1978;19:1154-1161[PubMed\n\n3.\n\nOehr P. Transport and metabolism of glucose and FDG. In: Oehr P, Biersack HJ, Coleman RE (eds) PET and PET-CT in onclogy. Springer, Berlin, 2004CrossRef\n\n4.\n\nOehr P. Radiopharmaceutical production and safety of 18F] FDG. In: Oehr P, Biersack HJ, Coleman RE (eds) PET and PET-CT in onclogy. Springer, Berlin, 2004[CrossRef\n\n5.\n\nMejia AA, Nakamura T, Masatoshi I, Hatazawa J, Masaki M, Watanuki S. Estimation of absorbed doses in humans due to intravenous administration of fluorine-18-fluorodeoxyglucose in PET studies. J Nucl Med 1991;32:699-706PubMed\n\n6.\n\nDowd MT, Chen C, Wendel WJ, Faulhaber PJ, Cooper MD. Radiation dose to the bladder wall from 218F] fluoro-2-deoxy-D-glucose in adult humans. J Nucl Med 1991;32:707-712[PubMed\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_4(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 4. Imaging of Liver and Spleen Morphology\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nIn most nuclear medicine departments throughout the world, gamma cameras have completely replaced rectilinear scanners. A large field of view gamma camera with a single or dual head, fitted with a low-energy, parallel hole, all-purpose collimator, is generally chosen for most planar studies using technetium-99m-labeled agents. The main advantage of the dual-head gamma camera is patient convenience, where the data collection time is reduced by one-half as it allows simultaneous anterior and posterior image acquisition. The reduction in imaging time often improves the spatial resolution because of less patient movement during data collection. A triple-head gamma camera, when available, is preferred for SPECT images. The gamma camera image acquisition parameters are identical for both the liver and spleen.\n\nIn most nuclear medicine departments throughout the world, gamma cameras have completely replaced rectilinear scanners. A large field of view gamma camera with a single or dual head, fitted with a low-energy, parallel hole, all-purpose collimator, is generally chosen for most planar studies using technetium-99m-labeled agents. The main advantage of the dual-head gamma camera is patient convenience, where the data collection time is reduced by one-half as it allows simultaneous anterior and posterior image acquisition. The reduction in imaging time often improves the spatial resolution because of less patient movement during data collection. A triple-head gamma camera, when available, is preferred for SPECT images. The gamma camera image acquisition parameters are identical for both the liver and spleen.\n\n## 4.1 Imaging with Radiocolloid\n\n### 4.1.1 Patient Preparation\n\nIn general, there is no special patient preparation required for morphology imaging with radiocolloids. This is a distinct advantage over functional imaging with Tc-99m HIDA where the patient preparation requirements are quite stringent. The morphology imaging studies obtained immediately after a full meal may cause image artifacts and obscure the spleen in the anterior view because of photon attenuation by the gastric contents. The posterior and left lateral view images usually clarify this situation.\n\nRadiocolloid imaging introduced in the early 1950s with the use of rectilinear scanners marked the birth of nuclear hepatology. Morphology imaging with radiocolloids remained very popular until the early 1980s, when it was overtaken by CT and ultrasound. Diagnosis of various diseases is made from assessing the changes in image pattern of the organ morphology. A thorough knowledge of normal morphology of the liver and spleen and normal variant patterns is critical to be able to detect disease. This section deals mainly with liver and spleen morphology as seen on a radiocolloid image (Table 4.1.1).\n\nTable 4.1.1\n\nData acquisition with Tc-99m-sulfur colloid\n\nInstrument | Single, dual, or a triple head, large field of view gamma camera\n\n---|---\n\nCollimator | Low-energy, parallel hole, all purpose collimator\n\nAgent | Technetium-99m-sulfur colloid or Tc-99m-albumin colloid\n\nDose | Adults, 2-4 mCi for planar images, 4-10 mCi for perfusion or SPECT images. Children, 30-50 \u03bcCi Kg -1 (minimum 300 \u03bcCi)\n\nSpectrometer setting | 140 keV photo peak at 15-20% window\n\nPerfusion images | At 1 or 2 s\/frame seconds for 60 s\n\nPlanar image data collection | 500,000-100,000 counts for each of anterior, posterior, and two lateral views. Additional views are obtained as needed. A 5- or 10-cm-long lead marker is placed along the right costal margin to facilitate measurement of liver size and position. The same marker is used for measurement of spleen size using the posterior image\n\nSPECT data collection\n\nMatrix | 64 \u00d7 64 word or 128 \u00d7 128 word mode. Rotation, clockwise 360\u00b0, angle 3-6\u00b0 for each stop. (360\/64 = 6\u00b0)\n\nFilters | Depends upon the computer and gamma\n\nViews | Transaxial, coronal, and sagittal\n\nPerfusion images are obtained immediately after the injection of the radiotracer at 1 or 2 s per frame for 60 s using the setup for the planer mode described above and reformatted at 4-8 s\/image for clinical interpretation. The planar and SPECT image data are collected 15-30 min after intravenous injection when all of the radiocolloid particles from blood are extracted by the RE cells\n\n## 4.2 Normal Liver\n\n### 4.2.1 Perfusion\n\nLiver and spleen perfusion images are obtained either in the anterior or posterior view using Tc-99m in any form. The aorta is the first abdominal organ to be seen, followed by the spleen, kidneys, and liver (Fig. 4.1.1). Aorta to spleen transit time is 2-4 s, and aorta to kidney transit time is 3-6 s. Despite the fact that both the hepatic artery and the splenic artery arise from a common celiac artery, there is an apparent delay in the appearance of liver perfusion due to dilution of hepatic artery radioactivity by the cold portal venous blood, as the portal vein receives its radioactivity much later than the splenic artery. The delay in arrival of the portal vein radioactivity is due to a delay in intestinal capillary phase. The liver receives 25% of its blood supply through the hepatic artery and 75% through the portal vein. The liver portal perfusion is clearly seen 10-14 s after the appearance of the abdominal aorta [1].\n\nFig. 4.1.1\n\nLiver perfusion. Anterior perfusion image shows abdominal aorta (frame no. 6), followed by spleen and kidneys (no. 7). Liver appears faintly in the beginning (no. 8), representing hepatic artery perfusion, and becomes clear in late (no. 9) images due to arrival of portal venous blood flow\n\n### 4.2.2 Shape, Surface, and Borders\n\nThere are wide variations in the shape of a normal liver, and most of the variations occur along the superior and inferior margins [2, 3]. The most common shape of a normal liver is that of an approximate triangle consisting of a superior, inferior, and a right lateral border (Fig. 4.1.2). Superior and right lateral borders form a smooth rounded contour at the right upper quadrant. The superior and inferior borders meet at an acute angle at the left tip of the left hepatic lobe. The inferior and right lateral borders meet at various angles. Often the inferior tip of the right hepatic lobe is elongated, forming a Riedel's lobe. The superior border of the liver is \"S\" shaped, and the contour is influenced by the size of the heart, exit of the hepatic vein, and the elevation of the dome of the right hemi-diaphragm. The shape, which looks like a gendarme's hat, is primarily due to the elevation of the right hemi-diaphragm.\n\nFig. 4.1.2\n\nNormal variation in liver shape and frequency (%). Triangular shape is the most common type [2-4]\n\nThe contour of the inferior border is affected by the fossa for the gallbladder and the entrance of the structures at the porta hepatis. The gallbladder fossa is usually located at the junction of the lateral 1\/3 with the medial 2\/3 of the inferior border (Fig. 4.1.3). The position of the gallbladder can be located during physical examination by drawing a straight line between the left anterior superior iliac spine and the umbilicus and extending it superiorly to meet the right costal margin. The fundus of the gallbladder corresponds to the point where this line meets the right costal margin. The gallbladder can be located anywhere along the inferior border and may even be intrahepatic. The intrahepatic gallbladder causes a filling defect in a radiocolloid scan and looks like a focal hot spot in a Tc-99m-HIDA study. Alteration in liver shape is usually due to the effect of extrinsic compression. The anterior and right lateral surfaces are smooth in outline, whereas the inferior surface has grooves and fissures for the entrance and exit of vessels and ducts, respectively.\n\nFig. 4.1.3\n\nPlanar image. The liver (L) is seen clearly, and the spleen (s) faintly in an anterior (ANT) view. The spleen may project anterior to the liver in the right lateral (RL) view. In the left lateral (LL) view, the spleen appears clearly with the left lobe of the liver (L) projecting faintly anterior to it\n\n### 4.2.3 Lobes\n\nThe liver is divided into the right and left lobe on the basis of either morphology or physiology. The line of attachment of the falsiform ligament marks the boundary between the morphologic right and left lobe. The division of the liver into physiologic right and left lobes is based on the embryologic development of the bile ducts, hepatic artery, and portal vein. The line of physiological division runs between the fossa for the gallbladder in the front and the deep fissure for the inferior vena cava in the back. The point of entrance of the porta hepatis also indicates the boundary between the physiologic right and left lobes. The line of physiological division (porta hepatis) is situated on the right side of the anatomic line of division (falsiform ligament). Therefore, the physiologic left lobe is much larger than the morphologic left lobe. In the anterior view, the line of attachment of the falciform ligament is shown by a slight decrease in counts because of photon attenuation.\n\nThe anterior view usually shows the entire liver and inferior part of the spleen. In the posterior view, the liver appears triangular in shape with a rounded supero-lateral corner. The posterior border in the right lateral view often shows a concave impression because of the right kidney. A wide vertical photopenic area between the right and left lobes is due to absorption of photons by the dense thoracic vertebrae (Fig. 4.1.3). Normally, the uptake of the radiocolloid by the reticulo-endothelial (RE) cells of the vertebral body is seen very faintly. The caudate lobe is situated posteriorly along the superior border, but is not usually seen in the planar posterior image, mainly because of absorption of photons by the vertebrae.\n\n### 4.2.4 Dimensions of the Normal Liver and Spleen\n\nThe size of the liver is usually measured with an anterior view image and the size of the spleen with a posterior view (Fig. 4.1.4). A calibrated radioactive marker placed along the costal margin during data acquisition enables measurement of the organ size. The position of the liver is assessed with reference to the right costal margin. A normal liver is situated above the right costal margin and the normal spleen above the left costal margin. The right lobe of the liver measures 10.0-17.5 cm in the right mid-clavicular line. The maximum vertical height from the superior to inferior border of the right lobe is 10-20 cm The horizontal length from the right lateral border to the tip of the left lobe is 14-24 cm [4, 5]. Because of wide variations in shape at the tips, dimensions that include the tips tend to be less reliable as a measure of overall liver size. The measurement along the right mid-clavicular line serves as a better reference point for estimating true liver size than measurements along other lines. For accurate measurement of spleen size, an oblique line is drawn from the superior to inferior tip using a posterior view image. The upper limit of the normal spleen is about 10.5 cm along this oblique axis [6].\n\nFig. 4.1.4\n\nDimensions of the normal liver and spleen. In the anterior view, the right lobe measures 10.0-15.5 cm in the midclavicular line (a) and 10.0-20.0 cm from the dome to the inferior tip (c). The horizontal length from right lateral border to the tip of the left lobe ranges from 14.0 to 24.0 cm (b). In the posterior view, the upper limit of the normal spleen is 10.5 cm along the posterior oblique axis\n\n### 4.2.5 Pattern of Radiocolloid Uptake\n\nA normal liver weighs 1,500-1,800 g and the spleen 150-200 g. The bone marrow is estimated to weigh about 1,500 g [7]. The liver takes up about 90% of radiogold colloid (Au-198) and 85% of Tc-99m-sulfur colloid. The spleen concentrates 3% of Au-198 colloid and 7% of Tc-99m-sulfur colloid. Bone marrow takes up about 7% of Au-198 colloid and 5% of Tc-99m-sulfur colloid (Table 3.1.4). The difference in radiocolloid uptake among these three organs is a function of their overall size and the physico-chemical nature of the radiocolloid particles [8]. The smallest of the particles are preferentially taken up by the bone marrow, medium-size particles by the liver, and the largest particles by the spleen. As the liver disease progresses, there is a shift in radiocolloid uptake from the liver to the spleen and bone marrow. In moderate severity cirrhosis, radiocolloid uptake by the liver decreases (65-70%), and the uptake by the spleen and bone marrow increases. There is also uptake by lungs and other organs. In advanced cirrhosis, liver uptake may be as low as 30-35%. The spleen and bone marrow continue to show an increase in uptake of radiocolloid up to as high as 25-30% of the dose by each organ. The remaining 10-12% of the injected radiocolloid dose is taken up by activated RE cells in lungs and other organs.\n\n### 4.2.6 Spleen and Bone Marrow Uptake\n\nIn the posterior view, the intensity of radiocolloid uptake by a normal spleen is usually equal to that of the normal liver [9]. In cirrhosis, the intensity of splenic uptake increases in direct proportion to the degree of portal hypertension (Fig. 4.1.5). In advanced cirrhosis, the intensity of spleen and bone marrow uptake often exceeds that of the liver. Often, the intensity of thoracic and lumbar vertebral body radiocolloid uptake by the RE cells may match that of Tc-99m-MDP uptake by the bone mineral matrix. Decreased radiocolloid uptake by the spleen is also abnormal and often is noticed in patients with Hodgkin's disease, reticulum cell sarcoma, poorly differentiated lymphocytic lymphoma, mucosis fungoidis, or other types of lymphomas. In polycythemia rubra vera, the normal spleen\/liver ratio is maintained despite an enormous increase in the size of the spleen.\n\nFig. 4.1.5\n\nSitus inversus. In the anterior (ANT) view, the spleen is located on the right and liver on the left side of the body. In the right lateral (RL) view, the spleen is superimposed at the postero-inferior part of the liver. Posterior (POST) view shows liver on the left and spleen on the right, separated by a photon-deficient column because of absorption by the vertebral bodies\n\nThe liver moves 1-3 cm up and down with each respiration. The size of the liver, therefore, may falsely appear large if the patient takes deep breaths during scanning. When the liver enlarges and extends below the right costal margin, the radiocolloid uptake in the liver tissue extending below the right costal margin may appear greater than the tissue uptake behind the costal margin. This apparent effect is due to attenuation of photons by the ribs, and the right breast exaggerates the difference in women. The effect of extrinsic compression on the liver is ascertained by taking one image during deep inspiration and another during deep expiration. An intrinsic liver defect will not change its position, whereas a defect due to extrinsic compression moves with respiration [10]. Decreased radiocolloid uptake by the liver and increased uptake by the spleen, lungs, and other soft tissues are indicators of poor prognosis [11, 12]. Fatty infiltration of the liver causes irregular uptake of radiocolloid and accumulation of xenon-133 during a V\/Q study obtained for the diagnosis of pulmonary embolism.\n\n### 4.2.7 Appearance of the Normal Liver and Spleen on SPECT Images\n\nIncreased spatial resolution and high lesion to non-lesion contrast on single photon emission computed tomography (SPECT) show some of the normal structures much more prominently than in a planar image. Often such normal structures are misinterpreted as cold lesions in a radiocolloid scan or as hot lesions on a blood pool or Tc-99m-HIDA study. The right and left branches of the portal vein, hepatic artery, and bile ducts pass through the middle of the liver in the opposite direction, 180\u00b0 apart (Fig. 4.1.6). The coronal, sagittal, and transaxial slices passing through these structures may depict these normal structures as cold or hot lesions depending on the radiotracer used for the study. A cold lesion on a radiocolloid scan that fills in with Tc-99m RBC suggests a vessel or a hemangioma. A cold lesion that fills in with Tc-99m-HIDA suggests a biliary origin (choledochal cyst). In the sagittal slice passing through the middle of the right lobe, the right portal vein may appear as a curvilinear defect in the radiocolloid scan. Sagittal slices over the lateral aspect of the right lobe show a linear defect that is usually due to the posterior branch of the right portal vein. The anterior branch of the right portal vein is slightly smaller and is not always evident on sagittal slices. These anatomical variants may not be evident in the planar images due to overlying or underlying liver tissue. The right and left portal veins and the right posterior segmental vein are 1.5-2 cm in diameter, large enough to be seen on the SPECT images as defects (Fig. 4.1.6). The medial and lateral segmental veins of the left lobe are too small to cause a defect [13]. Two or three of the most anterior coronal slices may show only the left lobe, confirming its more anterior location. Lower transaxial slices show the gallbladder fossa as a pear-shaped defect along the anterior margin.\n\nFig. 4.1.6\n\nPortal vein. Transaxial CT with contrast shows division of the portal vein in the middle of the liver into right portal vein (RPV) and left portal vein (LPV). LPV divides into medial (M) and lateral (L), and RPV into anterior (A) and posterior (P) segmental branches\n\n## 4.3 Abnormal Liver\n\n### 4.3.1 Hepatomegaly\n\nA general response of the liver to any injury is one of diffuse enlargement. Hepatomegaly usually disappears when the offending agent is removed. Metabolic diseases in children are generally associated with hepatomegaly (Table 4.1.2). Most normal-size livers do not extend below the right costal margin. In patients with chronic obstructive lung disease, the liver may be pushed downwards to be palpable below the right costal margin. It is important to establish if a clinically palpable liver is due to displacement or enlargement.\n\nTable 4.1.2\n\nCauses of hepatomegaly\n\nCommon causes | Uncommon causes | Rare causes\n\n---|---|---\n\n(1) Hepatitis | (1) Hepatoma | (1) Glycogen storage disease\n\n(2) Fatty infiltration | (2) Hemochromatosis | (2) Gaucher's disease\n\n(3) Cirrhosis | (3) Granuloma | (3) Cystic fibrosis\n\n(4) Metastatic tumors | (4) Drug-induced hepatitis | (4) Galactosemia\n\n(5) Congestive heart failure | (5) Wilson's disease | (5) Kwashiorkor\n\n(6) Leukemia | (6) Infections | (6) Budd-Chiari syndrome\n\n(7) Lymphoma | (7) Hemangioendothelioma | (7) Amyloidosis\n\n(8) Abscess | (8) Polycystic disease | (8) Gangliosidosis\n\n(9) Biliary obstruction | (9) Cholangiocarcinoma\n\n|\n\nThe space-occupying lesions of the liver can be divided into four categories: (1) marginal lesions, (2) intrahepatic solitary focal lesions, (3) intrahepatic multiple focal lesions, and (4) intrahepatic diffuse lesions (Table 4.1.3).\n\nTable 4.1.3\n\nSpace-occupying lesions of the liver\n\nMarginal lesions | Intraparenchymal lesions\n\n---|---\n\nCompression by adjacent organs | Single focal | Multiple focal | Diffuse\n\nRight kidney (hypernephroma) | Hepatoma | Metastasis | Hepatitis\n\nEnlarged gallbladder | Abscess | Polycystic disease | Cirrhosis\n\nPancreatic Ca, Pseudocyst | Adenoma | Fatty infiltration | Fatty infiltration\n\nIntracapsular hematoma | Hemangioma | Hemangioma | Wilson's disease\n\nCholedochal cyst | FNH | \\-------- | Lymphoma\n\nColon mass in hepatic flexure | Metastasis | Multiple mets | Chemotoxins\n\nRight costal margin | Simple cyst | Multicystic disease | Hemochromatosis\n\nProminent portahepatis | Hydatid cyst | Hydatid cyst | Sclerosing cholangitis\n\nAscites | Infarction | Amoebic abscess | Biliary cirrhosis\n\nRight breast | Intrahepatic GB | - | -\n\nEnlarged heart | Pseudo tumor | - | -\n\nBile leak into GB fossa | - | -\n\n|\n\nFNH = Focal nodular hyperplasia\n\n### 4.3.2 Marginal Lesions\n\nMost marginal lesions are caused by compression of the liver margin by adjoining normal organs or lesions arising from them. A normal right kidney placed high in the posterior abdomen or a mass arising from it (hypernephroma) may cause a defect along the posterior border of the right lobe of the liver. Such lesions are seen as a focal defect in the posterior planar view or as a concave posterior border in the planar right lateral view. In a SPECT image, it may appear as a round defect in the posterior slices of the coronal view and in the mid and lower slices of the transaxial views. A fully filled gallbladder may cause a cold defect in a radiocolloid scan along the inferior border in the anterior planar image. The gallbladder fossa appears as a pear-shaped defect along the anterior border in the right lateral planar image. A large choledochal cyst arising from the common bile duct may compress the middle of the inferior liver margin, causing a cold defect near the porta hepatis in a radiocolloid scan.\n\nA normal stomach after a full meal or a mass arising from the stomach or pancreas (pseudocyst, cancer) may cause a defect along the inferior border of the left lobe. Depressed right lateral ribs or a hematoma following an auto accident may cause a defect along the lateral surface of the right lobe. A lesion arising from the hepatic flexure of the colon may cause compression along the inferior liver margin of the right lobe. Post-traumatic subcapsular hematomas cause defects along any surface depending upon the point of impact, but most tend to occur along the right lateral or the anterior surface [14]. A large pendulous right breast or breast prosthesis causes a concave defect along the superior border that may be misinterpreted as a filling defect or as hypoconcentration of radiocolloid. Breast artifact is corrected by taking a repeat image after lifting the pendulous breast or removing the prosthesis (Fig. 4.1.7). An enlarged heart because of congestive heart failure or cardiomyopathy causes an impression along the superior margin at the junction of the right and left lobes.\n\nFig. 4.1.7\n\nLiver artifact. A large defect over the superior part of the right lobe caused by a breast prosthesis (a) disappears in the repeat image after its removal (b)\n\nMarginal lesions of the spleen are seen mostly along the medial (hilum) or the lateral surface. Lateral surface lesions are mostly hematomas secondary to trauma due to auto accidents. Medial surface lesions are due to a large pancreatic pseudocyst, choledochal cyst, or a postprandial fluid-filled stomach. Most post-traumatic hematomas along the lateral surface resolve in 3-4 weeks [14].\n\n### 4.3.3 Intrahepatic Solitary Focal Lesions\n\nThese are the most common type of liver lesions seen when scintigraphy is obtained early in the course of liver disease. They tend to be associated with normal or mildly abnormal liver function tests. Most focal liver lesions appear to be round. Infarction appears wedge shaped, and radiation necrosis causes a characteristic appearance (quadrangular) depending upon radiation port. A thorough knowledge of the mode of clinical presentation, clinical findings, and changes in liver function tests are necessary to arrive at an etiological diagnosis. This is true for all types of liver imaging procedures, including radiocolloid scan, computerized tomography, ultrasound, and magnetic resonance imaging. No single imaging test or even a combination of imaging tests is capable of making an etiological diagnosis all of the time [15-18].\n\n### 4.3.4 Intrahepatic Multiple Focal Lesions\n\nMultiple metastases, polycystic or multicystic liver disease, and fatty infiltration are examples of multiple intrahepatic focal lesions. Multiple metastatic lesions are the most common (Fig. 4.1.8). In a patient with a known primary cancer elsewhere, multiple liver lesions are considered secondary until proven otherwise. Polycystic liver disease is associated with cysts in the kidney, spleen, and other organs and has an autosomal dominance pattern of inheritance. Fatty infiltration may cause focal or diffuse defects. On ultrasound, fatty infiltration appears as a hypoechoic mass with angulation and interdigitating margins. [19]. Liver with fatty infiltration shows xenon-133 retention after a lung ventilation study obtained to rule out pulmonary embolism. Xenon-133 retention by the liver is specific for fatty infiltration [20].\n\nFig. 4.1.8\n\nMultiple metastatic liver disease. Transaxial, coronal, and sagittal SPECT images with radiocolloid show multiple intrahepatic metastasis from colon cancer (courtesy of Dr. Kumaresan, Hyderabad)\n\n### 4.3.5 Intrahepatic Multiple Diffuse Lesions\n\nAlcoholic hepatitis, viral hepatitis, and cirrhosis are the most common causes followed by other rare diseases, such as hemochromatosis, Wilson's disease, primary biliary cirrhosis, primary sclerosing cholangitis, and drugs (chemotherapy) or toxin-induced hepatitis. Many of these diseases are associated with a changing image pattern, depending upon the phase of parenchymal liver disease. Viral and alcoholic hepatitis often heal completely when the offending agent is removed completely. Defects due to chemotherapy usually disappear after the completion of the course. The role of radiocolloid imaging in the detection of liver lesions has diminished recently and has been replaced by CT and ultrasound, which have better spatial resolution and provide additional information about structural changes in organs around the liver [21]. Radiocolloid imaging is now requested mostly to clarify an abnormality already seen with the CT or ultrasound study to confirm whether the lesion is hepatic in origin. The posterior view image shows all three organs that take up radiocolloid, the liver, spleen, and bone marrow, in the thoracic and lumbar vertebral bodies and provides information related to their relative function. Bone marrow replacement by a tumor causes a \"cold\" defect in the vertebra in a radiocolloid image and a \"hot\" lesion in a Tc-99m MDP at the corresponding site (Fig. 4.1.9).\n\nFig. 4.1.9\n\nDiscordant Tc-99m colloid and Tc-99m MDP uptake by a vertebra. A metastatic tumor in T-12 vertebra causes a \"cold\" defect (D) on the radiocolloid image (a) and a \"hot\" lesion on Tc-99m MDP bone scan (b)\n\n### 4.3.6 Relative Merits of the Diagnostic Tests\n\nThe accuracy of positive predictive and negative predictive values is similar for CT, ultrasound, and radiocolloid scan. The sensitivity of CT and radiocolloid scan is similar, but slightly low for ultrasound (Table 4.1.4). Any one of the three imaging modalities is capable of detecting a solitary liver lesion, but the choice of one over another depends upon local expertise, availability, reproducibility, and cost [22]. Because CT and ultrasound studies provide additional information about nearby organs, they have become clinically popular and have almost completely replaced radiocolloid scans for liver imaging today. Once a lesion is detected by one imaging modality, incremental information from the second or third imaging test is not substantial enough to justify obtaining more than one morphologic imaging procedure. This factor is observed more critically by insurance companies and other third party payers than by physicians and patients. The information obtained from a combination of one morphological and one physiological imaging may be better for patient management than the information gathered from a combination of two or more morphological imaging procedures.\n\nTable 4.1.4\n\nSensitivity, specificity, accuracy, positive predictive and negative predictive value of radiocolloid scan (RN), CT, and ultrasound (US) studies in the detection of space-occupying lesions of the liver\n\nNo. of patients | Sensitivity | Specificity | \\+ Predictive value | \u2212 Predictive value | Ref.\n\n---|---|---|---|---|---  \n|\n\nRN | CT | US | RN | CT | US | RN | CT | US | RN | CT | US\n\n|\n\n1,438 | 86 | 75 | 75 | 79 | 91 | 82 | 82 | 90 | 81 | 83 | 77 | 76 | [15]\n\n122 | 86 | 93 | 82 | 83 | 88 | 85 | 83 | 83 | 76 | 86 | 86 | 78 | [16]\n\n80 | 79 | 76 | 61 | 81 | 89 | 94 | 74 | 83 | 87 | 84 | 84 | 77 | [17]\n\n1,640 | 84 | 81 | 73 | 81 | 89 | 87 | 80 | 85 | 81 | 84 | 82 | 77\n\n|\n\nBiochemical tests specific for a disease may offer clues in arriving at an etiological diagnosis from an imaging procedure. Most hepatomas are associated with a rise in serum alpha-fetoprotein, and the tumor size correlates with serum levels [23]. However, a slight rise in serum alpha-fetoproteins levels is often seen in viral hepatitis, post-necrotic cirrhosis, chronic active hepatitis, drugs, and a variety of other liver diseases. Hepatomas may cause diffuse irregular radiocolloid uptake or present as a solitary or multiple focal liver lesion [24].\n\n## 4.4 Adenoma and Focal Nodular Hyperplasia\n\nAdenoma and focal nodular hyperplasia (FNH) are relatively rare solitary tumors of women in their reproductive years and show a close association with the use of oral contraceptives [1]. The tumors remain mostly asymptomatic (Fig. 4.2.1). They are discovered incidentally during abdominal CT and ultrasound examinations obtained for some other medical indication. These tumors may suddenly become symptomatic and present with acute onset of abdominal pain, hemorrhage, and hypotension [2]. Adenoma bleeds more frequently than focal nodular hyperplasia. One study reported bleeding incidence at presentation of 4 in 27 patients with adenoma and none of 23 patients with focal nodular hyperplasia [3]. They may extend beyond the liver border in some patients and become clinically palpable on routine examination. Liver function tests are usually normal in both tumors.\n\nFig. 4.2.1\n\nA schematic diagram (top) of focal nodular hyperplasia and liver cell adenoma. Focal nodular hyperplasia consists of radiating dense fibrous tissue with all types of liver cells, but without any capsule. Histology (bottom, left) shows the hepatocytes, Kupffer cells, and fibrous tissue with formation of small nodules. Adenoma (bottom, right) consists of a capsule with monotonous sheets of hepatocytes without any Kupffer cells or fibrous tissue (courtesy of Dr. Ted Pinkert)\n\nBoth tumors appear as non-specific space-occupying lesions in a radiocolloid scan, ultrasound, MRI, or CT examination. Arteriography, contrast CT, or blood pool imaging may show hypervascularity in FNH. Adenoma, on the contrary, usually shows no hypervascularity. But these morphologic and arteriographic characteristics are not distinct enough to separate FNH reliably from adenoma (Table 4.2.1) or from other space-occupying lesions of the liver listed in Table 4.1.2.\n\nTable 4.2.1\n\nCharacteristic features of hepatic adenoma and focal nodular hyperplasia\n\nParameter | Adenoma | Focal nodular hyperplasia\n\n---|---|---\n\nAge | 30-40 years | 30-40 years\n\nFemale:male ratio | 30:0 | 10:1\n\nOral contraceptive association | +++ | ++\n\nWell-defined capsule | Present | Absent\n\nBile ducts | Absent | Decreased and narrowed\n\nFibrosis | Absent | Present\n\nHypervascularity | ++ | ++++\n\nHepatocyte number (in lesion) | Normal or increase | Normal or decrease\n\nKupffer cells | Absent or decrease | Normal or decrease\n\nRadiocolloid uptake | Absent | Normal or decrease\n\nTc-99m-HIDA uptake | Increase or normal | Normal\n\nTc-99m-HIDA excretion | Absent | Slow\n\nTc-99m-NGA receptors | not known | Increase or normal\n\nHIDA = Hepatic iminodiacetic acid, NGA = galactosyl neoglyco-albumin\n\n### 4.4.1 Adenoma\n\nAdenoma is a well-encapsulated, round, solitary lesion, varying in size from 8 to 15 cm. It consists of sheets of hepatocytes without any bile ducts or fibrous septa (Fig. 4.2.1). Kupffer cells are either completely absent or markedly decreased in number. Few of those Kupffer cells that are present lack phagocytic capacity and hence the nodule appears as \"cold\" in a radiocolloid scan [4]. The hepatocytes are able to concentrate Tc-99m-HIDA, but cannot secrete into bile because of the lack of bile ducts [5]. About 80% of adenomas show mixed echogenecity on the ultrasound examination, and about 86% appear as a hypodense mass on non-contrast CT examination [4]. The most consistent pattern of hepatic adenoma on a multimodality imaging is one of a well-circumscribed solitary mass lesion on CT or US with no uptake on a radiocolloid scintigraphy. Atypical forms with functioning Kupffer cells are rare [6]. Some adenomas may show a nodule-in-nodule pattern on CT and MRI and are indistinguishable from hepatocellular carcinoma. Adenomas may be separated from carcinomas by depicting its functional characteristics. Lack of Ga-67 citrate uptake (in contrast to hepatocellular carcinoma) and no radiocolloid uptake, as well as late uptake with no excretion of Tc-99m HIDA, may distinguish adenoma from hepatoma and FNH and other types of focal liver tumors [7].\n\n### 4.4.2 Focal Nodular Hyperplasia\n\nIn contrast to hepatic adenoma, which consists mostly of sheets of hepatocytes, focal nodular hyperplasia (FNH) usually contains almost all of the cellular components of a normal liver, including the hepatocytes, Kupffer cells, bile ducts, and other supporting cells. There is a central area of fibrosis with radiating fibrous connective tissue that divides the nodule into several smaller sections of varying size, mimicking the pattern seen with pseudonodules of cirrhosis [8]. A capsule is absent, a clear distinction from adenoma (Fig. 4.2.1). Bile ducts show proliferation with narrow lumens impeding bile flow through them. The hepatocytes show a clear to dark cytoplasm with sparse bile canaliculi [2]. Most FNHs are found just beneath the liver surface, and some are pedunculated. The size of the lesions varies from 1 to 15 cm. Malignant transformation is uncommon. About 90% of FNH are hypervascular, and the rest are hypovascular on the angiogram. On the ultrasound examination, 50% are hyperechoic, 40% hypoechoic, and 10% show a mixed pattern [9, 10].\n\n### 4.4.3 Scintigraphic Features\n\nBoth focal nodular hyperplasia and a regenerating nodule of cirrhosis contain Kupffer cells. Most of the other focal liver lesions (adenoma, hemangioma, primary and metastatic liver lesions) do not contain any Kupffer cells, or those few Kupffer cells that are present lack phagocytic function. A normal radiocolloid uptake pattern is seen in 64% of FNH, and the remaining 34% show decreased uptake [11]. A characteristic scintigraphic feature of FNH includes a hypervascularity seen on contrast CT (Fig. 4.2.2a). About 76% of them showed hypervascularity in a perfusion study with Tc-99m-HIDA (Fig. 4.2.2b). Early phase functional images (within 10 min) show Tc-99m-HIDA uptake by the nodule equal to that of the adjoining normal liver (Fig. 4.2.2c). Late phase images (after 45 min) show slow clearance by the nodule and a normal clearance from adjoining normal liver. At 60 min, the radioactivity retained by FNH is about twice as much as the normal liver and hence appears as \"a hot nodule\" on the late image (Fig. 4.2.2 d and e). Mean excretion half time of 18 min for the normal liver increases to 40 min for FNH, explaining the reason for the appearance of a hot lesion [11]. The slow excretion is due to narrowing of the cholangioles draining the FNH. The time of appearance of the hot nodule is a function of both how rapidly the radiotracer is cleared from the normal liver and how slowly it is cleared from the nodule. The nodule is usually seen clearly between 18 and 60 min after injection of Tc-99m-HIDA. Routine inclusion of the perfusion phase as an integral part of hepatobiliary imaging enhances the nodule detectability by showing its hypervascularity. The radiocolloid image depicts the lesion as \"cold\" (Fig. 4.2.2f). The overall detectability of FNH is 92% with Tc-99m-mebrofenin cholescintigraphy, 84% with CT, and 84% with MRI [10] (Fig. 4.2.3).\n\nFig. 4.2.2\n\nFunctional characteristics of focal nodular hyperplasia. It is hypervascular as seen on a contrast CT (a) and perfusion study with Tc-99m-HIDA (b). Early images show normal uptake (c), and late images at 45 min (d) and 60 min (e) show retention of Tc-99m HIDA (e). The lesion appears as \"cold\" on a radiocolloid image (f). (Reproduced with permission from the publisher, [11])\n\nFig. 4.2.3\n\n(a- c) Blood pool features. A large focal nodular hyperplasia in the posterior right lobe appears as hypodense on a CT scan without contrast (a) and as non-uniform hyperdense lesion with the contrast agent (b). Blood pool imaging with autologous Tc-99m RBCs shows a non-filling center (c)\n\n### 4.4.4 Surface Receptors\n\nThe hepatocytes of FNH show an increase in the number of surface receptors for Tc-99m-galactosyl-human serum albumin much more intensely than the adjoining normal liver parenchyma. In a study comprising 12 patients with focal nodular hyperplasia, 9 with hepatocellular carcinoma, and 3 patients with metastatic liver cancer, the authors were able to distinguish FNH from primary and metastatic liver lesions by calculating a nodule\/normal liver ratio obtained with Tc-99m- neoglycoalbumin. Eight of 12 patients with FNH showed an increase in ratio, and the remaining 4 showed an uptake equal to that of the adjoining normal liver tissue. The nodule\/normal liver mean ratio was 1.7 \u00b1 0.3 in patients with FNH and 0.4 \u00b1 0.2 in patients with primary and metastatic cancer, enabling clear separation of benign from malignant liver lesions [12]. Multimodality imaging with tumor-seeking agents like Ga-67 citrate and Tl-201 chloride, combined with Tc-99m phytate (colloid) and a hepatobiliary agent (Tc-99m-pyridoxyl-5-methyl tryptophan), often aids in separating benign from malignant hepatic lesions [13, 14].\n\n### 4.4.5 Treatment\n\nA flexible treatment approach is recommended, and asymptomatic patients are managed conservatively [15]. Some nodules regress spontaneously on discontinuation of oral contraceptives [16]. Surgical resection is preferred when the nodule grows rapidly in size or becomes acutely symptomatic. Because both hepatic adenoma and FNH occur more frequently in young women during their child-bearing years and are often detected serendipitously on US or CT, done for unrelated reasons, proper management requires clear differentiation of adenoma from FNH before deciding on a specific form of therapy [17, 18]. Biopsy is not mandatory.\n\nAdenomatosis (multiple small adenomas) is a distinct entity and behaves much differently from adenoma and focal nodular hyperplasia in terms of its clinical presentation. Adenomatosis occurs in both sexes, shows no association with oral contraceptives, and is associated with elevation of serum alkaline phosphatase and gamma glutamyl transpeptidase. Hemorrhage is uncommon, and it requires no specific form of therapy [19].\n\n## 4.5 Hemangioma\n\nHemangiomas are the most common liver lesions, accounting for nearly 5-7% of all benign tumors [1]. They are congenital vascular malformations at birth that increase in size with the growth of the liver. Hemangiomas affect both sexes and occur at all ages, but manifest clinical symptoms usually in the 3rd-5th decades of life. They are relatively more common in women than in men, with a ratio of 4:1-6:1 [2]. They are more frequent in multiparous women and increase in size during pregnancy and after administration of estrogens [3].\n\n### 4.5.1 Histopathology\n\nCavernous hemangioma is usually a solitary lesion consisting of multiple vascular channels, lined by a single layer of flat endothelial cells, and supported by an intervening fibrous tissue. They vary in size from few millimeters to several centimeters, some as large as 20-30 cm in size. Hemangiomas larger than 4 cm are referred to as giant cavernous hemangiomas. Most are sessile without a capsule and are located deep inside the superior part of the liver. Occasionally, a pedunculated lesion may be seen well separated from the main liver mass. Hemangiomas consist of a large blood pool, but show a decreased blood flow (ml gm-1 min-1) through the lesion when compared to the adjoining normal liver tissue [4].\n\n### 4.5.2 Clinical Presentation\n\nMost hemangiomas are asymptomatic. In the past they were usually discovered at autopsy [2]. Today hemangiomas are discovered serendipitously while performing an ultrasound or CT scan of the abdomen, often when these imaging studies are obtained for assessment of other abdominal organs [5]. Large hemangiomas may cause abdominal pain because of compression of the adjoining organs or thrombosis within the lesion. Acute onset of severe abdominal pain may indicate hemorrhage.\n\n### 4.5.3 Diagnosis\n\nMost hemangiomas are discovered today during their asymptomatic phase with the ultrasound or CT as space-occupying lesions of the liver. The real challenge, therefore, is not one of discovery, but that of differentiation from other types of liver lesions, such as adenoma, focal nodular hyperplasia, primary or metastatic tumors. Blood pool imaging with Tc-99m RBC, contrast CT, MRI, and contrast angiography have been used for diagnosis [6-9]. Imaging with Tc-99m-labeled autologous red blood cells carries the highest specificity and is considered the diagnostic modality of choice for confirmation of hemangiomas [10].\n\n### 4.5.4 Blood Pool Scintigraphy\n\nPatient red blood cells are labeled with Tc-99m using an in-vitro method as described in detail in Chap 3.2. A rapid sequence perfusion study is obtained after injecting 15-30 mCi of autologous Tc-99m RBC (or Tc-99m pertechnetate for in vivo method) by collecting data at one frame\/2 s for 60 s. Planar blood pool images in the anterior, posterior, and two lateral views are obtained after the perfusion study. Delayed images are obtained at 30 or 60 min by collecting at least 1 million counts per image. When not seen clearly in planar images by 60 min, SPECT imaging study is obtained between 1 and 2 h. The SPECT data are collected over a 360\u00b0 rotation by obtaining 64 frames at 30 s\/frame using a 64 \u00d7 64 \u00d7 8 matrix. After appropriate correction for camera nonuniformity and center of rotation deviation, the projections are reconstructed with the vendor-specific filtered back-projection algorithm. Transaxial, coronal, and sagittal slices are obtained with known pixel size to be able to measure size accurately. Images are recorded on 8 \u00d7 10-inch X-ray film.\n\n### 4.5.5 Scintigraphic Features\n\nA normal study (Fig. 4.3.1) clearly shows a blood pool in the abdominal aorta, inferior vena cava, two kidneys, liver, and spleen. Generally, the inferior vena cava is seen much more prominently than the aorta. The heart is the hottest organ in the chest, and the spleen is the brightest organ in the abdomen in the posterior view.\n\nFig. 4.3.1\n\nNormal abdominal blood pool. Anterior (ANT) and posterior (POST) planar images show inferior vena cava (I), aorta (A), liver (L), spleen (S), and two kidneys (K). Liver appears faint in the right lateral (RL) view and spleen appears bright in the left lateral (LL) view\n\nHemangiomas typically show a decreased perfusion followed by delayed filling, reflecting their basic pathophysiology. Despite an enormous increase in the blood pool, blood flow (ml gm-1 min-1) is generally reduced relative to surrounding normal liver tissue. Due to reduction in blood flow, mixing of radiolabeled RBC with the unlabeled RBC within the hemangioma occurs slowly over several minutes or hours, depending upon the size of the hemangioma. Very large hemangiomas are often missed when sufficient time is not allowed for complete mixing or equilibration, prior to acquisition of SPECT data. Giant hemangiomas are delineated better in delayed SPECT images obtained 2-4 h after injection of the labeled red blood cells.\n\nSmall hemangiomas at the peripheral part of the liver equilibrate early and are seen faintly on planar blood pool images and become very clear on the SPECT images (Fig. 4.3.2). Complete equilibration with unlabeled RBC takes a much longer time as the size of the hemangioma increases. They manifest varied characteristics on the ultrasound and CT image. Many appear as hypodense on CT without contrast and become isodense (Fig. 4.3.3) or hyper-dense after the contrast. Some fill in only partially and others not at all. These varied features make it difficult to distinguish hemangioma from other benign and malignant liver lesions from a CT scan.\n\nFig. 4.3.2\n\nSolitary hemangioma. Planar images at 10, 20, and 40 min show blood pool at the tip of the right lobe equal to that of the rest of the liver. Coronal SPECT image at 60 min clearly shows increased blood pool at the tip, establishing hemangioma\n\nFig. 4.3.3\n\nVariable pattern hemangioma. A CT without contrast (upper left) shows a hypodense lesion in the right lobe that becomes isodense (upper right) after injection of the radiocontrast agent. Immediate planar Tc-99m RBC blood pool scintigraphy shows hemangioma faintly, which becomes much clearer at 5 and 15 min and in the right anterior oblique (RAO) view\n\nGiant hemangiomas often involve one complete segment or lobe of the liver (Fig. 4.3.4). Rapid sequence perfusion study shows markedly decreased blood flow, followed by delayed equilibration. Some may equilibrate only partially even at the end of 3-4 h and may require images at 18-24 h. Biopsy of such large lesions is a high risk procedure and should be avoided.\n\nFig. 4.3.4\n\nGiant cavernous hemangioma. A perfusion scintigraphy (upper left) shows no blood flow through a giant hemangioma involving the superior part of the right lobe and the medial left lobe in a patient with breast cancer. Coronal view SPECT at 60 min shows hemangioma with a small supero-lateral region not yet equilibrated (upper right). An anterior (ANT) and posterior (POST) planar image at 2.5 h shows complete filling in of the hemangioma (middle left). A CT with contrast (lower left) shows a variable blood pool within the hemangioma and an ultrasound study (lower right) shows mixed hyper- and hypoechoic regions (courtesy of Dr. Ronald Hagelman, Tucson, AZ)\n\nThe sensitivity and accuracy of an imaging test depend very much on the size of the hemangioma. For lesions larger than 2 cm, the sensitivity and accuracy of Tc-99m RBC perfusion and SPECT blood pool imaging varies from 89 to 92% and 89 to 94%, respectively. For similarly sized lesions, MRI sensitivity varies from 85 to 100% and accuracy from 81 to 100% [10]. For lesions less than 2 cm, scintigraphic sensitivity is 58% and accuracy 60%, and MRI carries a sensitivity of 83% and accuracy of 84% (Table 4.3.1). As MRI often fails to differentiate hemangioma from hypervascular neoplasm or focal nodular hyperplasia, blood pool imaging with SPECT is considered as the method of choice for confirmation of hemangioma [6, 10]. Angiography is necessary only in those patients who do not show a blood pool pattern typical for hemangioma. Needle biopsy is avoided in most patients unless the lesion is small and the diagnosis is not confirmed from blood pool imaging. MRI with contrast may be preferred over angiography and needle biopsy for small lesions not seen on the blood pool study [10].\n\nTable 4.3.1\n\nComparison of Tc-99m red blood cell SPECT and MR imaging in the diagnosis of hepatic hemangioma [10] | Hemangioma size in cm (n = 64)\n\n---|---  \n|\n\n1.0-1.9\n\n(n = 24) | 2.0-2.9\n\n(n = 13) | 3.0-13.0\n\n(n = 27)\n\nSPECT\n\nNo. positive (n = 50) | 14 | 12 | 24\n\nNo. negative (n = 14) | 10 | 1 | 3\n\nSensitivity (%) | 58 | 92 | 89\n\nAccuracy (%) | 60 | 94 | 89\n\nMR imaging\n\nNo. positive (n = 58) | 20 | 11 | 27\n\nNo. negative (n = 6) | 4 | 2 | 0\n\nSensitivity (%) | 83 | 85 | 100\n\nAccuracy (%) | 84 | 81 | 100\n\nAbout 90% of hemangiomas are single, found in both hepatic lobes, and in the right lobe nine times more frequently than the left (Table 4.3.2). Most are situated along the superior margin of both lobes [11]. Multiple hemangiomas may involve both lobes at different locations (Fig. 4.3.5). The typical pattern of a \"cold\" lesion on blood flow and a delayed filling (hot) on the blood pool image is found in 66% of the hemangiomas. Others show atypical patterns of early incomplete and delayed complete filling. For lesions between 1 and 2 cm, SPECT increases sensitivity by 11% over planar images. On ultrasound examination, 59% appear as hyperechoic, 11% hypoechoic, and 30% show a mixed pattern.\n\nFig. 4.3.5\n\nMultiple hemangiomas. Anterior (ANT) and posterior (POST) view planar images (top) show three hemangiomas of variable sizes. Superior (S) and inferior (I) cut transverse SPECT images (left bottom) show one hemangioma in the left lobe (no. 1) and another in the posterior part of the right lobe (no. 2). Anterior (A) and posterior (P) coronal slices confirm no. 1 lesion, and the posterior slice shows an additional (no. 3) hemangioma. A CT with contrast agent shows three hypodense lesions. Only lesion no. 1 shows slight enhancement at the periphery\n\nTable 4.3.2\n\nFeatures of 130 hemangiomas [11]\n\nFeature | Number (%)\n\n---|---\n\nDistribution\n\nSingle | 116 (89)\n\nMultiple | 14 (11)\n\nRight lobe | 118 (91)\n\nSubdiaphragmatic | 103 (87)\n\nLeft lobe | 12 (9)\n\nSuperficial | 109 (84)\n\nDeep | 21 (16)\n\nPosterior | 83 (64)\n\nAnterior | 47(36)\n\nScintigraphic features\n\nTypical filling pattern | 86 (66)\n\nAtypical filling pattern | 44 (34)\n\nUltrasound features\n\nHyperechoic | 76 (59)\n\nHypoechoic | 14 (11)\n\nMixed pattern | 39 (30)\n\n### 4.5.6 Treatment\n\nNo treatment is required for most patients without symptoms. Lobectomy or segmentectomy is recommended for patients with recent onset of pain or with a rapidly expanding lesion [12, 13].\n\n## 4.6 Somatostatin Receptor Scintigraphy\n\n### 4.6.1 Somatostatin Source\n\nSomatostatin belongs to a multigene family peptide and is synthesized, stored, and released by many cells in the body [1]. Upon release from cells, somatostatin acts as an autocrine, paracrine, and endocrine hormone. Two forms of somatostatin are identified: one with 14 (Chap. 3, Fig. 3.4.1) and the other with 28 amino acids. The larger form is a dimer formed by the union of two shorter molecules, attached at the N-terminal end [2, 3]. The cells secreting somatostatin are distributed throughout the body. High concentration of somatostatin is found in the anterior pituitary, thyroid, lungs, liver, spleen, gastrointestinal tract, pancreas, kidneys, adrenal medulla, and paraganglions of the nervous system. Somatostatin-secreting cells were once called APUD (amine precursor uptake decarboxylation) cells and now have been renamed neuroendocrine cells [4].\n\n### 4.6.2 Action of Somatostatin\n\nIn contrast to most hormones, which generally have a stimulatory effect on their target cells in the body, somatostatin has predominantly an inhibitory effect on its target cells. It is a short peptide with a serum half life of less than 3 min. It inhibits secretion of: (1) growth hormone and thyrotropin from the anterior pituitary gland; (2) insulin, glucagon, and exocrine secretion from the pancreas; (3) gastrin, vasoactive intestinal polypeptide (VIP), secretin, and cholecystokinin from the gastrointestinal tract, and (4) hormones secreted by tumors arising from various organs (Table 4.4.1). By its ability to inhibit the production and release of the hormone, somatostatin either reduces or totally abolishes the hormonal effect on the target cells and often reduces the size of the primary and metastatic tumors. Other physiological actions of somatostatin include reduction of hepatic blood flow, inhibition of gallbladder contraction and bile emptying, and inhibition of gastrointestinal motility. It increases absorption of water and electrolytes from the intestine [5].\n\nTable 4.4.1\n\nSomatostatin receptor-positive tumors\n\nGastrinoma | Carcinoid\n\n---|---\n\nInsulinoma | Medullary thyroid cancer\n\nGlucagonoma | Pituitary adenoma\n\nSmall cell lung cancer | Neuroblastoma\n\nVIPoma | Paraganglioma\n\nCholangiocarcinoma | Meningioma\n\nPheochromacytoma | Motilinoma\n\n### 4.6.3 Somatostatin Receptors\n\nFive subtypes of somatostatin receptors have been recognized [5]. Each subtype has its own chromosome location and manifests a different level of affinity for somatostatin uptake (Table 4.4.2). Normal organs that are seen faintly on a indium-111 pentetreotide (OctreoScan) scan include the lungs, anterior pituitary, and G-I tract, and the organs that are seen intensely include the thyroid, liver, and spleen (Fig. 4.4.1). Neuroendocrine tumors with the heaviest concentration of somatostatin receptors and visible on In-lll pentetreotide (OctreoScan) scans are shown in Table 4.4.3.\n\nFig. 4.4.1\n\nTwo foci of carcinoid tumor seen with In-111 OctreoScan. Both lesions seen in the 4-h image become much crisper in the 24-h image. Colon seen at 24 h represents bile and often makes it difficult to separate from the tumor\n\nTable 4.4.2\n\nCharacteristics of human somatostatin receptor subtypes [5]\n\nCharacter | Subtype 1 | Subtype 2 | Subtype 3 | Subtype 4 | Subtype 5\n\n---|---|---|---|---|---\n\nChromosome no. | 14 | 17 | 22 | 20 | 16\n\nG protein binding | + | + | + | + | +\n\nReceptor affinity to:\n\nSomatostatin-14 | +++ | +++ | ++ | ++++ | +++\n\nOctretide | \u00b1 | +++ | ++ | \u00b1 | ++\n\nVapreotide | \u00b1 | ++ | + | + | +++\n\nLantreotide | \u00b1 | ++ | + | + | ++++\n\nDistribution in normal organs | Brain, lungs, stomach, jejunum, kidneys, liver, pancreas | Brain, kidneys, bile ducts | Brain, pancreas | Brain, lungs | Brain, heart, adrenals, pituitary, small- intestine, skeletal muscle\n\nTable 4.4.3\n\nSomatostatin receptor positivity by in-vivo scintigraphy and in-vitro autoradiography [12]\n\nTumor type | In-vivo scintigraphy (%) | In-vitro autoradiography (%)\n\n---|---|---\n\nMeningioma | 100 | 98\n\nParaganglioma | 100 | 92\n\nSmall cell lung cancer | 100 | 57\n\nHodgkin's disease | 98 | 100\n\nCarcinoid | 95 | 88\n\nGastrinoma | 93 | 100\n\nUnclassified APUDoma | 89 | 100\n\nNeuroblastoma | 89 | 65\n\nPheochromacytoma | 87 | 73\n\nNon-Hodgkin's lymphoma | 83 | 87\n\nNon-functioning pituitary adenoma | 75 | 55\n\nPituitary GH producing tumor | 70 | 98\n\nMedullary thyroid cancer | 69 | 38\n\nBreast cancer | 68 | 46\n\nInsulinoma | 46 | 67\n\nSarcoidosis | 100 | 100\n\nTuberculosis | 100 | 100\n\nRheumatoid arthritis | 100 | 86\n\n### 4.6.4 Octreotide\n\nSomatostatin with a serum half life of less than 3 min is unsuitable for diagnostic or therapeutic application. This problem is solved by making molecular substitution of its basic structure and creating somatostatin analogues of longer serum half life. The first successful synthetic compound was octreotide with eight amino acids. It behaves much like the parent hormone with 14 or 28 amino acids in inhibiting somatostatin secretion by the tumor. The serum half life of octreotide is about 2 h after a subcutaneous administration. In order to accomplish both the task of binding to the receptors and at the same time carry its physiological action, all somatostatin analogues must retain the basic loop structure and four receptor-binding amino acids, phenylalanine (Phe), tryptophan (Trp), lysine (Lys), and threonine (Thr). Octreotide differs from somatostatin in not only having only eight amino acids, but also by carrying D-Phe in place of -Phe. Vapreotide (RC-160) and lanreotide (BIM-23014) are newer synthetic analogues of somatostatin used in the treatment of somatostatin receptor-positive tumors [5].\n\n### 4.6.5 Radiolabeling of Octreotide\n\nOctreotide was radiolabeled first with radioiodine I-123. The loop structure and three of the four receptor-binding amino acids were retained; the fourth receptor binding amino acid, phenylalanine, was replaced by tyrosine to enable easy radioiodination [6, 7]. The radiolabeling technique was cumbersome and the cost of production and delivery very high due to the short physical half life of I-123 (13 h). Because of these drawbacks, imaging did not become very popular clinically. Replacement of radioiodine I-123 with indium-lll appeared logical and was readily accomplished (Chap. 3, Fig. 3.4.1).\n\n### 4.6.6 Indium-111 Pentetreotide (OctreoScan)\n\nA bifunctional chelate, diethylenetriaminepentaacetic acid (DTPA), attaches to the ligand (octreotide) at one end and to the radiotracer indium-111 at the other end [8]. The loop structure and the four receptor-binding amino acids, Phe, D-Trp (in place of Trp), Lys, and Thr, are retained. To facilitate firm chelation with DTPA, Phe is replaced by D-Phe [9]. Following intravenous injection, In-111 pentetreotide (OctreoScan) distributes rapidly in the extravascular space with only 33% of the dose remaining in the intravascular pool at the end of 10 min and less than 1% at the end of 20 h. About 50% of the dose is excreted in urine in 6 h, 85% in 24 h, and more than 90% in 72 h. A very small amount is secreted into bile, which is excreted in the stool, with about 2% of the dose in 72-h stool (Fig. 4.4.1). The biokinetics of In-lll pentetreotide differ slightly from those of C-14 octreotide. In rats, most of C-14 octreotide enters the liver to be excreted in bile [9], whereas most of In-lll pentetreotide enters the kidney to be excreted in urine [9, 10]. The usual scan dose of In-lll pentetreotide is 3-6 mCi bound to 10 \u03bcgm of the peptide. The biological half time of In-111 pentetreotide is about 6 h [9]. Soon after injection, most of In-111 is attached to the receptors on the surface of the cell. After about 6 h, 50% of the cell radioactivity gets internalized. Auto radiographic studies show that In-111 inside the cell remains with the cytoplasm and the nucleus of cultured cells from carcinoid and glucagonoma [11]. This feature indicates a therapeutic potential for In-lll pentetreotide.\n\n### 4.6.7 OctreoScan Imaging Protocol\n\nFor patient preparation, discontinue therapy with somatostatin analogues for 24-48 h before injection and throughout imaging. Hydrate the patient with 16-24 oz of liquids just before and after the dose. For image acquisition, see Table 4.4.4.\n\nTable 4.4.4\n\nOctreoScan imaging protocol\n\nAgent | In-lll pentetreotide\n\n---|---\n\nDose | 3 mCi for planar and 6 mCi for SPECT images\n\nRoute | Intravenous\n\nImaging time | 4 and 24 h. Repeat at 48 or 72 h if necessary. SPECT images are taken at 4 h\n\nBowel preparation | Laxatives (Bisacodyl, fleet enema) before scan\n\nImage acquisition parameters\n\nGamma camera | Large field of view camera\n\nCollimator | Medium energy parallel-hole collimator\n\nSpectrometer settings | One set over 172 keV and the other over 245 keV energy with 20% window\n\nMatrix | 64 \u00d7 64 or 128 \u00d7 128 word matrix\n\nCounts per image | 300,000 for head and neck or 10-min image\n\n|\n\nChest and abdomen, each 500,000 counts or 10 min per view\n\nSPECT protocol\n\nMatrix | 64 \u00d7 64 or 128 \u00d7 128 matrix, 360\u00b0 rotation, with 4 or 6\u00b0, 60-90 stops\n\nFilter | Hemming or Wiener\n\n### 4.6.8 Somatostatin Receptor-Positive Tumors\n\nSuccessful detection of hepatic and extrahepatic somatostatin receptor positive tumors with In-lll OctreoScan depends upon several factors, including tumor size, histology, location, and receptor subtype within the tumor (Fig. 4.4.2). A clear distinction must be made between tumor somatostatin receptor content versus tumor positivity with In-lll OctreoScan. Tumors may have differing concentrations of receptor subtypes with varying affinity levels for somatostatin-14 or somatostatin-28 vs. In-lll pentetreotide (Table 4.4.2). Octreotide has a relatively higher affinity for receptor subtypes 2, 3, and 5 than for subtypes 1 and 4. Since In-lll pentetreotide differs in structure slightly from that of octreotide, it could have a slightly different affinity for tumor uptake than octreotide and may explain lower or higher rate of scintigraphic tumor detection rate in clinical studies.\n\nFig. 4.4.2\n\nSomatostatin receptor-positive neuroendocrine tumor with liver metastasis. Metastatic lesion in the liver is seen better in the posterior than in the anterior view. Note normal bowel activity with focal collection in the cecum mimicking a carcinoid lesion. Normal uptake is seen in the kidneys, liver, spleen, and genitalia\n\nOverall detection and localization of somatostatin receptor-positive tumors with In-lll pentetreotide scintigraphy alone vary from 98 to 100% for Hodgkin's disease, meningioma, lung cancer, and paraganglioma, 90-95% for gastrinoma and carcinoid, and 80-89% for pheochromacytoma and neuroblastoma [12]. The detection and localization of metastatic gastrinoma in the liver are 92% by In-lll pentetreotide scintigraphy alone compared to a sensitivity of 83% by multimodality imaging with ultrasound, CT, MRI, and contrast angiogram [13]. Overall, in-vivo scintigraphy shows an excellent correlation with in-vitro autoradiography, but wide variations are seen in a few specific types of tumors (Table 4.4.3). In vivo scintigraphy with In-lll pentetreotide often may show results much better than those predicted from in vitro autoradiographic studies, suggesting a role for factors other than somatostatin receptor binding alone. Such findings are commonly seen in the case of carcinoid, small cell lung cancer, paraganglioma, neuroblastoma, pheochromacytoma, and medullary thyroid cancer. In the case of insulinoma, growth hormone-producing pituitary adenoma, and unclassified APUDomas, scintigraphy may detect lesions less often than predicted from autoradiographic results. Both planar and SPECT images are obtained early at 3-4 h when the likelihood of bowel activity due to bile is less (Fig. 4.2.1). Segmented bowel activity can mimic focal tumor, and SPECT images taken at a later time (beyond 4 h) may not be able to separate the two.\n\nSeveral factors, both technical and physiological, contribute towards false-positive results, which occur in one in ten patients with Zollinger-Ellison syndrome [14]. High specificity of In-111 somatostatin receptor scintigraphy can be achieved by reducing false-positive results through clear understanding of the disease and circumstances that cause false-positive scans. An intrahepatic gallbladder may mimic hepatic metastasis by accumulating the radiotracer secreted into bile. An improvement in specificity aids in the proper management of patients. Planar images may identify only a few of the intrahepatic lesions, whereas SPECT may identify many more intrahepatic lesions (Fig. 4.2.3).\n\nFig. 4.4.3\n\nMetastatic gastrinoma. Planar images (top) in the anterior and posterior view show lesions in parapancreatic and paragastric lymph nodes. Normal activity is seen in the kidneys and spleen. Coronal view SPECT images show (bottom) multiple intrahepatic lesions in the liver, not shown by planar images (Post = posterior; Ant anterior slices)\n\n### 4.6.9 Radiation Dosimetry\n\nFollowing intravenous injection, In-111 OctreoScan is distributed diffusely throughout the body. Good hydration and frequent urination reduce the radiation dose to the organs [15]. A dose of 3 mCi In-lll pentetreotide is sufficient for planar imaging, and a dose of 6 mCi is required for a SPECT study. SPECT imaging has now become a routine standard for achieving the best sensitivity and specificity of the test. SPECT of the chest, abdomen, and pelvis are obtained routinely. Kidneys are the critical organs receiving the largest dose, followed by the spleen, urinary bladder, and liver [16]. The radiation to the kidneys from a 6-mCi (222-MBq) dose is 11.4 rad (115.44 mGy). The effective dose equivalent is 2.28 rem 6 mCi (22.2 mSv 222-1 MBq). Internalization of In-lll into the cytoplasm and nucleus of the cells from carcinoid and glucagonoma from In-lll pentetreotide raises the therapeutic potential for In-lll [11].\n\nSomatostatin receptor status of the tumor may have great impact on clinical diagnosis and management, especially in the selection of the type of therapy. Documentation of somatostatin receptor positivity can reduce the number and necessity of other diagnostic imaging tests. It is suggested that somatostatin receptor scintigraphy be used as the imaging modality of first choice in the case of gastrinoma because of its cost-effectiveness and also for its impact on patient management [17, 18]. Somatostatin receptor-positive tumors have been successfully treated medically with a combination of octreotide and prednisone [19]. Although somatostatin has been labeled with technetium-99m, it has not gained widespread clinical acceptance [20].\n\nReferences\n\n1.\n\nDeNardo GL, Stadalnik RC, DeNardo SJ, Raventos A. Hepatic scintiangiographic patterns. Radiology 1974;111:135-141PubMed\n\n2.\n\nQuinn JL lll. Nuclear medicine in gastroenterology. Hospital practice 1972, pp 115-122\n\n3.\n\nMcAfee JG, Ause RG, Wagner HN Jr. Diagnostic value of scintillation scanning of the liver. Follow-up of 1,000 studies. Arch Intern Med 1965;116:95-110PubMedCrossRef\n\n4.\n\nMould RF. An investigation of the variations in normal liver shape. Br J Radiol 1972;45:586-590PubMedCrossRef\n\n5.\n\nRosenfield AT, Schneider PB. Rapid evaluation of hepatic size on radioisotope scan. J Nucl Med 1974;15:237-240PubMed\n\n6.\n\nSiegel RM, Becker DV, Hurley JR. Evaluation of spleen size during routine liver imaging with Tc-99m and the scintillation camera. J Nucl Med 1970;11:689-692\n\n7.\n\nMIRD. Summary of current radiation dose estimates to humans with various liver conditions from Tc-99m-sulfur colloid. J Nucl Med 1975;16:108A-108B\n\n8.\n\nMIRD. Dose estimate report no. 4. Summary of current radiation dose estimate to humans with various liver conditions from Au-198 colloid. J Nucl Med 1975;16:173-174\n\n9.\n\nBekerman C, Gottschalk A. Diagnostic significance of the relative uptake of liver compared with spleen in 99m-Tc-sulfur colloid scintiphotography. J Nucl Med 1971;12:237-240PubMed\n\n10.\n\nOppenheim BE, Hoffer PB, Gottschalk A. The use of inspiration-expiration scintiphotos to determine the intrinsic or extrinsic nature of liver defects. J Nucl Med 1972;13:554-556PubMed\n\n11.\n\nKeyes JW Jr, Wilson GA, Quinones JD. An evaluation of lung uptake of colloid during liver imaging. J Nucl Med 1973;14:687-691PubMed\n\n12.\n\nAhmad M, Witztum KF, Fletcher JW, Hendershott LR, Klos D, George EA, Donati RM. Xenon-133 accumulation in hepatic steatosis. J Nucl Med 1977;18:881-885PubMed\n\n13.\n\nPettigrew RI, Witztum KF, Perkins GC, Johnson ML, Burks RN, Verba JW, Halpern SE. Single photon emission computed tomography of the liver: Normal vascular intrahepatic structures. Radiology 1984;150:219-223PubMed\n\n14.\n\nFroelich JW, Simone JF, McKussick KA, Winzelberg GC, Strauss HW. Radionuclide imaging and ultrasound in liver\/spleen trauma: a prospective comparison. Radiology 1982;145:457-461PubMed\n\n15.\n\nMcClees EC, Gedgaudas-McClees RK. Screening for diffuse and focal liver disease: the case for hepatic scintigraphy. JCU J Clin Ultrasound 1984;12:75-81PubMedCrossRef\n\n16.\n\nAnderson PO, Adams DF, McNeil BJ, Sanders R, Siegelman SS, Finberg HJ, Hessel SJ, Abrams HL. Computed tomography, ultrasound, and scintigraphy of the liver in patients with colon or breast carcinoma: a prospective comparison. Radiology 1983;149:225-230\n\n17.\n\nKemeny MM, Sugarbaker PH, Smith TJ, Edwards BK, Shawker T, Vermess M, Jones AE. A prospective analysis of laboratory tests and imaging studies to detect hepatic lesions. Ann Surg 1982;195:163-167PubMedCrossRef\n\n18.\n\nBrendel AJ, Leccia F, Drouillard J, San Galli F, Eresue J, Wynchank S, Barat JL, Ducassou D. Single photon emission computed tomography (SPECT), planar scintigraphy, and transmission computed tomography: a comparison of accuracy in diagnosing focal hepatic disease. Radiology 1984;153:527-532PubMed\n\n19.\n\nQuinn SF, Gosink BB. Characteristic sonographic signs of hepatic fatty infiltration. AJR Am J Roentgenol 1985;145:753-755PubMed\n\n20.\n\nPatel S, Sandler CM, Rauschkolb EN, McConnell BJ. Xe-133 uptake in focal hepatic fat accumulation: CT correlation. AJR Am J Roentgenol 1982;138:541-544PubMed\n\n21.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology. J Nucl Med Tech 1995;23:35S-45S\n\n22.\n\nMcGarrity TJ, Samuels T, Wilson FA. An analysis of imaging studies and liver function tests to detect hepatic neoplasia. Dig Dis Sci 1987;32:1113-1117PubMedCrossRef\n\n23.\n\nTonami N, Aburano T, Hisada K. Comparison of alpha 1 fetoprotein radioimmunoassay method and liver scanning for detecting primary hepatic cell carcinoma. Cancer 1975;36:466-470PubMedCrossRef36%3A2<466%3A%3AAID-CNCR2820360224>3.0.CO%3B2-U)\n\n24.\n\nBloomer JR, Walman TA, McIntire KR, Klastskin G. Alpha-fetoprotein in non-neoplastic hepatic disorders. JAMA 1975;233:38-41PubMedCrossRef\n\nReferences\n\n1.\n\nBaum JK, Holtz F, Brookstein JJ, et al. Possible association between benign hepatoma and oral contraceptives. Lancet 1973;2:926-929PubMedCrossRef92594-4)\n\n2.\n\nStauffer JQ, Lapinski MW, Donold DJ, Myers TK. Focal nodular hyperplasia of the liver and intrahepatic hemorrhage in young women on oral contraceptives. Ann Intern Med 1975;83:301-306PubMed\n\n3.\n\nMathieu D, Bruneton JN, Drouillard J, Pointreau CC, Vasile N. Hepatic adenoma and focal nodular hyperplasia: Dynamic CT study. Radiology 1986;160:53-58PubMed\n\n4.\n\nWelsh TJ, Sheedy PF, Johnson CM, Stephen D, Charboneau JW, Brown ML, May GR, Adson MA, McGill DB. Focal nodular hyperplasia and hepatic adenoma: comparison of angiography, CT, US, and scintigraphy. Radiology 1985;156:593-595\n\n5.\n\nDrane WE, Krasicky GA, Johnson DA, Radionuclide imaging of primary tumors and tumor like conditions of the liver. Clin Nucl Med 1987;12:569-582PubMedCrossRef\n\n6.\n\nLubbers RP, Ros PR, Goodman ZD, Ishak KG. Accumulation of technetium-99m sulfur colloid by hepatocellular adenoma: scintigraphic pathologic correlation. Am J Roentgenol 1987;148:1105-1108\n\n7.\n\nKume N, Suga K, Nishigauchi K, Shimizu K, Matsunaga N. Characterization of hepatic adenoma with atypical appearance on CT and MRI by radionuclide imaging. Clin Nucl Med 1997:22;825-831PubMedCrossRef\n\n8.\n\nKnowles DM, Wolff M. Focal nodular hyperplasia of the liver, a clinicopathologic study and review of the literature. Human Pathol 1976;7:533-545CrossRef80101-3)\n\n9.\n\nBiersack HJ, Thelen M, Torres JF, Lackner K, Winkler CG. Focal nodular hyperplasia of the liver as established by Tc-99m-sulfur colloid and HIDA scintigraphy. Radiology 1980;137:187-190PubMed\n\n10.\n\nRogers JV, Mack LA, Freeny PC, Johnson ML, Sones PJ. Hepatic focal nodular hyperplasia: angiography, CT, sonography, and scintigraphy. Am J Roentgenol 1981;137:983-990\n\n11.\n\nBoulahdour H, Cherque D, Charlotte F, Rahmouni A, Dhumeaux D, Zafrani E, Meignan M. The hot spot hepatobiliary scan in focal nodular hyperplasia. J Nucl Med 1993;34:2105-2110PubMed\n\n12.\n\nKurtaran A, Muller C, Novacek G, Kaserer K, Mentes M, Raderer M, Pidlich J, Eibenberger K, Angelberger P, Virgolini I. Distinction between hepatic focal nodular hyperplasia and malignant liver lesions using technetium-99m-galactosyl-neoglycoalbumin. J Nucl Med 1997;38:1912-1915PubMed\n\n13.\n\nBernard EJ, Nicholls W, Howman-Giles R, Kan A, Stevens M. Tl-201 positive, Ga-67 negative hepatoblastoma: a case report of a 12-year-old boy. Clin Nucl Med 1997:22;835-837PubMedCrossRef\n\n14.\n\nShuke N, Yoshikawa D, Saito Y, Sato J, Ishikawa Y, Yoshida H, Kino S, Miyokawa N, Aburano T. Focal nodular hyperplasia of the liver. Scintigraphic demonstration using three imaging agents. Clin Nucl Med 1999;24:451-453PubMedCrossRef\n\n15.\n\nPain JA, Gimson AE, Williams R, Howard ER. Focal nodular hyperplasia of the liver: results of treatment and options in management. Gut 1991;32:524-527PubMedCrossRef\n\n16.\n\nRoss D, Pina J, Mirza M, Galvan A, Ponce L. Regression of focal nodular hyperplasia after discontinuation of oral contraceptives. Ann Intern Med 1976;85:203-204PubMed\n\n17.\n\nSandler MA, Petrocelli RD, Marks DS, Lopez R. Ultrasonic features and radionuclide correlation in liver cell adenoma and focal nodular hyperplasia. Radiology 1980;135:393-397PubMed\n\n18.\n\nSherlock S, Dooley J. Diseases of the liver and biliary system. Blackwell Science, Malden, MA, 1997, 10th edn, pp 337-369\n\n19.\n\nFlejou J Barge J, Menu Y, Degott C, Bismuth H, Potet F, Benhamou J. Liver adenomatosis. An entity distinct from liver adenoma? Gastroenterology 1985;89:1132-1138\n\nReferences\n\n1.\n\nIshak KG, Rabin L. Benign tumors of the liver. Med Clin North Am 1975;59:995-1013PubMed\n\n2.\n\nEdmondson HA. Tumors of the liver and intrahepatic bile ducts. In: Atlas of tumor pathology. Section VII, Fascicle 25. Washington DC, Armed Forces Institute of Pathology, 1958, p 113\n\n3.\n\nKew MC. Tumors of the liver. In: Zakim D, Boyer TD (eds) Hepatology. A textbook of liver disease. WB Saunders, Philadelphia, 1996, p 1513\n\n4.\n\nTaylor RD, Anderson PM, Winston MA, Blahd WH. Diagnosis of hepatic hemangioma using multiple radionuclide and ultrasound technique. J Nucl Med 1976;17:362-364PubMed\n\n5.\n\nSherlock S, Dooley J. Hepatic tumors. In: Diseases of the liver and biliary system.10th edn, Blackwell Science, Malden, MA 1997\n\n6.\n\nRabinowitz SA, McKusick KA, Strauss HW. Tc-99m red blood cell scintigraphy in evaluating focal liver lesions. AJR Am J Roentgenol 1984;143:63-68PubMed\n\n7.\n\nBrodsky RI, Friedman AC, Maurer AH, Radecki PD, Caroline DF. Hepatic cavernous hemangioma: diagnosis with Tc-99m-labeled red cells and single photon emission CT. AJR Am J Roentgenol 1987;148:125-129PubMed\n\n8.\n\nBree RL, Schwab RE, Glazer GM, Fink-Bennett D. The varied appearance of hepatic hemangioma with sonography, computed tomography, magnetic resonance imaging and scintigraphy. RadioGraphics 1987;7:1153-1175PubMed\n\n9.\n\nWhitney WS, Herfkens RJ, Jeffrey RB, McDonnell CH, Li KCP, Van Dalsem WJ, Low RN, Francis IR, Dabatin JF, Glazer GM. Dynamic breath-hold multiplanar spoiled gradient-recalled MR imaging with gadolinium enhancement for differentiating hepatic hemangiomas from malignancies at 1.5 T. Radiology 1993;189:863-870PubMed\n\n10.\n\nBirnbaum BA, Weinreb JC, Megibow AJ, Sanger JJ, Lubat E, Kanamuller H, Noz ME, Bosniak MA. Observations on the growth of renal neoplasms. Radiology 1990;176:95-101PubMed\n\n11.\n\nEl-Desouki M, Mohamadiyeh M, Al-Rashed R, Othman S, Al-Mofleh. Features of hepatic hemangioma on planar and SPECT Tc-99m-labeled red blood cell scintigraphy. Clin Nucl Med 1999,24:583-589PubMedCrossRef\n\n12.\n\nBelli L, DeCarlis L, Beati C, et al. Surgical treatment of symptomatic giant hemangiomas of the liver. Surg Gyn Obstet 1992;174:474-478\n\n13.\n\nSinanan MN, Marchioro T. Management of cavernous hemangioma of the liver. Am J Surg 1989;157:519-522PubMedCrossRef90652-1)\n\nReferences\n\n1.\n\nKrulich L, Dhariwal APS, McCann SM. Stimulatory and inhibitory effects of purified hypothalamic extracts on growth hormone release from rat pituitary in-vitro. Endocrinology 1968;83:783-790PubMedCrossRef\n\n2.\n\nReichlin S. Somatostatin, part 1. N Engl J Med 1983;309:1495-1501PubMedCrossRef\n\n3.\n\nReichlin S. Somatostatin, part 2. N Engl J Med 1983;309:1556-1563PubMedCrossRef\n\n4.\n\nReubi JC, Kvols L, Krenning E, Lamberts SWJ. Distribution of somatostatin receptors in normal and tumor mice. Metabolism 1990;39:78-81PubMedCrossRef90217-Z)\n\n5.\n\nLamberts SWJ, Vanderlely A, De Herder WW, Hofland LJ. Octreotide. N Engl J Med 1996;334:246-254PubMedCrossRef\n\n6.\n\nKrenning EP, Bakker WH, Breeman WAP et al. Localization of endocrine- related tumors with radioiodinated analogue of somatostatin. Lancet 1989;1:242-244PubMedCrossRef91258-0)\n\n7.\n\nKvols LK, Brown ML, O'Connor MK et al. Evaluation of a radiolabeled somatostatin analogue (I-123 octreotide) in the detection and localization of carcinoid and islet cell tumors. Radiology 1993;187:129-133PubMed\n\n8.\n\nKrenning EP, Bakker WH, Kooiji PPM et al. Somatostatin receptor scintigraphy with indium-lll DTPA-D-Phe-1-octreotide in man. Metabolism, dosimetry, and comparisons with iodine-123-Tyr-3-octreotide. J Nucl Med 1992;33:652-658PubMed\n\n9.\n\nSomatostatin receptor imaging for neuroendocrine tumors. Product monograph. OctreoScan. Mallincrodt Medical Inc. Mallincrodt Nuclear Medicine Division, St. Louis, MO, 1994\n\n10.\n\nKrenning EP, Kwekkeboom DJ, Bakker WH, et al. Somatostatin receptor scintigraphy with (In-lll -DTPA-D-Phe-1) and (I-123-Tyr-3)-octreotide: the Rotterdam experience with more than 1,000 patients. Eur J Nucl Med 1993;20:716-731PubMedCrossRef\n\n11.\n\nAndersson P, Forssel-Aronsson E, Johanson V, Wangberg B, Nilsson O, Fjalling M, Ahlman H. Internalization of indium-lll into human neuroendocrine tumor cells after incubation with indium-lll-D-Phe-1-octreotide. J Nucl Med 1996;37:2002-2006PubMed\n\n12.\n\nKrenning EP, Kwekkeboom DJ, Pauwels S, Kvols K, Reubi JC. Somatostatin receptor scintigraphy. In: Freeman LM (ed). Nuclear medicine annual 1995. Raven Press Ltd, New York, 1995, pp 1-50\n\n13.\n\nGibril F, Reynolds JC, Doppman JL, Chen CC, Venzon DJ, Tremanini B, Weber HC, Stewart CA, Jensen RT. Somatostatin receptor scintigraphy: its sensitivity compared with that of other imaging methods in detecting primary and metastatic gastrinoma. A prospective study. Ann Intern Med 1996;125:26-34PubMed\n\n14.\n\nGibril F, Reynolds JC, Chen CC, Yu F, Goebel SU, Serrano J, Doppman JL, Jensen RT. Specificity of somatostatin receptor scintigraphy: a prospective study and effects of false-positive localization on management in patients with gastrinomas. J Nucl Med 1999;40539:553\n\n15.\n\nYamada T, Niinuma K, Lemaire M, Terasaki T, Sugiyama Y. Mechanism of the tissue distribution and biliary excretion of the cyclic peptide octreotide. J Pharmacol Expt Ther 1996;279:1357-1364\n\n16.\n\nStabin MG, Kooji PPM, Bakker WH, Inoue T, Endo K, Coveney J, deJong R, Minegishi A. Radiation dosimetry for indium-111-pentetreotide. J Nucl Med 1997;38:1919-1922PubMed\n\n17.\n\nTermanini B, Gibril F, Reynolds JC, Doppman JL, Chen CC, Stewart CA, Sutliff VE, Jensen RT. Value of somatostatin receptor scintigraphy: A prospective study in gastrinoma of its effects on clinical management. Gastroenterology 1997;112:335-347PubMedCrossRef\n\n18.\n\nJamar F, Fiasse R, Laners N, Pauwels S. Somatostatin receptor imaging with indium-lll-pentetreotide in gastroenteropancreatic neuroendocrine tumors: Safety, efficacy and impact on patient management. J Nucl Med 1995;36:542-549PubMed\n\n19.\n\nPalmieri G, Lastoria S, Colao A, Vergara E, Varrella P, Biondi E, Selleri C, Catalano L, Lombardi G, Bianco AR, Salvatore M. Successful treatment of a patient with a thymoma and pure red-cell aplasia with octreotide and prednisone. N Engl J Med 1997;336:263-265PubMedCrossRef\n\n20.\n\nVallabhajosula S, Moyer BR, Lister-James J, McBride BJ, Lipszyc H, Lee H, Bastidas D, Dean RT. Preclinical evaluation of technetium-99m-labeled somatostatin receptor-binding peptides. J Nucl Med 1996;37:1016-1022PubMed\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_5(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 5. Imaging and Quantification of Hepatobiliary Function\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nThe liver is one of the most frequently imaged organs in the body, using ultrasound, CT, MRI, or scintigraphy. The first three imaging techniques depend upon morphological changes to detect disease, whereas scintigraphy uses both morphological and physiological changes to discover liver pathology. Since physiological changes usually precede morphological alterations by several weeks or months, there is great potential for early diagnosis by scintigraphy, well before irreversible functional changes take place. Once very popular, imaging with radiocolloids now has been almost completely replaced by quantitative hepatobiliary functional imaging with Tc-99m HIDA [1].\n\n## 5.1 Hepatobiliary Imaging\n\nThe liver is one of the most frequently imaged organs in the body, using ultrasound, CT, MRI, or scintigraphy. The first three imaging techniques depend upon morphological changes to detect disease, whereas scintigraphy uses both morphological and physiological changes to discover liver pathology. Since physiological changes usually precede morphological alterations by several weeks or months, there is great potential for early diagnosis by scintigraphy, well before irreversible functional changes take place. Once very popular, imaging with radiocolloids now has been almost completely replaced by quantitative hepatobiliary functional imaging with Tc-99m HIDA [1].\n\nFunctional studies are obtained with the protocol outlined in Table 5.1.1, by using any one of several Tc-99m-HIDA agents that delineates the entire hepatobiliary tree as it travels from the hepatocyte to enter the duodenum (Chap. 3). Time of appearance of various normal biliary structures depends upon many factors, of which the tonus of the sphincter of Oddi plays the major role[2]. Following intravenous injection of Tc-99m-disofenin or Tc-99m-mebrofenin, the liver peak uptake is reached within 10 min, and the common bile duct is seen by 20 min. Both the gallbladder and small intestine are seen within 30 min in the great majority of patients (Table 5.1.2). Some patients show a reciprocal relationship between the time of appearance of the gallbladder and small intestine, with the intestine appearing late when the gallbladder appears early and vice-versa. Normally about 50% of gallbladders are seen within 15 min, 90% within 30 min, and 95% within 50 min. In the remaining 5%, gallbladders appear between 50 and 60 min after injection of the radiotracer [3].\n\nTable 5.1.1\n\nHepatobiliary imaging protocol\n\nPatient preparation | Patient should fast overnight (6-10 h optimal), minimum 4 h and maximum 24 h. Routine pre-emptying of the gallbladder with cholecystokinin is unnecessary and should be avoided. Pre-emptying may be needed only when the patient is fasting for longer than 24 h or on parenteral nutrition. When a pre-emptying protocol is used, one should wait for 60 min after CCK-8 to begin hepatic phase imaging with Tc-99m-HIDA\n\n---|---\n\nAgent | Tc-99m-mebrofenin or Tc-99m-disofenin\n\nDose | 2-4 mCi for serum bilirubin less than 2 mg%\n\n|\n\n5-8 mCi for serum bilirubin 3-10 mg%\n\n|\n\n10 mCi for serum bilirubin greater than 11 mg%\n\nChildren | 200 \u03bcCi kg -1 (minimum 1 mCi)\n\nPosition | Supine\n\nCamera | Large field of view dual-head gamma camera\n\nCollimator | Low energy, all purpose, parallel hole\n\nWindow | 20% at 140 keV photopeak\n\nMatrix | 128 \u00d7 128 \u00d7 16\n\nComputer data acquisition | Data acquisition is separated into two parts: (1) Hepatic phase and (2) gallbladder phase\n\nHepatic phase | Obtain 1 frame 2 s-1 for 30 frames (first minute) and 1 frame per min for 59 min (total 60 min). Obtain a right lateral view when gallbladder appearance is not certain at 60 min\n\nGallbladder phase | 1 frame per min for 30 min (61-90 min)\n\nBeginning at 5 min, CCK-8 is infused at a dose rate of 3 ng kg-1 min-1 for 10 min through an infusion pump\n\nTable 5.1.2\n\nTime of appearance of normal common bile duct, gallbladder, and small intestine\n\nAppearance of the common bile duct within 20 min | 100%\n\n---|---\n\nAppearance of the gallbladder: | within 15 min | 50%\n\n|\n\nwithin 30 min | 90%\n\n|\n\nwithin 50 min | 95%\n\n|\n\nwithin 60 min | 100%\n\nAppearance of the small intestine within 60 min | 80%\n\n### 5.1.1 Identification of Lobes, Segments, and Areas from Tc-99m-HIDA Images\n\nPhysiologically, the liver is divided into three lobes (including the caudate lobe), four segments, and eight areas (Fig. 5.1.1). The right lobe is divided into anterior and posterior segments, and the left lobe into medial and lateral segments. The right and left branches of the portal vein travel through the middle of the liver in opposite directions and divide the liver into superior and inferior areas. The right and left lobe each consists of four areas. The caudate lobe is situated along the superior margin of the posterior surface and is considered an independent lobe because of its unique blood supply. Its veins drain blood directly into the inferior vena cava.\n\nFig. 5.1.1\n\nBiliary anatomy. The bile ducts from the medial (nos. 4a, 4b) and lateral (nos. 2, 3) segments of the left lobe unite to form the left hepatic duct (LHD) and are seen separately in an anterior image. The ducts from the anterior (nos. 5, 8) and posterior (nos. 6, 7) segments of the right lobe join to form the right hepatic duct (RHD), and a right lateral view is required to separate them and their branches. RHD and LHD unite to form the common hepatic duct, which in turn forms the common bile duct after joining with the cystic duct from the gallbladder. The caudate lobe in the posterior view is usually obscured by photon attenuation by vertebral bodies\n\nDivision of the liver into physiologic right and left lobes is currently preferred over anatomic division because it serves as a useful boundary line during surgical resection of the liver. The lobes, segments, and areas are identified on an anterior, right lateral, and posterior view image, much like identifying the lobes and segments of a lung from a perfusion scan. Obstruction of a segment or an area bile duct is seen as bile stasis over the corresponding region, similar to identifying a lack of perfusion of a lobe or segment in a lung scan due to pulmonary embolism. The numbers shown in Fig. 5.1.1 are adopted from Table 1.1.1 of Chap. 1, as developed by different authors over the years. Healy and Schroy suggested a directional nomenclature after careful dissection of nearly 100 cadaver livers [4].\n\nThe medial segment of the physiologic left lobe (4a, 4b) forms a part of the right lobe when the liver is divided morphologically into right and left lobes on the basis of the attachment of the falciform ligament. The caudate lobe (no. 1) is posterior in location, but usually not seen on a posterior view image due to attenuation of photons by the vertebrae. The inferior area of the medial segment of the physiologic left lobe (4b) is often referred to as the quadrate lobe.\n\nThere are many variations in the manner in which the segmental ducts unite to form lobar ducts. The right hepatic duct is formed by the union of its anterior and posterior segmental ducts and the left hepatic duct by the union of its medial and lateral segmental ducts in 72% of the patients. The posterior segmental duct from the right lobe joins the left hepatic duct directly in 22% of patients. In the remaining 6%, the anterior segmental duct from the right lobe joins with the left hepatic duct directly [4]. It is very rare for the bile from either the medial or lateral segmental duct of the left lobe to drain directly into one of the segmental ducts of the right lobe (Fig. 1.1.4, Chap. 1).\n\nThe distal 0.5-1.5 cm of the right and left hepatic ducts, and the entire common hepatic and common bile ducts are outside of the liver parenchyma (extrahepatic), although they may appear as intrahepatic in an anterior view Tc-99m-HIDA study. This apparent depiction is due to extension of the inferior liver border in front of these ducts. The common hepatic duct usually measures about 2-7 cm, and the common bile duct is about 7-17 cm in length. The total length of the common duct (common hepatic plus common bile ducts) from its origin at the union of the right and left hepatic ducts to its termination into the duodenum varies from 10 to 20 cm. On a Tc-99m-HIDA image, however, total length of the common duct measures about 6.6 \u00b1 1.3 cm [3]. This foreshortening is caused by the position of the gamma camera (placed anteriorly) and its relationship with the direction of the common hepatic and common bile duct.\n\n### 5.1.2 Duct Asymmetry\n\nAsymmetry in appearance of the right and left hepatic duct is common on cholescintigraphy. Normally, the left hepatic duct appears much more prominent than the right in 55% of the subjects; the right hepatic duct is more prominent than the left in 13%, and both ducts appear as equal in 10% of the subjects (Table 5.1.3). In the remaining 22% of the subjects, neither duct is seen because of rapid bile flow through a lax sphincter of Oddi [3]. Several reasons are offered for duct asymmetry, including: (1) a more anterior location of the left liver lobe than the right, (2) a more anterior location of the left hepatic duct in comparison to the right hepatic duct, (3) a variant bile flow pattern where either the posterior or the anterior segmental duct from the right lobe drains bile directly into the left hepatic duct, (4) an undivided portion of the left hepatic duct is twice as long as the right duct and hence prone to tortuosity, impeding bile flow through it, and (5) a short right hepatic duct that lies in direct line with the common hepatic duct offers less impedance to bile flow through it. A slower bile flow allows relatively more counts to accumulate in the image to manifest as an apparent prominence.\n\nTable 5.1.3\n\nVariations in the appearance the normal right and left hepatic ducts\n\nLeft hepatic duct more prominent than right hepatic duct | 55%\n\n---|---\n\nRight hepatic duct more prominent than the left hepatic duct | 13%\n\nRight hepatic duct = left hepatic duct | 10%\n\nNeither duct seen clearly | 22%\n\nHepatobiliary studies are usually carried out 4-10 h after the fast, which establishes the basal state. Fasting less than 4 h or more than 24 h is avoided. Cholecystokinin reaches its lowest serum level during fasting, promoting maximum increase in the tonus of the sphincter of Oddi and maximum relaxation of the smooth muscle of the gallbladder wall. Acting together, both of these factors promote rapid filling of the gallbladder to its normal volume of 50 ml. The liver normally secretes about 600 ml bile per day (0.4 ml min-1) continuously, of which about 70% (0.3 ml min-1) enters the gallbladder, and the remaining 30% (0.1 ml min-1) enters the duodenum directly during fasting [5, 6]. A fully filled gallbladder is still able to accommodate this constant inflow of hepatic bile (0.3 ml min-1) by absorbing an equal volume of water through the wall. The lateral intercellular spaces between the columnar epithelial calls are kept widely open during fasting, allowing free passage of water from the gallbladder lumen into the interstitium. Fasting for less than 4 h results in either non-visualization or low Tc-99m-HIDA counts within the gallbladder because of the preferential flow of bile directly into the duodenum through a lax sphincter of Oddi.\n\n### 5.1.3 Effect of Food Intake on Uptake and Excretion of Tc-99m-HIDA\n\nPhysiological changes that take place soon after a meal affect some of the functional parameters obtained with Tc-99m-HIDA study and should be taken into account during data interpretation. In the immediate postprandial state, time to peak hepatic uptake of Tc-99m-HIDA decreases compared to studies performed after 6-10 h of fasting (Fig. 5.1.2). These changes are attributed to an increase in postprandial liver blood flow and faster extraction of Tc-99m-HIDA by the liver [7]. The radiotracer also clears from the liver parenchyma much more rapidly in the immediate post-prandial state, which is attributed to an increase in ductal bile flow induced by endogenous release of secretin, cholecystokinin, and other gastrointestinal hormones. Faster uptake combined with rapid liver clearance shifts the peak of the hepatic curve to an earlier time. The gallbladder does not fill in because of its contraction induced by post prandial release of endogenous cholecystokinin. When the gallbladder is the organ of interest for study, it is essential to maximize hepatic bile entry into it by fasting for at least 8-10 h, when both the absorption of water through the wall and the tonus of the sphincter of Oddi are at their peak [8]. Longer duration of fasting provides much better counting statistics because of preferential entry of Tc-99m HIDA mixed hepatic bile into the gallbladder [9]. Fasting longer than 24 h has an adverse effect on gallbladder filling because of the formation of bile sludge, which decreases water absorption through the wall.\n\nFig. 5.1.2\n\nEffect of feeding on the kinetics of Tc-99m-HIDA: In the fasting state (top), increased tonus of the sphincter of Oddi diverts more of the hepatic bile into the gallbladder than intestine. There is residual radioactivity in the liver at 60 min. In the post-prandial state (bottom), there is more rapid hepatic uptake and excretion, shifting the peak of the curve to an earlier time, and very little residual radioactivity remains in the liver beyond 15 min. The gallbladder does not fill in because of a lax sphincter\n\n### 5.1.4 Quantification of Liver Function\n\nBesides providing an excellent morphology of the entire hepatobiliary system, imaging with Tc-99m-HIDA enables simultaneous quantification of liver and gallbladder function as an integral part of imaging. Traditionally, the liver function is monitored by obtaining the serum level of various substances produced by the liver, including albumin, bilirubin, alkaline phosphatase, and transaminase. Serum levels are indirect indicators of liver function and are influenced by the status of the cardiac and renal function, and hence may not reflect accurately the hepatocyte function in the presence of heart or kidney failure. Measurement of radioactivity emitted from the liver serves as a direct indicator of the physiological status of the hepatocyte, which is unaffected by renal function [10]. The biokinetic pathway of Tc-99m-HIDA involves several steps before its elimination from the liver into the small intestine (Chap. 3.1). Quantification of function allows differentiation of hepatocyte from biliary disease. New FDA-approved software called Krishnamurthy Hepato-Biliary Software (KHBS) is now available for quantification of liver and gallbladder function and can be loaded onto a PC. It has seven main components for analysis: Hep-function, HEP-segments, HEP-static, GB-function, GB-segments, GB-static, and HPS (hepatopulmonary syndrome). Setup block allows entering local parameters and the option to edit images. GB-phase parameters are entered for CCK-8 and fatty meal stimulation (Fig. 5.1.3). Hepatic extraction fraction and excretion half time are two of the functional parameters measured routinely as an integral part of hepatobiliary imaging [1]. Hepatic extraction fraction measures the integrity of the basolateral border, and excretion halftime reflects intracellular transit from the basolateral border to the canalicular border, secretion into canaliculi, and flow through the small and large bile ducts.\n\nFig. 5.1.3\n\nSetup and GB-input data for KHBS. Activation of the setup block provides the option to enter desired parameters pertaining to local need. User login, data location (or study location), image size, color option, hospital details, font size, agents, and normals, etc., are entered into the SetUp menu once for permanent storage. Images can be resized with magnification or minimizing buttons. Annotation and move option are available for image editing for report or for power point presentation. Gallbladder parameters are changed depending upon CCK-8 or fatty meal stimulus\n\n### 5.1.5 Hepatic Extraction Fraction (HEF)\n\nStudies are acquired as the patient lies in the supine position underneath a large field of view dual-head gamma camera, and the data are collected as described in Table 5.1.1. Both Hep-phase and gallbladder-phase data are transferred from the gamma camera terminal to the PC where KHBS is located. By activating the browse button, data location is identified, and both phase image data of a patient are uploaded onto KHBS. Report block at the top creates desired images for interpretation. The perfusion, HEP-phase, GB-phase, and multiple image presentation formats are changed to meet local preference. The perfusion part of the study is analyzed subjectively using 30 frames of the first minute data. HEP-function block at the top of the screen is then activated. The software sums up the first 30-frame perfusion data, labels it as frame one, and uses the remaining 59 min frames (total 89 frames) for assessment of the liver function. When interrupted data are acquired, instead of continuous data, the HEP-static format is activated for image presentation.\n\nAfter activating the HEF-function block at the top, seven regions of interest (ROI) are drawn, one each over the heart, background (spleen), right lobe, left lobe, gallbladder, stomach, and intestine, as shown at the bottom of the screen (Fig. 5.1.4). Each ROI consists of at least 50-75 pixels. Heart and background regions are usually drawn on the first minute frame. The heart ROI may include one or both ventricles. Background is drawn over the spleen. Raw data curve from each ROI is displayed instantly after completion of the ROI. Often intestinal activity may overlay the spleen region in later images and give a false background. Normally, the spleen curve parallels the heart curve when there is no intestinal overlap. A different background region is chosen if there is intestinal overlap of the spleen. The liver ROIs include only the parenchyma of the superior right lobe and left lobe, and are usually drawn on the 10- to 20-min frames when ducts become visible. Care is taken to avoid inclusion of heart or bile ducts with the liver ROI. Superior and right lateral liver margins, and gallbladder, which move in and out of the ROI during deep inspiration or upon coughing, are excluded from the liver ROIs. The spleen, which appears clearly in the first minute summed frame, disappears in the later frames. Stomach, gallbladder, and intestinal ROIs are usually drawn on the last (60-min) frame. After selecting all ROIs, the entire 60-min study is reviewed in cine mode to ensure separation of the regions of interest. Regions of interest are altered if there is superimposition by other structures. After checking all seven ROIs for accuracy, the HEP-function result block is activated to obtain the result (Fig. 5.1.5).\n\nFig. 5.1.4\n\nHepatic phase ROIs. Heart and background (Bkg) regions of interest are chosen on the first-minute frame. Right and left lobe ROIs are drawn over the liver parenchyma in 10-20-min frame by excluding bile ducts. Gallbladder, stomach, and intestinal ROIs are drawn on the last 60-min frame. Curves on the right represent the same color ROIs on the left\n\nFig. 5.1.5\n\nResults of Hep-phase: Hepatic extraction is calculated by deconvolutional analysis using the heart for the input and liver for the output function. The excretion half time is measured by non-linear least-square fit using spleen as the background. Excretion T 1\/2 is slightly longer for the left than the right liver lobe (statistically not significant). Basal differential hepatic bile flow and DGBR values are shown on the right. Middle panel shows the ROIs for each structure to check for accuracy\n\nThe software first smoothes the liver curves and then subjects them to deconvolution. The liver true response curve is deconvoluted from the input (heart) and output (liver) curve using Fourier transformation. Since the hepatic curve represents the sum of counts from the hepatocyte and hepatic blood pool, the deconvolution corrects for hepatic blood pool [11]. A smoothed decreasing long tail in the shape of one-half of a cosine wave is appended to the end of the input and output curves. This long tail avoids errors due to abrupt data termination at 30 min. The append begins at the 30th frame and falls to zero at the 128th added frame, giving approximately six times the duration of acquisition [12]. Duration of such a length is a minimum required to avoid artifacts in the deconvolution process. The formula for the appended tail in frame i of the heart or liver curve is given by:\n\n![$$\n{\\\\rm Tail} = 0.5 \\\\times {\\\\rm AMP} \\\\times \\\\left\\( {{\\\\rm Cos\\[}\\\\pi  \\\\times \\\\left\\( {{\\\\rm i - 30}} \\\\right\\)\\\\left\\( {128 - 30} \\\\right\\)\\] + 1} \\\\right\\)$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ1_5.gif)\n\nwhere i = 30-128, and AMP is the heart or liver curve value (counts per pixel) at frame 30.\n\nThe hepatic extraction fraction (HEF) is the ratio of the Y intercept of the exponential fit to the maximum data point in the liver response curve. The exponential fit is by linear least square, working in reverse from 30 min to the first frame, which visually departs significantly from the exponential fit. HEF is calculated by the following equation.\n\n![$$\n{\\\\rm Hepatic}\\\\,{\\\\rm Extraction}\\\\,{\\\\rm Fraction}\\\\left\\( {{\\\\rm HEF}} \\\\right\\) = \\\\frac{{{\\\\rm{Y\\\\ intercept\\\\ exponential\\\\ fit\\\\ liver\\\\ response\\\\ curve}}}}{{{\\\\rm Y - MAX}\\\\,{\\\\rm data}\\\\,{\\\\rm value\\\\ liver\\\\ response\\\\ curve}}}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ2_5.gif)\n\nThe deconvolutional technique separates hepatocyte counts from the hepatic blood pool counts. A deconvoluted liver curve, therefore, represents a hypothetical true response as though Tc-99m HIDA was injected directly into the hepatic artery or portal vein [11, 12]. The normal hepatic extraction fraction with Tc-99m-mebrofenin and Tc-99m-disofenin varies from 92% to 100%. The extraction fraction decreases as the hepatocyte function decreases. Functional changes show good correlation with Child's classification (Table 5.1.4) of the severity of liver disease [13].\n\nTable 5.1.4\n\nChild's classification of liver disease\n\nClinical and laboratory findings | Child's class\n\n---|---\n\nA | B | C\n\nAscites | None | Controlled | Uncontrolled\n\nNeurological Findings | None | Minimal | Advanced\n\nNutrition | Excellent | Good | Poor\n\nBilirubin (mg%) | <2.0 | 2.0-3.0 | >3.0\n\nAlbumin (gm%) | >3.5 | 3.0-3.5 | <3.0\n\n### 5.1.6 Hepatic Excretion Half Time\n\nAfter the uptake, Tc-99m-HIDA is secreted by the hepatocytes in its native state into bile canaliculi, where it mixes thoroughly with the canalicular bile. Secretion of radioactive bile into canaliculi serves as the direct in vivo, non-invasive method of radiolabeling hepatic bile, without altering basal liver physiology. After mixing with the canalicular bile, Tc-99m- HIDA follows the path taken by the hepatic bile. Excretion half time is a measure of how fast the radiotracer is secreted by the hepatocyte into bile canaliculi and how rapidly it flows through the intrahepatic bile ducts to enter the common hepatic duct and common bile duct before entering the gallbladder and duodenum. Measurement of excretion half time uses the liver and spleen ROI (Fig. 5.1.4). Since both the liver and spleen receive their arterial blood supply from a common source, the celiac artery, the spleen serves as the most appropriate organ for subtraction of the blood background. The background subtracted liver curve is modeled by an uptake and excretion compartment and is given by the following equation [12].\n\n![$$\n{\\\\rm L}\\\\left\\( {\\\\rm t} \\\\right\\){\\\\rm  = k}\\\\left\\( {{\\\\rm e}^{{\\\\rm  - 0}{\\\\rm .693t\/TE}} {\\\\rm  - e}^{{\\\\rm 0}{\\\\rm .693t\/TU}} } \\\\right\\)$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ3_5.gif)\n\nwhere L(t) = background corrected liver counts\/pixel at time t,\n\nk = a constant of the model, TE = excretion effective T \u00bd, and TU = uptake effective T\u00bd.\n\nAlthough the hepatic phase data are collected for 60 min, calculation of HEF uses only the first 30-min data, whereas excretion T 1\/2 uses all 60-min data points. Patient values are shown along with normal range (Fig. 5.1.5). Although in most patients with normal liver function, both HEF and T 1\/2 excretion can be obtained by collecting total data only for 45 min, in patients with moderate to severe liver disease (serum bilirubin levels above 5 mg%), it is necessary to collect data for a minimum of 60 min to obtain a reliable excretion half time [13]. Normal T \u00bd excretion values obtained with KHBS using Tc-99m mebrofenin range from 6 to 38 min for the right lobe and from 6 to 58 min for the left lobe (Fig. 5.1.5). A longer excretion T 1\/2 value of the left lobe is due to influence of bile within the left hepatic duct, which is more superficial than the right hepatic duct. Both HEF and T 1\/2 excretion values are highly reproducible, both within and between institutions, and among different technologists [14]. HEF values remain within a normal range in early biliary disease, but decrease in hepatocellular disease. When the liver disease is severe and progressive, the HEF value begins to decrease, and excretion half time increases in both hepatocyte and biliary disease [15]. Both parameters provide a reliable measure of the severity of hepatobiliary diseases, irrespective of the etiology (Fig. 5.1.6).\n\nFig. 5.1.6\n\nRelationship between hepatic extraction fraction (HEF) and excretion half time in health and disease. HEF remains near normal level in early disease and begins to decrease as bilirubin increases (a). Excretion half time increases from the very beginning and raises further as serum bilirubin value increases (b). HEF and excretion half times show an inverse relationship (c)\n\n### 5.1.7 Effect of Bile Duct Obstruction on Liver Function\n\nIn the case of hyperacute or acute total obstruction of the common bile duct, HEF values remain within a normal range for 4-5 days, as long as the serum bilirubin level remains below 8 mg% (Fig. 5.1.6A). HEF begins to decrease when obstruction persists and the serum bilirubin level rises above 8 mg% [16]. Excretion half time, on the other hand, increases from the very beginning (Fig. 5.1.6B). Prolongation of the excretion half time in biliary obstruction is due to bile stasis within the canaliculi and intrahepatic bile ducts. In congenital biliary atresia, a condition resulting from extrahepatic bile duct obstruction, HEF remains high for about 2 months after birth and then begins to decrease if the obstruction is not relieved [17, 18]. Excretion half time and HEF show an inverse relationship; as the HEF decreases, excretion half time increases, and vice-versa (Fig. 5.1.6C). High serum bilirubin levels decrease HEF by two mechanisms: first, it displaces Tc-99m-HIDA from its carrier protein, albumin, and second, bilirubin competes with Tc-99m-HIDA for the hepatocyte uptake by receptor mediated endocytosis.\n\n### 5.1.8 Basal Differential Hepatic Bile Flow\n\nThis parameter is obtained as a part of HEP-phase data analysis as shown in Figs. 5.1.3 and 5.1.4. After leaving the liver, the hepatic bile in the basal state enters the gallbladder and duodenum, with volume depending upon the tonus of the sphincter of Oddi. Normal gallbladders are usually visualized within 60 min, and 10-100% of the hepatic bile enters the gallbladder. In about 20% of normal subjects, all of the hepatic bile enters the gallbladder and none the intestine, so that intestinal bile entry at 60 min remains at 0%. Intestinal bile entry, therefore, normally ranges from 0 to 100%. Longer duration of fasting increases the sphincter tone and diverts more of the hepatic bile to enter the gallbladder than intestine. Total bile produced during 60 min of hepatic phase imaging is obtained by adding gallbladder and intestinal counts at 60 min. Percent of the hepatic bile entering the gallbladder is obtained by the following formula.\n\n![$$\\\\begin{array}{rl}\n{\\\\rm Hepatic\\\\ bile\\\\ flow\\\\ into\\\\ gallbaldder}\\\\,\\\\left\\( {\\\\rm \\\\% } \\\\right\\) & = \\\\frac{{{\\\\rm Gallbladder}\\\\,{\\\\rm total}\\\\,{\\\\rm counts}\\\\,{\\\\rm at 60 min } \\\\times {\\\\rm 100\\\\_}}}{{{\\\\rm Gallbladder\\\\ total\\\\ counts\\\\ at\\\\ 60\\\\ min  +  Intestinal\\\\ total\\\\ counts\\\\ at\\\\ 60\\\\ min}}}\\\\\\\\\n{} &  = \\\\frac{{49,700 \\\\times 100}}{{49,700 + 50,300}} = 49.7\\\\%\n\\\\end{array}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ4_5.gif)\n\n![$$\\\\begin{array}{rl}\n{\\\\rm Hepatic\\\\ bile\\\\ flow\\\\ into\\\\ Intestine}\\\\,\\\\left\\( {\\\\rm \\\\% } \\\\right\\) & = \\\\frac{{{\\\\rm Intestinal}\\\\,{\\\\rm total}\\\\,{\\\\rm counts}\\\\,{\\\\rm at 60 min } \\\\times {\\\\rm 100\\\\_}}}{{{\\\\rm Gallbladder\\\\ total\\\\ counts\\\\ at\\\\ 60\\\\ min  +  Intestinal\\\\ total\\\\ counts\\\\ at\\\\ 60\\\\ min}}}\\\\\\\\\n{} & = \\\\frac{{50,300 \\\\times 100}}{{49,700 + 50,300}} = 50.3\\\\%\n\\\\end{array}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ5_5.gif)\n\n### 5.1.9 Basal Duodeno-Gastric Bile Reflux (Basal-DGBR)\n\nThis parameter is obtained as a part of HEP-phase data analysis as shown in Figs. 5.1.4 and 5.1.5. Bile entering the duodenum during fasting flows forward to enter the jejunum. Normally, there is no bile reflux into the stomach. The stomach ROI is selected carefully by avoiding inclusion of the left lobe of the liver or duodenal loop in the stomach ROI, both of which will result in a falsely high DGBR. Normal DGBR values up to 8% represent mostly background activity. The DGBR value should be ignored when there is no visible bile entry into the intestine. A high DGBR value in such cases represents only the background activity in the stomach and intestine. DGBR values are checked with the images to confirm bile reflux. DGBR values higher than 8% are usually associated with visible bile reflux into the stomach (Fig. 5.1.5)\n\nThe DGBR value is obtained by dividing total stomach counts at 60 min by the sum of stomach and intestinal counts at 60 min.\n\n![$$\n{\\\\rm DGBR}\\\\left\\( {\\\\rm \\\\% } \\\\right\\) = \\\\frac{{{\\\\rm Stomach\\\\ counts\\\\ at\\\\ 60\\\\ min} \\\\times {\\\\rm 100}}}{{{\\\\rm Stomach\\\\ counts +  Intestinal\\\\ counts\\\\ at\\\\ 60\\\\ min}}}$$](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ6_5.gif)\n\nBoth differential hepatic bile flow and basal DGBR values are shown on the right side of the Hep-function result along with normal values (Fig. 5.1.5). Three figures in the middle show the ROIs for each region to enable the physician to check for accuracy. Since radiolabeled bile has to enter the duodenum to have any reflux into the stomach, all DGBR values are ignored when there is no bile entry into the intestine. Occasionally, DGBR may empty in the middle of data acquisition; in such an instance, the peak reflux value is obtained by changing the frame number as shown in the option block at the bottom (Fig. 5.1.5).\n\n### 5.1.10 Quantification of Gallbladder Function\n\nA normal gallbladder measures about 50 ml in volume and requires 3-4 h to fill to its full capacity after complete emptying. Since the gallbladder is already filled to its full capacity after 4-6 h of fasting, two mechanisms are responsible for accommodating a constant inflow of 0.3 ml min-1 of the hepatic bile: (1) absorption of water through the gallbladder wall and (2) an increase in tonus of the sphincter of Oddi. During fasting, the epithelium of the gallbladder wall absorbs water from the lumen through widely opened lateral intercellular spaces between the columnar cells of the mucosa. Bile salts, bile pigments, cholesterol, and other bile consti-tuents are not absorbed. This process of selective absorption of water resulting in a higher concentration of solutes is called the concentration function of the gallbladder [8]. After an overnight fast, the mean pressure within the sphincter of Oddi is 15 mmHg, 12 mmHg in the common bile duct, and 10 mmHg inside the gallbladder. Because of the pressure difference at various levels, hepatic bile follows the path of the least resistance and enters the gallbladder.\n\nBile from the common hepatic duct enters the gallbladder in a step-wise fashion and corresponds to the phasic waves passing through the sphincter of Oddi [19]. Radioactive hepatic bile first enters the gallbladder along its central long axis and moves slowly laterally towards the wall [20]. After entering the central long axis, radiolabeled bile usually takes at least 30 more minutes to reach the wall (Fig. 5.1.7). One should wait till the entire gallbladder bile is radiolabeled before embarking on measurement of its emptying. For example, when a gallbladder appears first at 45 min of the hepatic phase imaging, the measurement of the ejection fraction should start at 75 min (45 + 30 = 75 min) to allow sufficient time for radiolabeling of the entire gallbladder bile. After completion of 60 min of HEP-phase data collection, in such an instance, the patient is made to wait for an additional 15 min before starting GB-phase imaging with cCK-8. The ejection fraction value would be falsely high if partially radiolabeled gallbladder bile were measured.\n\nFig. 5.1.7\n\nFilling of the gallbladder: Gallbladder fills from inside out. Radiolabeled bile first enters the gallbladder at 12 min along its central long axis and moves laterally to reach the wall at 48 min, taking a total of 36 min. One must wait for all of the gallbladder bile to be radiolabeled before embarking on study emptying. Partially radiolabeled gallbladder bile may result in overestimation of its ejection fraction\n\nFig. 5.1.7\n\nGallbladder bile volume and Tc-99m HIDA count relationship. A rubber balloon filled with 50 ml water and Tc-99m representing the gallbladder is placed inside a container placed underneath a gamma camera. One milliliter of water is removed at a time through the syringe, and counts are taken with the gamma camera after each withdrawal (a). Counts show a linear relationship with the bile volume (b). Ejection fraction measured by volume and Tc-99m-HIDA count methods show a perfect linear (c) relationship [23]\n\n### 5.1.11 Gallbladder Ejection Fraction\n\nMeasurement of gallbladder emptying is clinically popular primarily due to the availability of a simple, non-invasive, and reliable quantitative diagnostic test. In the past, gallbladder emptying was measured with oral cholecystogram by applying a technique called the sum of the cylinder method, which was introduced in 1949 by De Silva [21]. On the oral cholecystogram, the gallbladder image is divided into series of small cylinders, and the volume of each cylinder is computed by applying a mathematical formula for the volume of a cylinder. By summing the volume of all cylinders, gallbladder total volume is obtained. A slightly modified version of sum of the cylinder method has been adopted for measuring the gallbladder volume with the ultrasound [22]. Both oral cholecystogram and ultrasound are geometric techniques and are based on the assumption that the gallbladder is a cylinder before, during, and after contraction. It is frequently seen that the gallbladder is not a cylinder before contraction, and it often changes its shape during and after contraction. A count-based, non-geometric technique overcomes these shortcomings [23]. Cholescintigraphy with Tc-99m-HIDA is a non-geometric method and enables precise measurement of both the ejection fraction and ejection rate. The scintigraphic method uses Tc-99m HIDA counts to represent bile volume as there is a direct linear relationship between bile volume and counts within the gallbladder (Fig. 5.1.8).\n\nFig. 5.1.8\n\nGallbladder phase ROIs: Gallbladder, bkg, CHD, and CBD ROIs are drawn usually on the first-minute frame, stomach, and intestinal ROIs on the last-minute frame. Curves on the right represent the counts from regions of the same color\n\n### 5.1.12 Data Collection\n\nThe gallbladder phase data are acquired using the protocol outlined in Table 5.1.1 at 1 frame per minute for 30 min when CCK-8 is used as the stimulus for contraction. The data are collected for a minimum of 60 min, preferably 60-120 min, when a fatty meal is used as the stimulus to induce gallbladder contraction. A magnification factor of 1.2-2.4 may be used during data acquisition. The gamma camera angle is changed to a degree that maximally separates the CBD from the gallbladder and the duodenum [9]. Infusion of CCK-8 is begun at 3 min at a dose rate of 3 ng kg-1 min-1 and infused for 10 min through an infusion pump. The first 5 min counts prior to CCK-8 infusion represent the basal volume of the gallbladder.\n\n### 5.1.13 Dose Rate and Duration of Cholecystokinin Infusion\n\nIn the United States, a fragment of the hormone cholecystokinin is available for clinical use as CCK-8 (Kinevac). In Europe and other countries, the entire molecule with 33 or 39 amino acids is made available. The hormone is prepared according to the manufacturer's instructions in the package insert (Kinevac, Sincalide, Bracco Diagnostics, Princeton NJ). Volume is adjusted with saline to achieve the desired dose rate and duration of infusion. Selection of a proper dose and dose rate within the physiologic range is critical for accurate results. Duration of the infusion is a matter of personal preference. We routinely use a dose rate of 3 ng kg-1 min-1 and infuse for a total duration of 10 min through an infusion pump. Before the test begins, the patient is given instructions to raise the hand as soon as the symptoms begin and to raise the hand again when symptoms abate. The patient is asked to grade pain intensity as mild, moderate, or severe. The technologist notes down the time of onset, total duration, and intensity of pain on a work sheet for interpretation.\n\n### 5.1.14 Effect of Non-Physiologic Dose of Cholecystokinin\n\nThe package insert (Sincalide, Kinevac by Bracco Diagnostics, Princeton, NJ) suggests a CCK-8 dose of 0.02 \u03bcg kg-1 (20 ng kg-1) infused over 30 or 60 s. This dose rate was originally developed in 1970s with the use of oral cholecystogram, and studies since have demonstrated that this dose rate is too large for cholescintigraphy and often produces a falsely low ejection fraction in 20-26% of normal subjects [24-28]. A change in dose rate and\/or duration of infusion produces different values for the gallbladder ejection fraction (Table 5.1.5). Ideally, one should establish local values when the technique chosen is different from the published literature [29].\n\nTable 5.1.5\n\nEffect of dose and duration of CCK-8 infusion on gallbladder ejection fraction (mean \u00b1 S.E)\n\nCCK-8 dose rate (ref) | Duration of CCK-8 infusion\n\n---|---  \n|\n\n3 min | 30 min | 60 min\n\n0.5 ng kg-1 min-1 [27] | - | 79.3% \u00b1 6.9% | 91.3% \u00b1 5.3%\n\n3.3 ng kg-1 min-1 [23] (10 ng kg-1 3 min-1) | 59.4% \u00b1 4.0% | - | -\n\n5.0 ng kg-1 min-1[27] | - | 82.4% \u00b1 6.7% | 94.0% \u00b1 5.1%\n\n### 5.1.15 Calculation of Gallbladder Ejection Fraction\n\nAfter uploading the gallbladder phase data onto KHBS, the gallbladder function button at the top is activated. Six ROIs are drawn: gallbladder, background, common hepatic duct (CHD), common bile duct (CBD), stomach, and intestine (Fig. 5.1.8). The background ROI is drawn over the liver, superior and lateral to the gallbladder. The CHD region includes both the right hepatic duct and left hepatic ducts in the form of a letter T or Y. The gallbladder, background, CHD, and CBD regions are drawn using the first frame. Stomach and intestinal ROIs are drawn on the last frame. Net gallbladder counts are obtained after subtraction of the background counts and corrected for decay [9]. Region of interest over the CHD enables identification of possible bile reflux in the presence of critical obstruction of the common bile duct. The software also calculates post-CCK-8 duodeno-gasrtic bile reflux (Fig. 5.1.9).\n\n![$$\n{\\\\rm Gallbladder\\\\ ejection\\\\ fraction}\\\\left\\( {{\\\\rm GBEF}} \\\\right\\)\\\\left\\( \\\\%  \\\\right\\) = \\\\frac{{{\\\\rm GB\\\\ Peak\\\\ counts-First\\\\ minimum\\\\ GB\\\\ counts }\\\\left\\( {\\\\rm B} \\\\right\\) \\\\times 100}}{{{\\\\rm GB\\\\ Peak\\\\ counts}}}\n$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ7_5.gif)\n\n![$$\n{\\\\rm GBEF = }\\\\frac{{{\\\\rm A--B} \\\\times {\\\\rm 100}}}{{\\\\rm A}}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ8_5.gif)\n\n  * Latent period (LP) = Time from beginning of CCK - 8 infusion to beginning of gallbladder emptying\n\n  * Ejection period (EP) = Time from beginning of gallbladder emptying to the first minimum counts\n\n  * Normal values for 10 min infusion of 3ng \/ kg \/ min of CCK - 8\n\n  * Ejection rate (ER) = % Ejection fraction \/ Ejection period = % \/ minute\n\n  * Normal values for 10 min infusion of 3ng \/ kg \/ min of\\ CCK - 8\n\n  * Latent period (LP)\n\n  * Ejection period (EP) = 7-19 min\n\n  * Ejection period (EF) \u2265 50%\n\n  * Ejection rate (ER) \u2265 3.5% \/ min\n\nFig. 5.1.9\n\nGB-phase results. Occasionally gallbladder counts may increase just before it begins to empty (first vertical bar). First minimum counts represent the end of gallbladder emptying (second vertical bar). Ejection fraction (EF) is calculated by dividing counts emptied between two vertical bars by counts at the first vertical bar. Time between two vertical bars is the ejection period (EP). Ejection rate (ER) is calculated by dividing % EF by EP. Post-CCK DGBR is obtained by dividing stomach counts by the sum of stomach and intestinal counts\n\nPost-CCK-8 duodeno-gastric bile reflux is calculated by dividing stomach counts by the sum of stomach and intestinal counts. Normally cholecystokinin acts on the gallbladder, promoting its contraction and emptying. It acts on the pylorus sphincter of the stomach and prevents bile reflux. Occasionally, one may find a large amount of DGBR with CCK-8 that may explain a patient's symptoms.\n\n### 5.1.16 Ejection Fraction with Fatty Meal Stimulation\n\nFatty meal stimulates the release of endogenous cholecystokinin from the endocrine cells lining the mucosa of the duodenum, jejunum, and upper ileum. It may take as long as 6-26 min after a meal for the endogenous CCK level to rise above the serum threshold to initiate gallbladder contraction and emptying. Once the gallbladder begins to empty, it continues ejection for 1-3 h post-meal. The duration of data collection with the fatty meal, therefore, should be for a minimum of 60 min, preferably for 120 min. The data are collected at 1 frame per min for 60 or 120 min (Fig. 5.1.10). A standardized test meal (8 oz 70 kg-1 body weight) of known nutritional contents and caloric value is ingested at 5 min, such that a baseline count prior to the meal represents basal gallbladder volume [30, 31]. Mean (\u00b1 SD) ejection fraction for 1 h fatty meal stimulation study is 50% \u00b1 20%. Individual values can be as low as 32%. In the same group of normal subjects, 10 min infusion of 3 ng kg-1 min-1 of CCK-8 produces a mean EF of 70% \u00b1 17% [32]. In the USA, the nutritional value of Half and Half (H & H) milk varies from city to city (Table 5.1.6). One must standardize the technique and establish local normal values.\n\nFig. 5.1.10\n\nGallbladder emptying with fatty meal stimulation: Meal is ingested at 10 min. There is a latent period of 16 min before the gallbladder begins to empty. Ejection fraction is 73%, ejection period of 34 min, and an ejection rate 2.1% per min [31]\n\nTable 5.1.6\n\nVariations in nutritional contents and total calories of Half-and-Half milk in six US cities [33]\n\nNutrient content per 30 ml | Portland, OR (Alpenrose) | New York, NY (America choice) | Detroit, MI (CFBerger) | Jackson, MS (Dairy fresh) | Los Angeles, CA (Altadena) | Miami, FL (McArthur dairy)\n\n---|---|---|---|---|---|---\n\nTotal fat (g) | 3.0 | 3.0 | 3.0 | 3.5 | 3.0 | 3.0\n\nCholesterol (mg) | 10.0 | 15.0 | 10.0 | 15.0 | 15.0 | 15.0\n\nCarbohydrate (g) | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0\n\nProtein (g) | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0\n\nSodium (mg) | 10.0 | 20.0 | 10.0 | 20.0 | 15.0 | 15.0\n\nTotal calories (30 ml) | 40.0 | 40.0 | 35.0 | 40.0 | 40.0 | 40.0\n\n### 5.1.17 Data Analysis\n\nSoftware is adapted for measurement of the ejection fraction with fatty meal. Two regions of interest, one over the gallbladder and the other over the liver as background, are drawn. Due to the slow rate of bile emptying, CBD and CHD are not well delineated with the fatty meal stimulation. The value of the gallbladder ejection fraction with a fatty meal is reported with a reference to its total duration of measurement, i.e., at 60 min or 120 min, post-meal. Both a 30-min continuous infusion of CCK-8 or a 60-min post fatty meal appear to produce a mean ejection fraction of about 80% (Table 5.1.7). The latent period (the time from meal ingestion to beginning of gallbladder emptying) is variable depending upon the time for release of endogenous CCK [28]. A delay in gastric emptying may also cause late release of cholecystokinin. Since there are no CCK-secreting cells in the esophagus and stomach [33], hormone-induced gallbladder emptying does not begin until food reaches the duodenum. The gallbladder ejection fraction is low in patients with gallstones and diabetes [34]. Obese diabetics have a much more pronounced reduction in EF compared to non-obese diabetic patients [35]. A cephalic phase emptying because of cholinergic nerve stimulation, independent of hormonal action may induce gallbladder emptying [36]. A comparison of fatty meal stimulation with cholecystokinin in the same group of normal subjects showed wide variation in the ejection fraction [32]. The fatty meal ejection fraction at the end of 1 h ranges from 23 to 91% (mean 54%), whereas a 10-min infusion of CCK-8 in the same group of normal subjects produces values ranging from 37 to 91% (mean 76%). ROI over the stomach region enables calculation of duodeno-gastric bile reflux.\n\nTable 5.1.7\n\nEffect of type of meal and duration of emptying on gallbladder ejection fraction (%)\n\nMeal type | Meal volume | (Mean \u00b1 SE)\n\n---|---|---\n\nDuration from meal ingestion\n\n30 min | 60 min | 120 min\n\nHalf & Half [28] | 8 oz 70 kg-1 | - | 64.4 \u00b1 6.7% | -\n\nLipomul [27] | 15 ml | 49.8 \u00b1 5.2% | 71.7 \u00b1 3.6% | 77.8 \u00b1 2.0%\n\n### 5.1.18 Gallbladder Segmentation\n\nOften a septa or fold can divide the gallbladder chamber into two separate compartments, proximal and distal (Fig. 5.1.11). Ultrasound studies usually show the length, thickness, and position of the septa inside the gallbladder. Carefully done histopathological examination (Fig. 5.1.12) confirms the folds. Recognition of such compartments is essential during hepatic phase imaging as the two compartments may show a different degree of filling and emptying. Radiolabeled hepatic bile enters the proximal compartment first, followed 5-10 min later by entry into the distal compartment. Two compartments are easy to recognize with cholescintigraphy in the early images as the radiolabeled bile enters the gallbladder (Fig. 5.1.13). It becomes much more difficult to recognize it in late images as bile radioactivity equilibrates in both compartments. For calculation of the gallbladder segmental function, GB-Seg block at the top is activated, and the patient data are loaded. One ROI is drawn around the entire gallbladder and another between the two compartments (Fig. 5.1.14). The program calculates the total EF and EF for each compartment separately (Fig. 5.1.15). The distal compartment usually empties poorly because of septa acting as a one-way valve. Because these findings are new and not well appreciated, ultrasonographers should mention the presence of the septa or fold in their ultrasound report of the gallbladder to draw the attention of clinicians who may then request a Tc-99m HIDA study for further evaluation of abdominal pain [37].\n\nFig. 5.1.11\n\nGallbladder segmentation. CT scan shows a constriction near the neck dividing the gallbladder into proximal (GB-neck) and distal (GB-body) compartments. Gallstones are layered in the distal compartment\n\nFig. 5.1.12\n\nGallbladder fold or septa. A transverse fold divides the gallbladder into proximal and distal compartments. This fold acts in vivo as a barrier between two segments and reduces bile emptying from the distal segment\n\nFig. 5.1.13\n\nFilling of a segmental gallbladder (GB). The proximal segment appears first at 20 min (top row right), and distal segment begins to appear at 25 min (middle row left). Left hepatic duct (LHD) is seen much more prominently than the right hepatic duct (RHD). The distal segment is much larger in size than the proximal segment (bottom row right)\n\nFig. 5.1.14\n\nRegions of interest for gallbladder segmentation. One region is drawn around the entire gallbladder and the other over the septum that divides it into proximal and distal compartments. Counts and curves from the proximal and distal compartment and total gallbladder are displayed\n\nFig. 5.1.15\n\nResults of gallbladder segmentation. By drawing one region of interest around the entire gallbladder and another over the fold or septum (bottom), the software calculates the ejection fraction for each compartment separately along with the gallbladder total ejection fraction (top)\n\n## 5.2 Measurement of Hepatic Arterial vs. Portal Venous Blood Flow\n\nThe liver has a dual blood supply through the hepatic artery and portal vein. The hepatic artery supplies about 400 ml of arterial blood per min at 100-120 mmHg systolic blood pressure. Thus, approximately 25% of the total liver blood supply comes via the hepatic artery and the remaining 75% through the portal vein. After injection into a peripheral vein, the radiotracer arriving via the portal vein takes 7-10 s more to reach the liver than the radiotracer arriving via the hepatic artery. This delay via the portal vein is primarily due to the time taken for the radiotracer to traverse the intestinal veins and portal vein.\n\nThe hepatic arterial versus portal venous blood supply to the liver is measured using a first-pass curve obtained with any radiotracer that passes through the liver [1]. Technetium-99m pertechnetate, Tc-99m-DTPA, and Tc-99m-MDP have been used. These tracers that merely pass through, but are not retained by the liver do not allow any additional liver imaging. The agents that both pass through and are retained by the liver (Tc-99m S-colloid or Tc-99m HIDA) allow follow-up imaging of the liver. Immediately upon an antecubital vein injection, the radiotracer mixes thoroughly with blood in the ventricles before its arrival at the liver. The quantity of the radiotracer reaching the liver is directly proportional to the volume of blood supplied to the liver. The differential blood flow to the liver, via the hepatic artery versus portal vein, is calculated by two methods. One method is based on analysis of the slope of the uptake and washout [2], and the other method employs the area under the curve by deconvolutional analysis [3].\n\n### 5.2.1 Data Collection\n\nA fasting patient is positioned supine underneath a large field of view gamma camera fitted with a low-energy, all-purpose, parallel-hole collimator. The position of the gamma camera in either the anterior or posterior view is adjusted to make sure that it covers the lower part of the lungs, entire liver, spleen, and kidneys. A simultaneous anterior and posterior perfusion can be obtained with a dual-head gamma camera (Fig. 5.2.1A,B). About 10-15 mCi (370-555 MBq) of Tc-99m-labeled agent is injected intravenously as a rapid bolus followed by a 30-ml saline flush. Data are collected on 64-by-64 word mode matrix at 1 frame per 0.5 s for 100 s [2]. Data acquisition is begun just before the injection of the radiotracer. The first 30 frames are summed to form a composite image on which four regions of interest are drawn: (1) liver (mid part of the right lobe excluding the right kidney and aorta), (2) lower right lung, (3) spleen, and (4) cross talk region between the right lung and the liver (Fig. 5.2.2). The left kidney is substituted for the spleen in patients with splenectomy.\n\nFig. 5.2.1\n\nLiver perfusion study. Anterior (top) and posterior (bottom) view liver perfusion study obtained with 5 mCi Tc-99m-HIDA shows the passage of radiotracer serially through the right ventricle (RV), left ventricle (LV), abdominal aorta (A), spleen (S), kidneys (K), and liver. Left lobe perfusion is seen better in the anterior view, and the perfusion of the spleen and kidneys is seen better in the posterior view\n\nFig. 5.2.2\n\nRegions of interest. Regions of interest (ROI) are drawn over the middle of the liver, right lower lung, spleen, left kidney, and cross-talk region between liver and right lung. ROIs should exclude liver margins and aorta\n\n### 5.2.2 Slope Method\n\nTime-activity curves are generated over all four regions as outlined above (Fig. 5.2.3A). The cross-talk curve from the region between the right lung and liver (Fig. 5.2.3B) is scaled to the same height as the early part of the liver curve (before the arrival of the liver arterial phase, usually between 0 and 20 s) and subtracted from the liver and spleen curve to generate the corrected liver and spleen curves (Fig. 5.2.3C). Corrected liver and spleen curves are displayed separately (Fig. 5.2.3D,E). Three time points are identified on the corrected time-activity curve. The initial arrival of radioactivity at the liver is denoted by Ta, which corresponds to the beginning of the hepatic arterial phase. Because the hepatic and splenic arteries have a common origin from the celiac artery, the time of peak activity on the spleen curve (Sp) is considered the end of the arterial phase and beginning of the portal venous phase, and corresponds to time, Tp, on the liver curve (Fig. 5.2.3D). Normally, there is 7 \u00b1 2-s delay between the arrival of the hepatic arterial and portal venous blood supply to the liver. The slope of the arterial phase, La, is measured from Ta to Ta + 7 s, and the slope of the portal venous phase, Lp, is measured from Tp to Tp + 7 s. Total counts are integrated, and percent arterial blood flow to the liver is measured using the following formula from a linear fit to the curve [2].\n\nLa = slope of the hepatic arterial phase; Lp = slope of portal venous phase.\n\nFig. 5.2.3\n\nHepatic arterial vs. portal venous blood flow by the slope method. Time-activity curves are generated over the liver (a) and cross-talk region between the lung and liver (b). Both curves are scaled to the same height, and the corrected liver curve (c) is obtained after subtracting the cross-talk counts. The onset of the arterial (Ta) and portal venous (Tp) phases are noted on the corrected liver curve (d). La and Lp represent the slope of the arterial and portal venous phases measured over 7 s from Ta and Tp, respectively. Spleen curve (e) shows the onset of arterial (Ta) and peak arterial flow (Tp); Sa and Sp represent the slopes of the curve in a manner similar to La and Lp [2, 4]\n\nTo correct for the fraction of hepatic arterial component still present during the portal venous phase in the liver curve, the slope of the splenic curve is used with the following modification. The ratio of Sa\/Sp of the splenic curve is assumed to represent the fraction of the arterial flow present during the portal venous phase of the liver curve [2].\n\n### 5.2.3 Area Method\n\nThis method uses the deconvolutional analysis [2, 4]. Like the slope method, it is dependent upon the temporal separation between the arrival of the hepatic arterial and portal venous blood to the liver. It takes into account the role of recirculation of the injected radiotracer. Data acquisition is identical to the slope method described above (Fig. 5.2.1). Using a large of field of view gamma camera, computer data are collected on a 64 \u00d7 64 word matrix at one frame per 0.5 s for 100 s. The data collection is started just before injection of 10-15 mCi (555-740 MBq) of the radiotracer. On the first 30-frame composite image, regions of interest are drawn, and time\/activity curves are generated over: (1) liver, mid right lobe excluding the right kidney and aorta, (2) lower right lung, (3) spleen, and (4) cross-talk region between the right lung and liver (Fig. 5.2.2). The cross-talk curve is scaled to the same height as the initial part of the liver curve (before the arrival of the radiotracer to the liver) and subtracted from the liver and spleen curve to generate the corrected liver and spleen curve (Fig. 5.2.4A). Liver and spleen curves are deconvoluted with the lung curve using the modified Fourier transformation technique (Fig. 5.2.4B). The curve is expanded from 200 to 1,024 data points by addition of an exponentially decreasing tail that eliminates artifacts because of a sharp cutoff at the end of data termination. An assumption is made that the spleen blood flow pattern is similar to that of the hepatic artery. The spleen curve is used to approximate hepatic arterial blood flow. The spleen curve is multiplied by a constant so that the up-slope superimposes over the early part of the liver curve (Fig. 5.2.4C). The liver and modified spleen curves are integrated to give the areas under the curve, A L and A s, respectively\n\nFig. 5.2.4\n\nHepatic arterial vs. portal venous blood flow by the area method. Corrected spleen and liver curves are obtained first (a) after subtracting the background counts from the lung to liver cross-talk region and then subjected to deconvolutional analysis (b). Magnitude of the spleen curve is modified so that its upslope matches with that of the liver (c). A s and A L represent the area under the modified spleen and liver curves, respectively\n\nBoth the slope and area methods are found clinically useful and have been validated in experimental animals [5]. The slope method technically is much simpler, but carries wider variability between studies. The area method using the deconvolutional analysis provides the best separation between normal patients and those with increasing severity of liver disease. The arterial-to-venous ratio increases as the severity of liver disease increases from Child's class A to C (Table 5.1.3). In cirrhosis, low pressure (7-10 mmHg) portal venous blood flow is affected much earlier than high pressure (100-120 mmHg) hepatic arterial blood flow. Portal venous blood flow decreases as the portal venous pressure raises (Fig. 5.2.5). Measurement of the hepatic arterial vs. portal venous blood flow is found useful in the diagnosis of hepatic vein thrombosis and also in following patients treated for portal hypertension [4].\n\nFig. 5.2.5\n\nRelationship between portal venous blood flow vs. portal venous pressure. There is an inverse relationship between the two; as the portal venous pressure increases, the portal venous blood flow decreases [7]\n\nThe final shape of the liver and spleen curve depends upon whether or not the chosen agent is retained by these organs. Technetium-99m sulfur colloid, which is retained by both organs, and Tc-99m-HIDA, which is retained only by the liver but not by the spleen, produce curves whose shape is different from each other and also from those agents (Tc-99m labeled MDP, albumin, or pertechnetate) not retained by either organ. The choice of the agent does not usually affect the values of arterial vs. venous blood flow, because the first-pass study is independent of the biokinetic behavior of the radiotracer [5].\n\nNormal median portal venous blood flow is 78% and the median hepatic artery flow 22%. The median portal venous blood flow decreased to 68% in mild liver disease and remains below 49% in severe liver disease. The median portal venous blood flow falls below 4% in patients with portal vein thrombosis. Scintigraphic technique is shown to be 90% sensitive and 100% specific in patients with portal vein thrombosis when portal blood flow falls below 20% [4]. Perfusion changes and indices of hepatic arterial blood flow in patients with cirrhosis can be measured by comparing them to the renal or splenic arterial peak, thus avoiding the influence of portal venous reduction on the hepatic arterial peak [6]. Calculation of the hepatic arterial-to-portal venous ratio provides a non-invasive method to evaluate objectively the benefits of transjugular intrahepatic portosystemic shunt (TIPS) therapy. In a study involving 28 patients, the mean (SD) portal venous pressure of 25.5 \u00b1 4.6 mmHg before TIPS decreased to 18.5 \u00b1 3.9 mmHg after TIPS. The portal venous blood flow of 29.2 \u00b1 11.1% before then increased to 38.2 \u00b1 13.4% after TIPS, indicating its therapeutic benefits. Portal venous flow shows an inverse relationship with the portal venous pressure; portal venous blood flow decreases as the portal venous pressure increases. The relationship between portal venous flow and pressure tends to normalize after a successful TIPS procedure [7, 8]\n\n## 5.3 Hepatopulmonary Syndrome\n\nThe functional relationship between the liver and lung originally recognized in 1935 is now called hepatopulmonary syndrome (HPS). The syndrome consists of a triad of: (1) liver disease, (2) increased alveolar-arterial oxygen gradient, and (3) intrapulmonary vasodilatation [1, 2].\n\n### 5.3.1 Clinical Presentation\n\nPatients usually present with a combination of symptoms indicative of both liver and lung disease: esophageal varices, gastrointestinal bleeding, spider nevi, ascites, and splenomegaly, indicative of liver disease, and dyspnea, clubbing, platypnea, and orthodeoxia, indicative of lung disease [3, 4]. Platypnea is dyspnea in an upright position, which is relieved by assuming a supine position [5]. Orthodeoxia is arterial deoxygenation, exaggerated in the upright position and relieved by recumbency. Platypnea and orthodeoxia, which were found only in a small percentage of patients with cirrhosis (5%), are much more frequent and severe in intensity in patients with HPS, often reaching as high as 88-100% [6]. Spider nevi of the palms and around the umbilicus are considered the cutaneous markers of HPS [7]. As the liver reaches its end stage, the patients develop ascites, generalized edema, pleural effusion, and interstitial fluid accumulation in the lungs. Chest X-ray changes consist of either finely diffuse spidery infiltrates or focal arteriovenous malformations [8].\n\n### 5.3.2 Pathophysiology\n\nArterial deoxygenation due to an intrapulmonary shunt is the hallmark of HPS. Pulmonary artery pressure remains normal or slightly low [6]. Severe hypoxemia (PaO2 <60 mmHg), in the absence of primary lung disease, in combination with liver disease clinically should raise the suspicion of HPS. The pulmonary capillaries, which normally measure 8-15 \u03bcm, dilate up to 100 \u03bcm in diameter, often forming spider nevi on the pleural surface [9]. Radiolabeled macroaggregates of albumin (MAA) of 15-150 \u03bcm in diameter normally get trapped almost completely within the pulmonary capillary bed after intravenous injection. These radiolabeled Tc-99m MAA particles readily pass through the dilated pulmonary capillaries in patients with HPS and enter the systemic circulation to be trapped in normal size capillaries of the brain, liver, kidney, and other organs, in proportion to their blood supply [10, 11, 12]. Normally less than 6% of Tc-99m-MAA particles bypass the lung to lodge in other organs [11, 13]. It is theorized that the liver in HPS either produces vasodilators or is incapable of inactivating vasodilators produced elsewhere. Incriminated vasodilators include prostaglandins, vasoactive intestinal polypeptide, calcitonin, glucagon, nitric oxide, and atrial natriuretic factor, etc. [6].\n\n### 5.3.3 Diagnosis\n\nArterial blood gases are obtained to document hypoxemia (Table 5.3.1). Contrast 2D echo-cardiography (2D echo) with indocyanin green or agitated saline is the most preferred initial diagnostic imaging procedure [14, 15]. Saline agitation creates microbubbles of 60-90-\u03bcm size, which opacify the right heart chambers within one to three cardiac cycles after injection into an antecubital vein. The left heart chambers are not opacified due to filtration of all bubbles by the normal lung capillaries [16]. The bubbles pass through dilated intrapulmonary capillaries in HPS to enter the pulmonary veins and left heart chambers. A confirmatory diagnosis of HPS requires documentation of arterial hypoxemia (PaO2 less than 70 mmHg), normal pulmonary function tests, typical chest X-ray findings, and opacification of left heart chambers in the absence of a right-to-left cardiac shunt. Right-to-left cardiac shunt is suggested on a 2D echo when both right and left ventricular chambers are opacified simultaneously, within one to three cardiac cycles after intravenous injection of agitated saline [17].\n\nTable 5.3.1\n\nDiagnostic workup for hepatopulmonary syndrome (modified from [18])\n\nCirrhosis with hypoxemia\n\n|   \n---|---  \n|\n\nChest X-ray\n\n|\n\nNormal | Abnormal (treat, if hypoxemia persists)\n\nContrast echo (EC) and pulmonary function tests (PFTs)\n\n(\u2212) CE and normal PET | (+) CE and normal PFT's | (+) CE and abnormal PFT's\n\n\u2193 | \u2193 | \u2193\n\nNo HPS | HPS | Tc-99m MAA Scan\n\n|  |\n\nShunt >6%Shunt <6%\n\n|  |\n\n\u2193\u2193\n\n|  |\n\nHPSNo HPS\n\n### 5.3.4 Scintigraphic Quantification\n\nA mild form of HPS is found in as many as 4-17% of patients with varieties of chronic liver diseases [18]. Despite being very sensitive, 2D echo lacks the specificity and ability to quantify the degree of shunt. A perfusion scintigraphy supplements 2D echo by providing both quantification and specificity for a definitive diagnosis of HPS.\n\n### 5.3.5 Procedure\n\nThe patient is made to sit upright for 5 min to maximize the degree of intrapulmonary shunt. Macroaggregates of Tc-99m-albumin particles are prepared carefully as per instructions provided in the package insert. A drop of the prepared material is fed into a hemocytometer chamber and examined under the light microscope to ascertain that at least 90% of the particles are in the 15-90-\u03bcm size range. A radiochromatogram is obtained to confirm that there is better than 90% radiolabeling. About 2-3 mCi Tc-99m-MAA is injected into an antecubital vein while the patient is seated. After injection, the patient is made to lay supine. A large field of view dual-head gamma camera, fitted with a low-energy, all purpose, parallel-hole collimator, is positioned laterally on each side, or in front and behind the head. The spectrometer is set for 140-keV photon peak energy with a 20% symmetrical window. The camera heads are positioned above the shoulders to avoid counts below the neck. The counts are taken for a preset time of 5 min with each head and recorded on a 64 \u00d7 64 computer matrix. After taking 5-min head counts, the detectors are moved over to the chest to the anterior and posterior position. Preset 5-min counts are taken again in the anterior and posterior view simultaneously and recorded on a 64 \u00d7 64 computer matrix.\n\n### 5.3.6 Data Analysis\n\nOn the lateral or anterior and posterior views of the head, regions of interest are drawn to cover the entire brain, excluding the scalp and superior sagittal sinus when they are visible. On the anterior and posterior view chest images, regions of interest are drawn to cover both lungs. Care is taken to avoid the liver or kidneys in the lung ROI (Fig. 5.3.1). Geometric mean counts are calculated using the following formula:\n\n![$$\\\\begin{array}{l}\n{\\\\rm Geometric\\\\ mean\\\\ brain\\\\ counts }\\\\left\\( {{\\\\rm GMBC}} \\\\right\\)\\\\\\\\\n\\\\quad = \\\\sqrt {{\\\\rm right\\\\ lateral\\\\ or\\\\ anterior\\\\ view\\\\ brain\\\\ counts } \\\\times \\\\,{\\\\rm left\\\\ lateral\\\\ or\\\\ posterior\\\\ view\\\\ brain\\\\ counts}}\\\\\\\\\n\\\\quad = \\\\sqrt {1022 \\\\times 1262}  = 1,135\\\\\\\\\n\\\\end{array}$$](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ23_5.gif)\n\n![$$\\\\begin{array}{l}\n{\\\\rm Geometric\\\\ mean\\\\ lung\\\\ counts }\\\\left\\( {{\\\\rm GMBC}} \\\\right\\)\n\\\\qquad = \\\\sqrt {{\\\\rm anterior\\\\ view\\\\ lung\\\\ counts } \\\\times \\\\,{\\\\rm posterior\\\\ view\\\\ lung\\\\ counts}}\\\\\\\\\n\\\\qquad = \\\\sqrt {637,417 \\\\times 970,115}  = 786,363\\\\\\\\\n\\\\end{array}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ24_5.gif)\n\nFig. 5.3.1\n\nQuantification of hepatopulmonary shunt: Regions of interest are drawn over the brain in two lateral views of the head and over the lungs in the anterior and posterior views of the chest. Total counts in 5 min are noted in each view. The geometric mean counts are obtained by using the equation given in the text. Hepatopulmonary shunt ratio is obtained by dividing brain counts by the sum of brain and lung counts\n\nAn assumption is made that about 13% of the cardiac output is delivered to the brain [19]. By applying this correction factor, the hepatopulmonary shunt is calculated by the following equation:\n\n![$$\\\\begin{array}{rl}\n{\\\\rm Hepatopulmonary\\\\ shunt }\\\\left\\( {{\\\\rm HPS}} \\\\right\\) & = \\\\frac{{\\\\frac{{{\\\\rm GMBC}\\\\left\\( {{\\\\rm Brain}} \\\\right\\)}}{{0.13}}}}{{\\\\frac{{{\\\\rm GMBC}\\\\left\\( {{\\\\rm Brain}} \\\\right\\)}}{{0.13}} + {\\\\rm GMLC}}}\\\\left\\( {{\\\\rm Lung}} \\\\right\\)\\\\\\\\\n{} & = \\\\frac{{{\\\\rm 1,135 \/ 0}{\\\\rm .13}}}{{{\\\\rm 1,135 \/ 0}{\\\\rm .13 786,363}}}\\\\\\\\\n{} & = {\\\\rm 8730 \/ 795,093 0}{\\\\rm .02 2\\\\% }\\\\\\\\\n\\\\end{array}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ25_5.gif)\n\nIn normal subjects and in patients with intrinsic lung disease or with cirrhosis but without shunt, the hepatopulmonary shunt ratio varies from 3 to 6% [11, 17]. A value higher than 6% is considered indicative of HPS [17, 18]. Patients with Child's class A, B, or C liver disease without HPS generally show values below 5%. The mean shunt value is 30 \u00b1 4% in patients with hepatopulmonary syndrome. A shunt value of 37% was found in an 8-year-old child (Fig. 5.3.2) waiting for liver transplantation [20].\n\nFig. 5.3.2\n\nHepatopulmonary shunt. An 8-year-old boy waiting for liver transplantation has 37% right-to-left shunt due to intrapulmonary vasodilatation. In addition to brain, kidneys and liver are seen in a Tc-99m MAA scan [20]\n\n### 5.3.7 Standardization\n\nThe technique of measuring hepatopulmonary shunt is very simple, and often there may be room for complacency. It is necessary to check rigidly for Tc-99m-MAA particle size and percent labeling. Greater than 90% of the particles should be between 15 and 90 \u03bcm in size, and labeling efficiency better than 90%. A preparation not meeting these two requirements is discarded. Injection of too many small particles (below 15 \u03bcm) overestimates the degree of the shunt, and the shunt is underestimated when too many particles are much larger than 90 \u03bcm in size.\n\n### 5.3.8 Treatment\n\nTreatment is medical in early liver failure and surgical for end-stage liver disease. Medically, the patients are treated with indomethacin [21], almitrine bismesylate [22], octreotide, or other drugs [6]. Surgical treatment involves liver transplantation for end-stage liver disease. Liver transplantation, once listed as a clear contraindication, is now considered an optimal therapy for HPS and is shown to improve both liver and pulmonary functions [23]. In the Cleveland Clinic study, the mean ratio of 18.7% in HPS patients decreased to 4.5% after liver transplantation with marked improvement of pulmonary blood gases [24].\n\n## 5.4 Duodenogastric Bile Reflux\n\nGastrointestinal peristalsis begins at the gastric pacemaker located near the gastro-esophageal junction and travels antegrade towards the gastric fundus, body, and pylorus, and progresses further along the small and large intestine. Peristaltic waves move the gastrointestinal intraluminal contents in an antegrade fashion. Duodenal contents are thus prevented from entering the stomach by the dual action of the antegrade peristalsis and contraction of pyloric sphincter [1]. Patients with atrophic gastritis, gastric ulcer, and esophagitis are often found to have bile in the stomach (duodeno-gastric bile reflux) raising an etiological relationship between dyspepsia and bile reflux [2].\n\nDetection of bile by chemical analysis in the gastric juice aspirated through a nasogastric tube has been used over the years as a test for duodeno-gastric bile reflux. Chemical analysis is not only cumbersome, but also the insertion of the naso-gastric tube itself may cause duodeno-gastric bile reflux (DGBR). Counting or imaging of radiolabeled bile in the stomach makes the test technically much simpler and avoids the necessity of chemical analysis and intubation [3]. Gamma camera imaging makes the test readily acceptable, enables detection, provides quantification of the degree of duodeno-gastric (D-G) bile reflux, and avoids the necessity of gastric juice aspiration through the N-G tube in both children and adults [4].\n\n### 5.4.1 Rationale\n\nAfter its secretion by the liver, the hepatic bile enters the gallbladder or duodenum, or both. During fasting, about 70% of the hepatic bile enters the gallbladder, and the remaining 30% enters the duodenum directly [5]. Facilitated by the peristaltic waves, bile entering the duodenum moves forward with the rest of the duodenal contents received from the stomach. Since only the amount of bile entering the duodenum is available for reflux into the stomach, a technique that enables quantitative measurement of bile entry into the duodenum will be ideal for measuring bile flow forward into the jejunum or backward into the stomach (D-G reflux). Bile entering the gastrointestinal tract is quantified by selecting two regions of interest: one over the stomach and another over intestinal tract (excluding liver, gallbladder, and bile ducts). Duodeno-gastric bile reflux is calculated by dividing total stomach counts by total counts in the stomach and intestine. The technique allows measurement of D-G bile reflux both during fasting and after administration of cholecystokinin or after feeding.\n\n### 5.4.2 Data Collection and Analysis\n\nHepatic phase imaging data are used for calculation of D-G bile reflux during fasting, and gallbladder phase imaging data for calculation of post-cholecystokinin or post-prandial D-G bile reflux. Data are collected as outlined in Table 5.1.1. By 60-min post-injection, most of Tc-99m HIDA clears from the liver, leaving the nearby gastric region free of interference by cross-talk counts from the left lobe of the liver (Fig. 5.4.1). All 60-min data are carefully reviewed in a cine display for any overlap of intestinal radioactivity onto gastric ROI [6]. A frame between 50 and 60 min (usually the 60-min frame) that does not contain any superimposition of intestinal loops onto the gastric bed is chosen for selection of gastric and intestinal ROIs. Gastric ROI includes the traditional gastric bed, below the left lobe of liver and to the left side of the distal common bile duct, and extending laterally up to the splenic bed. The intestinal ROI includes the rest of the upper abdomen, excluding the liver, gallbladder, and common bile duct. The urinary bladder is excluded from intestinal ROI (Fig. 5.4.2). Time\/activity curves are generated from both ROIs. By 60-min post-injection, most of radioactivity clears from the cardiac blood pool and kidneys. Sometimes the D-G reflux may occur early and empty in the late hepatic phase imaging. In such circumstances the frame with the peak D-G reflux is chosen for ROI selection. The counts are corrected for physical decay.\n\n![$$\\\\begin{array}{l}\n{\\\\rm Duodeno - gastric\\\\ bile\\\\ reflux }\\\\left\\( {\\\\rm \\\\% } \\\\right\\)\\\\\\\\\n\\\\qquad \\\\quad = \\\\frac{{{\\\\rm Total\\\\ counts\\\\ in\\\\ gastric\\\\ ROI} \\\\times {\\\\rm 100}}}{{{\\\\rm Total\\\\ counts\\\\ in\\\\ gastric\\\\ ROI  +  Total\\\\ counts\\\\ in\\\\ intestinal\\\\ ROI}}}\\\\\\\\\n\\\\qquad \\\\quad = \\\\frac{{54,173 \\\\times 100}}{{54,173 + 74,066}}\\\\\\\\\n\\\\qquad \\\\quad = 42\\\\%\\\\\\\\\n\\\\end{array}$$\n](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ26_5.gif)\n\nFig. 5.4.1\n\nBasal duodeno-gastric bile reflux. Duodeno-gastric bile reflux is rare in normal subjects. Reflux in this patient occurs early (frame no. 7) and continues throughout. It is calculated as a part of Hep-phase data analysis\n\nFig. 5.4.2\n\nPost-CCK-8 duodeno-gastric bile reflux. It is calculated as an integral part of GB-phase data analysis. The gastric ROI (S) is drawn below the left lobe of the liver, on the left side of the distal common bile duct extending laterally to the splenic region. The intestinal ROI (I) encompasses the rest of the abdomen. Basal D-G bile reflux of 42% (Fig. 5.4.1) increased to 58% with CCK-8\n\nBile reflux after CCK-8 is similarly calculated using data obtained during the gallbladder phase. Cholecystokinin normally induces the contraction and emptying of the gallbladder, stimulates contraction of the pyloric sphincter, and simultaneously increases small intestinal peristalsis, facilitating rapid antegrade bile movement through the small bowel. Contraction of the pyloric sphincter normally prevents D-G bile reflux. Post-CCK images are checked in the cine display to ascertain that there is no movement of bile radioactivity beyond the field of view of the gamma camera. If there is, then the gamma camera position is adjusted to include all bile regions, and an additional view over the lower abdomen is taken. Cine display of all frames is essential to ascertain that no intestinal loop is encroaching upon the gastric region, and when found, such frames are excluded for ROI selection [7]. Often there is no D-G bile reflux during fasting; rather, it occurs only after CCK-8 (Fig. 5.4.3).\n\nFig. 5.4.3\n\nDuodeno-gastric bile reflux only after CCK-8. There is no basal D-G bile reflux (0-2 min). Bile reflux of 10% occurs after CCK-8 administration (G stomach)\n\n### 5.4.3 Bile Reflux in Health and Disease\n\nThe data shown in Table 5.4.1 were collected in 22 patients without gallstones who were referred for measurement of the gallbladder ejection fraction. They did not have any symptoms of gastric dyspepsia. Mean D-G reflux in these subjects was 2.4% (95% CI = 0.4-4.4%). D-G reflux during fasting or after CCK-8 administration is rare and usually does not exceed 5%. When significant reflux is found, it suggests bile gastritis may be responsible for patient symptoms. Prokinetic agents are often prescribed for patients with large volume D-G reflux.\n\nTable 5.4.1\n\nBile flow into stomach vs. small intestine in 20 normal subjects\n\nNo. | Subject | Total stomach counts | Total intestinal counts | % Stomach | % Intestine\n\n---|---|---|---|---|---\n\n1 | HC | 93,729 | 3,830,883 | 2.3 | 97.7\n\n2 | H | 71,380 | 3,012,831 | 2.3 | 97.7\n\n3 | CC | 36,521 | 2,684,925 | 1.3 | 98.7\n\n4 | E | 51,226 | 1,483,318 | 3.3 | 97.3\n\n5 | EJ | 103,127 | 3,651,893 | 2.7 | 97,3\n\n6 | GE | 43,555 | 1,091,999 | 3.8. | 96.2\n\n7 | AP | 67,967 | 2.661,020 | 2.5 | 97.5\n\n8 | B | 42,169 | 1,309127 | 3.1 | 96.9\n\n9 | BB | 85,603 | 2,063,219 | 3.9 | 96.1\n\n10 | WD | 20,095 | 616,171 | 3.2 | 96.8\n\n11 | HR | 40,526 | 1,169,047 | 3.3 | 96.4\n\n12 | LC | 23,421 | 3,343,890 | 0.7 | 99.3\n\n13 | KD | 19,204 | 731,084 | 2.5 | 97.5\n\n14 | KJ | 15,746 | 2,107,383 | 0.7 | 99.3\n\n15 | KC | 26,342 | 2,259,335 | 1.1 | 99.9\n\n16 | MV | 16,093 | 459,163 | 3.4 | 96.6\n\n17 | MK | 20,084 | 1,299,986 | 1.5 | 98.5\n\n18 | NL | 27,480 | 680,653 | 3.8 | 96.2\n\n19 | O | 28,626 | 1,847,370 | 1.5 | 98.5\n\n20 | PJ | 24,585 | 1,545,024 | 1.6 | 98.4\n\n|  |  |\n\nMean \u00b1 SD | 2.4 \u00b1 1.05 | 97.6 \u00b1 1.05\n\n|  |  |\n\nS.E | 0.23 | 0.23\n\nNote: No background subtraction was made from either the stomach or intestine\n\n## 5.5 Imaging and Quantification of Hepatocyte Asialoglycoprotein Receptors with Tc-99m Galactosyl Human Serum Albumin\n\nHepatocyte plasma membrane is rich in asialoglycoprotein (ASGP) receptors, which are not found in any other cell in the body. The receptor is located along the basolateral and lateral domain, but not along the canalicular domain [1]. Technetium-99m-DTPA-galactosyl-human-serum albumin (Tc-99m GSA) binds to these receptors, and the amount bound varies inversely with the severity of liver disease [2-4]. It is not taken up by the spleen and like radiocolloid is not secreted into bile. ASGP receptor concentration on the membrane reflects the functional integrity of the hepatocyte accurately, much like indocyanin green, cholinesterase, serum albumin, and hepaplastin [3]. The quantity of Tc-99m GSA uptake correlates well with blood clearance of indocyanin green (Fig. 5.5.1). Technetium-99 GSA uptake decreases in patients with varieties of liver diseases including chronic hepatitis, cirrhosis, cholangiocarcinoma, hepatocellular cancer, metastasis, fulminant hepatic failure, and space-occupying benign lesions of the liver [2-4].\n\nFig. 5.5.1\n\nCorrelation between Tc-99m-GSA uptake (LU15, %) and indocyanin green blood retention. There is a good inverse relationship between Tc-99m GSA uptake by the liver with plasma clearance of indocyanin green at 15 min [2]\n\nAlmost all of the injected radiotracer clears from the blood and is taken up exclusively by the liver normally within 15 min. Several parameters have been developed to express the hepatocyte function, the most common one being the extraction index at 15 min. It represents the percentage of the integral of the cumulative counts in the liver for 1 min between 15 and 16 min to the total dose [2].\n\n### 5.5.1 Data Collection and Analysis\n\nAfter 4-6 h of fasting, with the patient in supine position, a gamma camera (single, double, or a triple head) fitted with a low-energy, high-resolution, parallel-hole collimator is positioned anterior to the liver. Sequential anterior planar images (128 \u00d7 128) at 1 frame per 30 s for 20 min are obtained immediately after a bolus injection of 5 mCi Tc-99m GSA (185 MBq) into the antecubital vein. Immediately after the planar images, SPECT data are acquired on a 128 \u00d7 128 \u00d7 16-matrix computer for 64 stops at 10 s per stop at a 5.6\u00b0 interval [2]. The spectrometer is set for 140 keV at a 20% window. Liver uptake at 15 min is calculated by using the following formula.\n\n![$$\n{\\\\rm Liver}\\\\,{\\\\rm uptake at 15min }\\\\left\\( {{\\\\rm LU15}} \\\\right\\) = \\\\frac{{\\\\int\\\\limits_{15}^{{\\\\rm 16}} {{\\\\rm C}\\\\left\\( {\\\\rm t} \\\\right\\){\\\\rm dt} \\\\times {\\\\rm 100\\\\% }} }}{{{\\\\rm Total injected dose}}}$$](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ27_5.gif)\n\nWhole liver counts and residual liver counts are obtained by measuring organ volume from SPECT images. Whole organ volume is determined by detecting the edge for each slice and then adding all of the slices. The volume of each lobe is obtained by selecting the gallbladder fossa -inferior vena cava plane (plane of Serege-Cantele), which divides the liver into physiologic right and left lobes, or by referring to the CT or MRI references [2]. After obtaining the volume, each lobe is divided into its physiologic segments: the right lobe into the anterior and posterior segments, and the left lobe into the medial and lateral segments [2-4]. The ratio of the counts in each lobe to the whole liver counts provides LU15 for the lobe.\n\nResidual count ratio (RCR) is determined by the following formula.\n\n![$$\n{\\\\rm RCR  =  RC \/ WC}$$](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ28_5.gif)\n\nwhere RC = residual liver count from SPECT images (counts from region of the liver left not to be resected), and WC = whole liver count calculated from SPECT images.\n\n![$$\n{\\\\rm Index\\\\ of\\\\ residual\\\\ liver\\\\ function\\\\ \\(RLU15\\)  =  LU15 \\\\times  RCR}$$](A978-3-642-00648-7_5_Chapter_TeX2GIF_Equ29_5.gif)\n\nSome authors express uptake as hepatic GSA clearance using the Patlak plot method and generate functional images of clearance (Ku). This method is powerful, but some may raise an issue with the chosen terminology \"clearance\" for an agent that does not clear from the liver [3, 4]. The uptake shows an excellent correlation with indocyanin green plasma clearance. Estimation of predicted postoperative residual function after resection of the liver for hepatocellular carcinoma, cholangiocarcinoma, and metastatic liver tumors shows good correlation with postoperative liver function (Fig. 5.5.2). This functional parameter may be ideal for predicting end-stage liver disease and timing of liver transplantation.\n\nReferences\n\n1.\n\nKrishnamuthy S, Krishnamurthy GT. Technetium-99m iminodiacetic acid organic anions: review of biokinetics and clinical application in hepatology. Hepatology 1989;9:139-153CrossRef\n\n2.\n\nBobba VR, Krishnamurthy GT, Kingston E, Brown PH, Eklem M, Turner FE. Comparison of biokinetics and biliary imaging parameters of four Tc-99m iminodiacetic acid derivatives in normal subjects. Clin Nucl Med 1983;8:70-75PubMedCrossRef\n\n3.\n\nWilliams W, Krishnamurthy GT, Brar HS, Bobba VR. Scintigraphic variations of normal biliary physiology. J Nucl Med 1984;25:160-165PubMed\n\n4.\n\nHealey JE, Schroy PC. Anatomy of the biliary ducts within the human liver. Analysis of the prevai-ling pattern of branchings and the major variations of the biliary ducts. Arch Surg 1953;66:599-616CrossRef\n\n5.\n\nSherlock S, Dooley. Diseases of the liver and biliary system, 10th edn Blackwell Science, Malden, MA, 1997, pp 217-237\n\n6.\n\nKrishnamurthy GT, Bobba VR, McConnell D, Turner FE, Mesgarzadeh M, Kingston E. Quantitative biliary dynamics: introduction of a new non-invasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n7.\n\nKlingensmith WC III, Spitzer CM, Fritzberg AR, Kuni CC. The normal fasting and post-prandial diisopropyl-IDA Tc-99m hepatobiliary study. Radiology 1981;141:771-776PubMed\n\n8.\n\nWheeler HO. Concentrating function of the gallbladder. Am J Med 1971;51:588-595PubMedCrossRef90283-X)\n\n9.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23:35S-44S\n\n10.\n\nKrishnamurthy GT, Krishnamurthy S. Cholescintigraphic measurement of liver function: how is it different from other methods? Eur J Nucl Med Mol Imaging 2006;33:11203-1106CrossRef\n\n11.\n\nTagge EP, Campbell DA Jr, Reichle R, Averill DR Jr, Merion RM, Dafoe DC, Turcotte JG, Juni JE. Quantitative scintigraphy with deconvolutional analysis for the dynamic measurement of hepatic function. J Surg Res 1987;42:605-612PubMedCrossRef90003-5)\n\n12.\n\nBrown PH, Juni JE, Lieberman DA, Krishnamurthy GT. Hepatocyte versus biliary disease: a distinction by deconvolutional analysis of technetium-99m IDA time-activity curves. J Nucl Med 1988;29:623-630PubMed\n\n13.\n\nDoo E, Krishnamurthy GT, Eklem MJ, Gilbert S, Brown PH. Quantification of hepatobiliary function as an integral part of imaging with technetium-99m-mebrofenin in health and disease. J Nucl Med 1991;32:48-57PubMed\n\n14.\n\nSpackman J, Bartlett ME, Ryals L, et al. Reproducibility of technetium-99m-mebrofenin hepatic functional parameters obtained with a semiautomatic software. J Nucl Med Technol 1991;19:228-231\n\n15.\n\nKrishnamurthy GT, Krishnamurthy S. Nuclear hepatology. A textbook of hepatobiliary diseases. Springer, Berlin, 2000\n\n16.\n\nJuni JE, Reichle R. Measurement of hepatocellular function with deconvolutional analysis: application in the differential diagnosis of acute jaundice. Radiology 1990;177:171-175PubMed\n\n17.\n\nHowan-Giles R, Moase A, Gaskin K, Uren R. Hepatobiliary scintigraphy in a pediatric population: Determination of hepatic extraction fraction by deconvolution analysis. J Nucl Med 1993;34:214-221\n\n18.\n\nHowman-Giles R, Uren R, Bernard E, Dorney S. Hepatobiliary scintigraphy in infancy. J Nucl Med 1998;39:311-319PubMed\n\n19.\n\nvan der Linden W, Kempi V. Filling of the gallbladder as studied by computer-assisted Tc-99m-HIDA scintigraphy: concise communication. J Nucl Med 1984;25:292-298PubMed\n\n20.\n\nKrishnamurthy GT, Krishnamurthy S. Hepatic bile entry and transit within the gallbladder lumen: a new quantitative cholescintigraphic technique for measurement of its concentration function. J Nucl Med 2002;43:901-908PubMed\n\n21.\n\ndeSilva GS. A simple method for computing the volume of the human gallbladder. Radiology 1949;52:94-102\n\n22.\n\nEverson GT, Braverman DZ, Johnson ML, Kern F Jr. A critical evaluation of real-time ultrasonography for the study of gallbladder volume and contraction. Gastroenterology 1980;79:40-46PubMed\n\n23.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: a technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology 1981;80:482-490PubMed\n\n24.\n\nKrishnamurthy S, Krishnamurthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n25.\n\nKrishnamurthy S, Krishnamurthy GT. Cholecystokinin and morphine pharmacological intervention during Tc-99m-HIDA cholescintigraphy: a rational approach. Semin Nucl Med 1996;26:16-24PubMedCrossRef80013-4)\n\n26.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Optimization of octapeptide of cholecystokinin (OP-CCK) dose for gallbladder emptying. In: Raynaud C (ed) Proceedings of the third world congress of nuclear medicine and biology, Paris, France. Pergamon Press, New York, 1982, pp 2244-2247\n\n27.\n\nZiessman HA, Fahey FH, Hixson DJ. Calculation of a gallbladder fraction: advantage of continuous sincalide infusion over the three-minute infusion method. J Nucl Med 1992;33:537-541PubMed\n\n28.\n\nToftdahl DB, Hojgaard L, Winkler K. Dynamic cholescintigraphy: induction and description of gallbladder emptying. J Nucl Med 1996;37:261-266PubMed\n\n29.\n\nKrishnamurthy S, Krishnamurthy GT. Gallbladder ejection fraction: a decade of progress and future promise (editorial). J Nucl Med 1992,32:542-544\n\n30.\n\nFisher RS, Rock E, Levine G, Malmud L. Effects of somatostatin on gallbladder emptying. Gastroenterology 1987;92:885-890PubMed\n\n31.\n\nBobba VR, Krishnamurthy GT, Kingston E, Turner FE, Brown PH, Langrell K. Gallbladder dynamics induced by a fatty meal in normal subjects and patients with gallstones: concise communication. J Nucl Med 1984;25:21-24PubMed\n\n32.\n\nKrishnamurthy GT, Brown PH. Comparison of fatty meal and intravenous cholecystokinin infusion for gallbladder ejection fraction. J Nucl Med 2002;43:1603-1610PubMed\n\n33.\n\nSjolund K, Sanden G, Hakanson R, Sundler F. Endocrine cells in human intestine: an immunocytochemical study. Gastroenterology 1983;85:1120-1130PubMed\n\n34.\n\nFisher RS, Stelzer F, Rock F, Malmud LS. Abnormal gallbladder emptying in patients with gallstones. Dig Dis Sci 1982;27:1019-1024PubMedCrossRef\n\n35.\n\nShreiner DP, Sarva RP, Van Thiel D, Yingvorapant N. Gallbladder function in diabetic patients. J Nucl Med 1986;27:357-360PubMed\n\n36.\n\nHopman WPM, Jansen JBM, Rosenbusch G, Lamers CB. Cephalic stimulation of gallbladder contraction in humans: role of cholecystokinin and the cholinergic system. Digestion 1987;38:197-203PubMedCrossRef\n\n37.\n\nKrishnamurthy GT, Krishnamurthy S, Milleson T, Brown PH, Urstadt DS. Segmentation of the gallbladder: effect on bile entry and exit and its clinical relevance in a patient with abdominal pain. Nucl Med Commun 2007;28:109-115PubMedCrossRef\n\nReferences\n\n1.\n\nSarper R, Tarcan YA. An improved method of estimating the portal venous fraction of total hepatic blood flow from computerized radionuclide angiography. Radiology 1983;147:559-562PubMed\n\n2.\n\nO'Connor MK, MacMathuna P, Keeling PWN. Hepatic arterial and portal venous components of liver blood flow: a dynamic scintigraphic study. J Nucl Med 1988;29:466-472PubMed\n\n3.\n\nBiersack HJ, Torres J, Thelen M, Monzon O, Winkler C. Determination of liver and spleen perfusion by quantitative sequential scintigraphy: results in normal subjects and in patients with portal hypertension. Clin Nucl Med 1981;6:218-220PubMedCrossRef\n\n4.\n\nMcMathuna P, O'Connor MK, Weir DG, Keeling PWN. Non-invasive diagnosis of portal vein occlusion by radionuclide angiography. Gut 1992;33:1671-1674CrossRef\n\n5.\n\nO'Connor MK, Krom RF, Carton EG, Sanchez-Urdazpal L, Juni JE, Ferguson DM, Wiesner RF. Ratio of hepatic arterial-to-portal venous blood flow-validation of radionuclide techniques in an animal model. J Nucl Med 1992;33:239-245PubMed\n\n6.\n\nKoranda P, Myslivecek M, Erban J, Seidlova V, Husak V. Hepatic perfusion changes in patients with cirrhosis. Indices of hepatic arterial blood flow. Clin Nucl Med 1999;24:507-510PubMedCrossRef\n\n7.\n\nMenzel J, Schober O, Reimer P, Domschke W. Scintigraphic evaluation of hepatic blood flow after intrahepatic portosystemic shunt (TIPS). Eur J Nucl Med 1997;24:635-641PubMed\n\n8.\n\nGanger DR, Klapman JB, McDonald V, Matolon JA, Kaur S, Rosenblate H, Kave R, Saker M, Jensen DM. Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiary syndrome and portal vein thrombosis. Am J Gastroenterol 1999;94:603-608PubMed\n\nReferences\n\n1.\n\nSnell AM. The effect of chronic disease of the liver on composition and physiochemical properties of blood: changes in the serum proteins; reduction in the oxygen saturation of the arterial blood. Ann Intern Med 1935;9:690-711\n\n2.\n\nKennedy TC, Knudson RJ. Exercise aggravated hypoxemia and orthodeoxia in cirrhosis. Chest 1977;72:305-309PubMedCrossRef\n\n3.\n\nKrowka MJ, Cortese DA. Hepatopulmonary syndrome: an evolving perspective in the era of liver transplantation. Hepatology 1990;11:138-142PubMedCrossRef\n\n4.\n\nRobin ED, Laman D, Horn BR, Theodore J. Platypnea related to orthodeoxia caused by true vascular lung shunts. N Engl J Med 1976;294:941-943PubMedCrossRef\n\n5.\n\nAltman M, Robin ED. Platypnea (diffuse zone 1 phenomenon?) N Engl J Med 1969;281:1347-1348PubMedCrossRef\n\n6.\n\nLange PA, Stoller JK. The hepatopulmonary syndrome. Ann Intern Med 1995;122:521-529PubMed\n\n7.\n\nSherlock S. Liver-lung interface. Semin Respir Med 1988;9:247-253CrossRef\n\n8.\n\nKrawka MJ, Dickson ER, Cortese DA. Hepatopulmonary syndrome. Clinical observation and lack of therapeutic response to somatostatin analogue. Chest 1993;104:515-521CrossRef\n\n9.\n\nBerthalot P, Walker JG, Sherlock S, Reid L. Arterial changes in the lungs in cirrhosis of the liver-lung spider nevi. N Engl J Med 1966;274:291-298CrossRef\n\n10.\n\nGenovesi MG, Tierney DF, Taplin GV, Eisenberg H. An intravenous radionuclide method to evaluate hypoxemia caused by abnormal alveolar vessels. Limitation of conventional technique. Am Rev Respir Dis 1976;114:59-65PubMed\n\n11.\n\nWolfe JD, Tashkin DP, Holly FE, Brachman MB, Genovesi MG. Hypoxemia of cirrhosis: detection of abnormal small pulmonary vascular channels by a quantitative radionuclide method. Am J Med 1977;63:746-754PubMedCrossRef90161-9)\n\n12.\n\nGates GF, Orme HW, Dore EK. Cardiac shunt assessment in children with macroaggragated albumin technetium-99m. Radiology 1974;112:649-653PubMed\n\n13.\n\nRobin ED, Horn B, Goris ML, Theodore J, Kessel AV, Mazoub J, et al. Detection, quantitation, and pathophysiology of lung spiders. Trans Assoc Am Physicians 1975;88:202-216PubMed\n\n14.\n\nHind CR, Wong CM. Detection of pulmonary arteriovenous fistulas in patients with cirrhosis by contrast 2D echocardiography. Gut 1981;22:1042-1045PubMedCrossRef\n\n15.\n\nShub C, Tajik AJ, Seward JB, Dines DE. Detecting intrapulmonary right-to-left shunt with contrast echocardiography. Observation in patients with diffuse pulmonary arteriovenous fistulas. Mayo Clin Proc 1976;51:81-84PubMed\n\n16.\n\nKrowka MJ, Tajik AJ, Dickson ER, Wiesner RH, Cortese Da. Intrapulmonary vascular disorders (IPVD) in liver transplant candidates. Screening by two-dimensional contrast-enhanced echocardiography. Chest 1990;97:1165-1170PubMedCrossRef\n\n17.\n\nAbrams GA, Jaffe CC, Hoffer PB, Binder HJ, Fallon MB. Diagnostic utility of contrast echocardiography and lung perfusion scan in patients with hepatopulmonary syndrome. Gastroenterology 1995;109:1283-1288PubMedCrossRef90589-8)\n\n18.\n\nAbrams GA, Nanda NC, Dubovsky EV, Krowka MJ, Fallon MB. Use of macroaggregated albumin lung perfusion scan to diagnose hepatopulmonary syndrome: a new approach. Gastroenterology 1998;114:305-310PubMedCrossRef70481-0)\n\n19.\n\nWade OL, Bishop JM. Cardiac output and regional blood flow. Blackwell Scientific, Oxford, England, 1962\n\n20.\n\nMurakami JW, Rosenbaum DM. Right-to-left pulmonary shunting in pediatric hepatopulmonary syndrome. Clin Nucl Med 1999;24:897PubMedCrossRef\n\n21.\n\nAndrivet P, Cadranel J, Housset B, Harigault R, Harf A, Anot S. Mechanism of impaired arterial oxygenation in patient liver cirrhosis and severe respiratory insufficiency. Effect of indomethacin. Chest 1993;103:500-507\n\n22.\n\nKrowka MJ, Cortese DA. Severe hypoxemia associated with liver disease. Mayo Clin experience and the experimental use of almitrine bismesylate. Mayo Clin Proc 1987;62:164-173PubMed\n\n23.\n\nScott VL, Dodson F, Kang Y. The hepatopulmonary syndrome. Surg Clin North Am 1999;79:23-41PubMedCrossRef70005-0)\n\n24.\n\nLange PA, Vogt DA, Carey WB, Stroller JK. Prevalence and reversibility of hepatopulmonary syndrome following liver transplantation. Am Rev Respir Dis 1993;147:540A (abstract)\n\nReferences\n\n1.\n\nFisher RS, Cohen S. Physiological characteristics of the human pyloric sphincter. Gastro-enterology 1973;64:67-75\n\n2.\n\nCapper WM, Airth GR, Kilby JO. A test for pyloric regurgitation. Lancet 1966;2:621-623PubMedCrossRef91930-1)\n\n3.\n\nRokkjaer M, Marqversen J, Kraglund K, Peterson J. Quantitative determination of pyloric regurgitation in response to intraduodenal bolus injection. Scand J Gastroenterol 1977;12:827-832PubMedCrossRef\n\n4.\n\nNicolai JJ, Silberbusch J, vanRoon F, Schopman W, Berg JWO. A simple method for quantification of biliary reflux. Scand J Gastroenterol 1980;15:775-780PubMedCrossRef\n\n5.\n\nKrishnamurthy GT, Bobba VR, McConnell D, Turner FE, Mesgarzadeh M, Kingston E. Quantitative biliary dynamics: introduction of a new non-invasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n6.\n\nSorgi M, Causer D, Wolverson RL, Mosimann F, Tulley N, Ghosh SK, Donovan IA, Alexander-Williams J, Harding LK. Quantification and the elimination of errors in bile reflux tests using a gamma camera. Scand J Gastroenterol 1984;19:33-35\n\n7.\n\nThomas WEG, Jackson PC, Cooper MJ, Davies ER. The problems associated with scintigraphic assessment of duodenogastric reflux. Scand J Gastroenterol 1984;19 (suppl 92):36-40\n\nReferences\n\n1.\n\nSteer CJ. Receptor-mediated endocytosis: mechanisms, biologic function, and molecular properties. In: Zakim D, Boyer TD (eds) Hepatology. A textbook of liver disease. WB Saunders, Philadelphia, 1996, pp 149-214\n\n2.\n\nUetake M, Koizumi K, Yagawa A, Nogata H, Tezuka T, Kono H, Ozawa T, Kusano T, Miyaburuko M, Hosaka M. Use of Tc-99m DTPA galactosyl human serum albumin to predict postoperative residual liver function. Clin Nucl Med 1999;24:428-434PubMedCrossRef\n\n3.\n\nHwang E, Taki J, Shuke N, Nakajima K, Kinuya S, Konishi S, Michigishi T, Aburano T, Tonami N. Preoperative assessment of residual hepatic functional reserve using Tc-99m-DTPA-galactosyl-humen-serum albumin dynamic SPECT. J Nucl Med 1999;40:1644-1651PubMed\n\n4.\n\nSasaki N, Shiomi S, Iwata Y, Nishiguchi S, Kuroki T, Kawabe J, Oci H. Clinical usefulness of scintigraphy with Tc-99m-galactosyl-human serum albumin for prognosis of cirrhosis of the liver. J Nucl Med 1999;1652-1656\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_6(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 6. Gallbladder, Sphincter of Oddi, Cholecystokinin, and Opioid Relation\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nThe bile, essential for digestion and absorption of nutrients, is secreted by the liver continuously, stored in the gallbladder during fasting, and discharged into the duodenum intermittently after each meal. The bile salts, which are an important component of bile, promote efficient digestion and absorption of essential nutrients from the intestine. The gallbladder has a unique mechanism to sequester almost all of the bile salts during fasting and release them into the duodenum after the arrival of food. Food stimulates the release of endogenous cholecystokinin into circulation from the endocrine cells lining the mucosa of the duodenum, jejunum, and upper ileum. Cholecystokinin (CCK) acts on its receptors located in the smooth muscle and initiates the contraction and emptying of concentrated bile from the gallbladder; it simultaneously relaxes the sphincter of Oddi to allow smooth passage of bile into the duodenum.\n\nThe bile, essential for digestion and absorption of nutrients, is secreted by the liver continuously, stored in the gallbladder during fasting, and discharged into the duodenum intermittently after each meal. The bile salts, which are an important component of bile, promote efficient digestion and absorption of essential nutrients from the intestine. The gallbladder has a unique mechanism to sequester almost all of the bile salts during fasting and release them into the duodenum after the arrival of food. Food stimulates the release of endogenous cholecystokinin into circulation from the endocrine cells lining the mucosa of the duodenum, jejunum, and upper ileum. Cholecystokinin (CCK) acts on its receptors located in the smooth muscle and initiates the contraction and emptying of concentrated bile from the gallbladder; it simultaneously relaxes the sphincter of Oddi to allow smooth passage of bile into the duodenum. During the evolutionary process it appears as though nature has placed these three organs very close to each other anatomically to obtain the maximum efficiency of the biological system (Fig. 6.1.1).\n\nFig. 6.1.1\n\nThe relationship among the sphincter of Oddi, gallbladder, and cholecystokinin. The sphincter of Oddi consists of three components: choledochal sphincter, pancreatic sphincter, and ampullary sphincter. Gallbladder wall contains mainly stimulatory (contraction) and the sphincter of Oddi inhibitory (relaxation) receptors for cholecystokinin. CCK-secreting endocrine cells are distributed densely in the mucosa of the duodenum [44]\n\n## 6.1 Effect of Cholecystokinin on the Gallbladder and Sphincter of Oddi\n\n### 6.1.1 Cholecystokinin\n\nA hormone being responsible for contraction and emptying of the gallbladder was proposed first by Ivy and Oldberg in 1928 [1]. A year later, Ivy and associates identified the hormone and named it \"cholecystokinin\" (from the Greek: chole = bile, cysto = sac, kinin = move; move the bile sac) because of its primary motor effect on gallbladder contraction [2].\n\n#### 6.1.1.1 Source\n\nCholecystokinin is found in various organs of the body, including the gastrointestinal, endocrine, genitourinary, and nervous systems [3]. The highest concentration is found in the upper intestinal tract, cerebral cortex, and anterior pituitary gland [4, 5]. In the gastrointestinal tract, the cells secreting cholecystokinin are distributed primarily in the mucosa of the duodenum, jejunum, and upper ileum (Fig. 6.1.2). There are about 40 million (1.3 million cm-1) CCK-secreting cells in the duodenum, 80 million (0.55 million cm-1) in the jejunum, and about 5 million cells in the entire ileum [4]. There are no CCK-secreting cells in the esophagus, stomach, distal ileum, colon, and rectum. The cerebellum and posterior pituitary gland do not contain any CCK-secreting cells. Two types of hormone-secreting cells are found in the intestinal mucosa: open endocrine cells and closed endocrine cells. Open endocrine cells are tall and flask shaped with microvilli along the free border, which enable direct contact with the digested nutrients passing through the intestinal lumen. Closed endocrine cells are basket shaped without any microvilli and do not reach the mucosal surface and hence have no direct contact with the nutrients passing through the intestinal lumen [6].\n\nFig. 6.1.2\n\nDistribution of cholecystokinin and fibroblast growth factor-secreting cells in the alimentary canal. The cholecystokinin-secreting cells are concentrated mainly in the duodenum, jejunum, and proximal ileum. There are no CCK-secreting cells in the esophagus, stomach, and intestinal tract beyond the proximal ileum [4]. Fibroblast growth factor stimulating cells are distributed mainly in the terminal ileum\n\n#### 6.1.1.2 Structure\n\nAt least five molecular forms of cholecystokinin have been identified. All five are linear- chain polypeptides, each with a varying number of amino acids in its molecule [3, 7]. The longer hormones with 33-58 amino acids can be cleaved at different locations to yield hormones of shorter molecular length. The component that retains the carboxyl terminal tetrapeptide exhibits most of the biological function of the parent molecule (Fig. 6.1.3). Component I with more than 40 and component II with 33-39 amino acids in the molecule are the most abundant forms. ComponentdIII contains 12, component IV has eight (octa-peptide or CCK-8), and component V consists of four amino acids. Component V with four amino acids is the shortest biologically active form.\n\nFig. 6.1.3\n\nMolecular structure of cholecystokinin. It consists of 33-39 amino acids that can be cleaved (scissors) at several locations to produce shorter fragments. Amino terminal tetrapeptide (CCK-4) is necessary for biological actions of the fragments [44]\n\nHormone CCK-8 has been synthesized and is available for clinical use as Sincalide (Kinevac). The terminal amino acid, phenylalanine, is amidated, and the seventh amino acid, tyrosine, is sulfated. Sulfation of the amino acid tyrosine is essential for retention of the biological potency of the hormone. To be biologically active, each component must possess the carboxy terminal tetrapeptide. When the amino acids are numbered serially beginning at the carboxyl terminal (CO-NH2) end, the hormonal fragments are called CCK-4, CCK-8, CCK-12, CCK-33, CCK-39, etc. The molecular weight of CCK-8 is 1,143. Because of its shorter length and lesser mass, CCK-8, on a molar basis, is four to five times biologically more potent than CCK-33. All five components of CCK are found in the small intestinal mucosa and the central nervous system. Currently, it is believed that each component is secreted, in-vivo, by a specific group of CCK-secreting cells. The concentration of larger components (CCK-33, CCK-39) is higher in the central nervous system and the gastrointestinal tract, whereas the concentration of smaller components (CCK-8) is higher in the anterior pituitary gland [5].\n\n#### 6.1.1.3 Cerulein\n\nOther peptides with a carboxyl terminal tetrapeptide identical to that of CCK also possess a cholecystokinetic effect. Gastrin and cerulein are two such peptides with an identical carboxy terminal tetrapeptide, and both exhibit a cholecystokinetic effect. Cerulein, isolated first from the skin of an Australian frog, is not found in humans. It closely resembles the CCK-8 structure and consists of ten amino acids (decapeptide), two more than CCK-8. The seventh amino acid, tyrosine, is sulfated. The sixth amino acid is threonine in cerulein, and methionine in CCK-8 (Fig. 6.1.4). Biologically, cerulein is ten times more potent than CCK-33 on a molar basis, and 47 times more potent on the basis of its net weight. The molecular weight is 1,352 [8].\n\nFig. 6.1.4\n\nStructure of CCK-8 and cerulein. Both contain an identical N-terminal tetrapeptide. The sixth amino acid is methionine in CCK-8 and threonin in cerulein. Both are sulfated on the seventh amino acid, tyrosine. Cerulein has two amino acids (decapeptide) more than CCK-8. Molecular weight of CCK-8 = 1,142 and cerulein = 1,352 [32]\n\n#### 6.1.1.4 Release of CCK\n\nCholecystokinin is released into circulation soon after the arrival of food into the duodenum. Fat is the most potent stimulant of all nutrients. Serum CCK level begins to rise 8-10 min after a meal and reaches the peak level by 30-60 min [9, 10]. The serum level remains above the basal level for 2-4 h post- meal, depending upon the nature of food ingested. The serum half life of CCK is 2.5 min [11].\n\n#### 6.1.1.5 Receptors\n\nCholecystokinin acts through two types of receptors, CCK-A (CCK-1) and CCK-B (CCK-2). CCK-A receptors are distributed predominantly in the smooth muscle of the gut and a few areas of the brain, and CCK-B receptors are distributed mainly in the brain. The gallbladder contains mostly CCK-A and the pancreas mostly CCK-B type receptors [12, 13]. These receptors are located on the surface of the cell and provide easy access to cholecystokinin. Cholecystokinin binds to CCK-A receptors in the gallbladder smooth muscle and initiates its contraction and bile emptying immediately. By binding to CCK-B type receptors, cholecystokinin stimulates pancreatic enzyme and bicarbonate secretion. CCK-B receptors manifest an inhibitory effect on the motility of the distal colon and pylorus of the stomach, acting via nitric oxide pathway [14]. Both cholecystokinin and leptin influence eating by acting on the brain as inhibitory hormones [15]. In humans, plasma cholecystokinin levels are associated with satiety [16]. Cholecystokinin antagonists (loxiglumide, devazepide, and TP-680) either block or reverse its actions by competitively binding to CCK receptors. These antagonists increase appetite, food intake, and weight gain in animals by blocking CCK brain receptors [17, 18].\n\n#### 6.1.1.6 Actions of CCK\n\nThe stimulation of gallbladder contraction and subsequent bile emptying is one of the most important and the best known actions of cholecystokinin. Cholecystokinin simultaneously relaxes the sphincter of Oddi and facilitates smooth passage of bile through it into the duo-denum [19]. Cholecystokinin also exhibits other biological actions listed in Table 6.1.1. It increases both the volume and flow of hepatic bile by increasing water secretion by bile canaliculi and bile ducts. For a short time, it was thought that a separate hormone (pancreozymin), different from CCK, acted on the pancreas to increase its enzyme and bicarbonate secretion [20]. It is now well recognized that a single hormone, cholecystokinin, is responsible for both actions: induction of gallbladder contraction and stimulation of pancreatic enzyme secretion [21]. In the pancreas, both cholecystokinin and secretin bind to the same receptor and increase enzyme and bicarbonate secretion [22]. Cholecystokinin increases intestinal peristalsis and promotes antegrade flow of bile and nutrients through the lumen. By inducing contraction of the pyloric sphincter, CCK prevents duodeno-gastric bile reflux.\n\nTable 6.1.1\n\nActions of cholecystokinin\n\n(1) Contracts and empties the gallbladder\n\n---\n\n(2) Increases pancreatic enzyme and bicarbonate secretion\n\n(3) Relaxes the sphincter of Oddi and lower esophageal junction\n\n(4) Increases secretion of insulin, glucagon, and somatostatin by Islet cells\n\n(5) Contracts the pyloric sphincter, preventing duodeno-gastric bile reflux\n\n(6) Increases hepatic bile secretion\n\n(7) Increases intestinal peristalsis\n\n(8) Increases intestinal blood flow\n\n(9) Suppresses appetite\n\n(10) Relaxation of lower esophageal sphincter.\n\n(11) Protection of gastric mucosa through release of somatostatin\n\n(12) Decreases systolic blood pressure\n\nCholecystokinin binds to stimulatory CCK-A receptors in the gallbladder smooth muscle and initiates its contraction [13]. Simultaneously, it binds to inhibitory receptors in the sphincter of Oddi smooth muscle and promotes its dilatation. These combined, but paradoxical, actions promote smooth passage of bile from the gallbladder into the duodenum [23]. CCK-A receptor-rich smooth muscle is distributed mostly in the fundus and body of the gallbladder. Very few receptors are found in the smooth muscle of the neck and the cystic duct. When serum CCK level rises above the threshold, the fundus contracts first, followed by the body. The relaxation of the sphincter of Oddi occurs at the same time, allowing smooth passage of bile through it [24, 25].\n\nCholecystokinin and cerulein both act on the same receptors [26-29]. The cystic duct smooth muscle, which has only a few CCK receptors, does not usually contract, because its threshold for contraction is set at a much higher level than the threshold for contraction of the smooth muscle in the body and fundus. When a large bolus dose of CCK-8 is injected, however, the cystic duct often contracts and prevents gallbladder emptying [30]. In chronic acalculous chronic cholecystitis (cystic duct syndrome), not only is there a decrease in the total number of CCK receptors in the body and fundus, but also the cystic duct smooth muscle threshold is lowered, allowing contraction of the body, fundus, and cystic duct, all at the same time, resulting in non-emptying of the gallbladder [31].\n\nDue to the low serum concentration of cholecystokinin during fasting, most CCK receptors in the smooth muscle are free, facilitating maximum relaxation of the gallbladder wall and a maximum increase in the tonus of the sphincter of Oddi. Both of these factors acting together promote preferential hepatic bile entry into the gallbladder during fasting. Upon CCK release post-meal, these receptors get saturated, initiating contraction of the gallbladder (stimulatory receptors) with simultaneous relaxation (inhibitory receptors) of the sphincter of Oddi. The degree of gallbladder bile emptying (ejection fraction) correlates directly with the total number of CCK receptors in the gallbladder smooth muscle [32].\n\n#### 6.1.1.7 Dose Response\n\nThe degree of gallbladder emptying is dependent both upon the dose rate and duration of infusion of cholecystokinin or cerulein [33]. The higher the dose is, the greater the degree of emptying, as long as the administered dose is within the physiological range (Fig. 6.1.5). The threshold for the beginning of gallbladder contraction and emptying lies between 0.5 and 1.0 ng kg min-1 of CCK-8 or cerulein. Peak emptying is noted between 3 and 5 ng kg min-1 dose [34, 35]. A further increase in CCK-8 dose actually decreases gallbladder emptying. An infusion of 0.02 \u03bcg kg-1 (20 ng kg-1) or 0.04 \u03bcg kg-1 (40 ng kg-1) over a 3-min period results in an ejection fraction that is much lower than that obtained with 0.01\u03bcg kg-1 over 3 min (Fig. 6.1.6). The CCK-8 doses listed in Table 6.1.2 are shown to be within the physiological range and promote smooth contraction and emptying of the gallbladder. For an identical dose, dose rate, and duration, it appears that ceruletide may be more potent than CCK-8. For a 3-min infusion of 5 ng kg-1, the gallbladder mean ejection fraction is 61% with ceruletide and 38% with CCK-8 (Fig. 6.1.6).\n\nFig. 6.1.5\n\nDose response curve. The gallbladder ejection fraction increases as the dose of ceruletide (or CCK-8) increases [32]\n\nFig. 6.1.6\n\nEffect of non-physiologic CCK-8 or ceruletide dose on gallbladder emptying. After the peak response at 5 ng kg-1 3 min for ceruletide and 10 ng kg-1 3 min for CCK-8, the gallbladder ejection fraction begins to decrease for any further increase in dose [31]\n\nTable 6.1.2\n\nCholecystokinin-33 (CCK-33), octa-peptide of cholecystokinin (CCK-8), and ceruletide dose for measurement of gallbladder ejection fraction\n\nHormone (Ref) | Route | Dose rate | Trade name | Manufacturer | GBEF (%)\n\n---|---|---|---|---|---\n\nCCK-33 (PI) | IV | 1 IDU\/kg\/min | CCK-33\/Kabi | Pharmacia Laboratory, Piscataway, NJ | -\n\nCCK-8 [31] | IV | 10 ng kg-1 3 min | Kinevac | Bracco Diagnostics, Princeton, NJ | >35%\n\nCeruletide [32] | IV | 5 ng kg-1 3 min | Tymtran | Adria Laboratory, Columbus, OH | >40%\n\nCeruletide (PI) | I M | 300 ng kg-1 | Tymtran | Adria Laboratory Columbus, OH | -\n\nIDU = Ivy dog unit, PI = package insert\n\n#### 6.1.1.8 Effect of a Large Dose of CCK-8\n\nThe dose required during quantitative cholescintigraphy, in general, is found to be much lower than the hormonal dose recommended in the package insert (Kinevac) by the vendor. The package insert dose originally was meant for oral cholecystogram or for stimulating pancreatic enzyme secretion [33]. The recommended dose in the package insert (0.02 \u03bcg kg-1 or 20 ng kg-1) often produces abdominal pain and low ejection fraction (Fig. 6.1.7) when used in control subjects [34-35]. A low ejection fraction response obtained with a larger dose of CCK-8 is attributed to reaching the cystic duct smooth muscle threshold for contraction, with the resultant effect of non-emptying of the gallbladder [36-37]. Cholecystokinin dual action of antegrade intestinal peristalsis and simultaneous contraction of the pyloric sphincter normally produces forward bile flow through the intestinal lumen and prevents duodenal-gastric bile reflux [38-40].\n\nFig. 6.1.7\n\nEffect of sequential CCK-8 doses on gallbladder emptying. A 5 ng kg-1 3 min CCK-8 dose given sequentially four times on a single occasion, with 30 min between doses, produces similar ejection fractions. Note that a 20 ng kg-1 3-min CCK-8 dose given on a different day produces a lower ejection fraction [38]\n\n#### 6.1.1.9 Sequential CCK Doses\n\nThe gallbladder ejection fraction remains constant for a fixed dose of cholecystokinin or ceruletide, given on two separate occasions (Fig. 6.1.7). A second identical dose of CCK-8 or ceruletide given 20-30 min after the first dose produces an ejection fraction similar to that of the first dose. There is neither a potentiation nor inhibition effect from the first dose when a period of 20-30 min is allowed between doses. A short serum half life of 2.5 min does not seem to leave any significant residual CCK activity from the first dose to influence the effect of the second dose [41, 42]. This unique feature enables cholescintigraphy to study the effect of various drugs on the sphincter of Oddi and the gallbladder after a single dose of Tc-99 m-HIDA. The dose of CCK-8 (Kinevac, Bracco Laboratory, Princeton, NJ) and ceruletide (Tymtran, Adria Lab, Columbus, OH) is measured in microgram units, and cholecystokinin-33 (CCK\u2122, Pharmacia Laboratory, Piscataway, NJ) in Ivy dog units. One Ivy dog unit is defined as the amount of CCK-33, when injected intravenously over 10-15 s, that raises the pressure within the gallbladder by 1 cm of H2O [43].\n\n### 6.1.2 Sphincter of Oddi\n\nRugero Oddi in 1887 first proposed the sphincter mechanism at the distal end of the common bile duct that today bears his name [44]. The existence of the sphincter remained controversial for many years, when Boyden in 1937 put an end to the controversy by showing both macroscopic and microscopic details of the sphincter in both animals and humans [45, 46].\n\n#### 6.1.2.1 Structure and Function\n\nThe human sphincter of Oddi is about 10-15 mm in length, situated within the muscular layer of the media of the duodenum (Fig. 6.1.1). It consists of three distinct segments: (1) sphincter choledochus, (2) sphincter pancreaticus, and (3) ampullary sphincter. The choledochal sphincter covers the distal end of the intraduodenal part of the common bile duct before it joins with the pancreatic duct (duct of Wirsung). The pancreatic sphincter is located at the distal end of the pancreatic duct. The ampullary sphincter covers the distal end of both ducts after they unite to form a single common channel that opens into the duodenal lumen at an elevation called the ampulla of Vater [46]. The term \"sphincter of Oddi\" refers to all three sphincters.\n\nThe main function of the sphincter of Oddi is regulation of bile flow through it and prevention of the reflux of duodenal contents into the common bile duct and pancreatic duct. Internally, it prevents bile reflux into the pancreatic duct and reflux of pancreatic enzymes into the common bile duct. In the majority of humans (86%), the distal common bile duct and the distal pancreatic duct join together, forming a common channel of 10-12 mm length that opens into the duodenum at the papilla of Vater. In 6% of patients, the two ducts join together just before opening into the duodenum with a common channel. In the remaining 8% of patients, the two ducts open separately into the duodenal lumen at the ampulla of Vater [46]. The sphincter consists of a circular and a longitudinal layer of muscle. In humans, the entire sphincter is located within the duodenal wall, and the wall has to be cut opened to expose the sphincter of Oddi for clinical and experimental studies. In American and the Australian opossums, however, the entire sphincter is situated outside of the duodenal wall, making it easy to study its function, without any need to cut open the duodenal wall.\n\n#### 6.1.2.2 Sphincter Pressure\n\nThe basal pressure within the sphincter Oddi is 15-18 mmHg and rises with the arrival of periodic phasic waves. Phasic waves occur at an average of 4 waves\/min, and each wave lasts for 10-15 s (Fig. 6.1.8). During the passage of a phasic wave, the pressure within the sphincter of Oddi rises sharply, reaching a peak amplitude as high as 90-140 mmHg [47, 48]. Normally, 80% of phasic waves progress antegrade (towards the duodenum), 9% retrograde (towards the liver), and 13% occur simultaneously (Table 6.1.3) at the proximal, middle, and distal segments of the sphincter. The wave normally begins proximally and travels distally within the sphincter. The sphincter of Oddi basal pressure, phasic wave frequency, and direction of propagation remain unchanged after cholecystectomy. Wide variations in normal sphincter of Oddi pressures reported in the literature are often due to technical differences among the studies and should be taken into account when comparing results of one study with the other. Pressure changes within the sphincter of Oddi remain constant between repeat studies when a standardized technique is applied [49].\n\nFig. 6.1.8\n\nManometric pressure changes in the common bile duct (CBD) and sphincter of Oddi. Sphincter of Oddi basal pressure of 15 mmHg raises to as high as 100-150 mmHg at the peak of a phasic wave. Pressure within common bile duct remains at 15-20 mmHg [46]\n\nTable 6.1.3\n\nPressure and wave frequency, sequence, and amplitude changes in a normal sphincter of Oddi [48]\n\nParameter | Median | Range\n\n---|---|---\n\nBasal pressure (mmHg) | 15 | 5-35\n\nWave amplitude (mmHg) | 135 | 95-195\n\nWave frequency (no\/min) | 4 | 2-6\n\nWave sequence (%):\n\n|  |\n\nAntegrade | 80 | 12-100\n\nSimultaneous | 13 | 0-50\n\nRetrograde | 9 | 0-50\n\n#### 6.1.2.3 Action of Cholecystokinin on the Sphincter of Oddi\n\nCholecystokinin acts on the sphincter of Oddi smooth muscle and immediately abolishes the phasic wave activity (Fig. 6.1.9). The hormone reduces the sphincter of Oddi wave amplitude and pressure from a peak 130-140 mmHg to less than 10 mmHg pressure and reduces the wave frequency from four to less than one. Abolition of waves and reduction in wave amplitude decrease the pressure inside and simultaneously promote dilatation of the sphincter orifice [50, 51]. Reduction in wave amplitude and frequency reaches the nadir within 2-4 min after a single bolus injection of CCK-8, and the basal state is reestablished after 8-10 min, reflecting the effect of a short serum half life (2.5 min) of the hormone [11]. The effect on the sphincter is maintained throughout the duration of infusion of the hormone. The sphincter remains open for 2-3 h post-meal because of the longer duration of endogenous CCK release.\n\nFig. 6.1.9\n\nAction of CCK-8 on normal sphincter of Oddi. CCK-8 abolishes the phasic waves in the sphincter of Oddi and increases the number of waves and pressure in the duodenum [46]\n\n### 6.1.3 Gallbladder\n\nThe main function of the gallbladder is to store and concentrate (bile salts) bile during fasting and discharge into the duodenum soon after the arrival of food from the stomach. A normal gallbladder holds up to 50 ml and empties almost completely following a fatty meal. Since bile salts are very essential for efficient digestion and absorption of nutrients, the gallbladder sequesters almost all of them by selectively absorbing water and electrolytes through the wall during fasting. Absorption of water takes place through widely open lateral intercellular spaces between columnar epithelial cells lining the mucosa. Although several hormones, including cholecystokinin, are known to act on gallbladder contraction and emptying, until recently not much was known about its filling. A new hormone called fibroblast growth factor (FGF19) in the portal blood that facilitates gallbladder relaxation and filling was identified recently [52]. After discharge into the duodenum, bile salts travel through the jejunum and ileum, helping the digestion and absorption of nutrients. After absorption in the terminal ileum, bile salts activate nuclear farnesoid X receptor (FXR), which stimulates the production and release of FGF19 (Fig. 6.2.2). Acting through cyclic adenosine monophosphate (cAMP), FGF19 promotes gallbladder relaxation, increases its volume, and facilitates filling [53].\n\nReduction in gallbladder ejection fraction in patients with biliary dyskinesia is attri-buted to either a decrease in the total number of receptors in the body and fundus or a decrease in the threshold for contraction of the CCK receptors in the neck and cystic duct or both [54, 55]. Because of this phenomenon, it is essential to keep the CCK-8 dose within the physiological range during quantitative cholescintigraphy in the diagnosis of biliary dyskinesia. Cholecystokinin antagonists like loxiglumide, devazepide, and TP-680 decrease gallbladder emptying by competitively occupying the CCK-A receptor in the gallbladder smooth muscle. Animals given CCK antagonists show a reduction in gallbladder emptying and an increase in appetite and weight gain [14, 15]. Cholecystokinin protects gastric mucosal integrity through the release of somatostatin, and it relaxes the lower esophageal sphincter through activation of CCK-A receptors at the distal end of the esophagus [56, 57]. Controversy about its action on the pancreas, whether acting on the pancreatic acinar cells directly or acting indirectly through the vagus nerve (cholinergic), seems to have been settled in recent studies by using freshly prepared normal human pancreatic cells. At physiologic concentration, cholecystokinin in humans stimulates enzyme secretion by pancreatic acinar cells directly through calcium signaling and mitochondrial activation. Blockade by atropine and tetrodotoxin does not inhibit the direct action [58]. After a century of trials, some feel that a judgment can now be made about the direct action of cholecystokinin on the pancreatic acinar cells [59].\n\n## 6.2 Opioids\n\nOpioids are the mainstay in the management of moderate to severe intensity pain of diverse etiology. They are the drugs of first choice for the treatment of postoperative pain. Opioids are often mixed with other pain medications, including many non-steroidal anti-inflammatory drugs, such as aspirin acetaminophen, and neproxin. Opioids raise the pressure in the sphincter of Oddi by acting on its smooth muscle and thus interfere with cholecystokinin- or fatty meal-stimulated gallbladder ejection fractions. The action of many opioids on the sphincter lasts much longer than their serum half-life would indicate, suggesting that the metabolites may also possess a constrictive action on the sphincter of Oddi. The interaction between the opioids and the sphincter of Oddi calls for their careful scrutiny during quantitative cholescintigraphy.\n\n### 6.2.1 History of Opioids\n\n\"Opioid\" is a generic name that refers to both natural and synthetic compounds with a morphine-like action. They are derived from the opium plant, which in Greek means juice. The juice comes from the capsule of the unripe seed of Papaver Somniferum. The milky juice from the seed is dried and made into opium powder, which contains more than 20 alkaloids. Serturner first isolated a pure substance from this powder in 1806, which produced somnolence first, followed by a dream state. He called it morphine after the Greek god of dreams, Morpheus. Codeine was isolated from opium powder in 1832 and papaverine in 1848 [1]. The analgesic action of all opioids is graded with reference to morphine, which serves as the gold standard for pain control. Table 6.2.1 shows different opioids available for pain control and their effect on the sphincter of Oddi.\n\nTable 6.2.1\n\nEffect of opioids on the sphincter of Oddi. The drugs are grouped under four major categories into marked, moderate, mild, or no effect based on the extent of sphincter of Oddi pressure rise | Generic name | Proprietary name\n\n---|---|---\n\nMarked rise in sphincter pressure\n\n|\n\nMorphine | Morphine\n\n|\n\nLevorphanol | Dromoran\n\n|\n\nMeperidine (methadone) | Demerol\n\nModerate rise in sphincter pressure\n\n|\n\nDextromoramide | Palfium\n\n|\n\nDiacetyl morphine | Heroin\n\n|\n\nCodeine | Codeine\n\n|\n\nFentanyl | Sublimaze\n\n|\n\nButorphanol | Stadol\n\n|\n\nNalbuphine | Nubain\n\n|\n\nHydrocodone | Hycodon\n\n|\n\nOxycodone | Roxicodone\n\n|\n\nPropoxyphene | Darvon\n\n|\n\nBupremorphine | Buprenex\n\nMild rise in sphincter pressure\n\n|\n\nDextropropoxyphene HCl | Doloxene\n\n|\n\nPentazocine | Talwin\n\n|\n\nPhenazocine | Norphen\n\n|\n\nPhenoperidine | Peridine\n\nNo effect on the sphincter\n\n|\n\nHydroxyzine | Hydroxyzine\n\n### 6.2.2 Biokinetics of Morphine\n\nMorphine consists of an OH group at positions 3 and 6 and a CH3 group at 17 (Fig. 6.2.1). Other opioids differ structurally from morphine by having different chemical substitutions at positions 3, 6, and 17. Morphine is administered by oral, subcutaneous, intramuscular, or intravenous routes. Many dermal patches are now available for long-term continuous application. Intravenous injections are preferred for hospital patients, especially during the immediate postoperative period. Upon intravenous injection, morphine distributes in an initial volume of 71.8 l kg-1 and clears from plasma with biexponential components: component I with a half time of 0.16 h and component II with a half time of 2.5 h (Table 6.2.2). Morphine is metabolized in the liver and converted into morphine glucuronide, which clears from plasma much more slowly than the parent molecule. About 60% of injected morphine is excreted in urine in 24 h, and 73% in 3 days. The excretion rate does not change in patients with cirrhosis of the liver [2].\n\nFig. 6.2.1\n\nStructure of morphine. Note OH group at positions 3 and 6 and CH3 at position 17. The structure of other opioids differs mainly in having different chemical substitution at these positions\n\n### 6.2.3 Dose\n\nA minimum of 0.04 mg kg-1 of intravenous morphine is recommended during Tc-99 m-HIDA cholescintigraphy [3]. Intravenous doses as large as 15 mg are well tolerated [4]. In adults, a total intravenous dose of 3-4 mg of morphine sulfate is usually adequate for confirmation of acute cholecystitis with cholescintigraphy. Liver extracts 60-80% of morphine on first pass and converts rapidly into a glucuronide form. Because of high extraction and rapid metabolism in the liver, oral morphine is not as effective as an intravenous dose.\n\n### 6.2.4 Action of Morphine on the Sphincter of Oddi\n\nMorphine acts on the sphincter of Oddi within 2-3 min after an intravenous injection, and increases the sphincter basal wave frequency from 4 to 10-12 min-1 and the wave amplitude from 70 mmHg to 136 mmHg (Fig. 6.2.2). The common bile duct basal pressure increases from 10 mmHg to 29 mmHg [4]. Low doses increase only the rate and amplitude, whereas higher doses increase basal pressure as well [5]. During a Tc-99 m-HIDA study, most gallbladders with a patent cystic duct are visualized within 5-15 min after an intravenous dose of morphine. The effect of morphine on the sphincter of Oddi is mediated by all types of opioid receptors. Naloxone and atropine slightly modify, but do not completely abolish the effect of morphine on the sphincter.\n\nFig. 6.2.2\n\nEffect of morphine on the sphincter of Oddi. Morphine increases both the number and the amplitude of wave pressure throughout the sphincter of Oddi and forces hepatic bile entry into the gallbladder when the cystic duct is patent [4]\n\nMorphine is the most potent of all opioids. The effect of other opioids on the sphincter of Oddi is a function of their structural configuration (Table 6.2.2). The effect of levorphonol, dextromoramide, and meperidine on the sphincter of Oddi is equivalent to that of morphine [6, 7]. Fentanyl, nolbuphine, hydrocodon, propoxyphene, and bupremorphine show a moderate spasmodic effect on the sphincter. Pentazocine, phenozocine, and phenoperidine show a mild effect, and hydroxyzine has no effect on the sphincter of Oddi [8].\n\nTable 6.2.2\n\nPharmacokinetics of morphine [2]\n\nInitial volume of distribution (l kg-1) | 71.8 \u00b1 65.2\n\n---|---\n\nClearance half time of the fast component (h) | 0.16 \u00b1 0.1\n\nClearance half time of the slow component (h) | 2.5 \u00b1 1.5\n\nPlasma protein binding (%) | 19.8 \u00b1 6.1\n\nUrinary excretion in 72 h (% dose) | 72.9 \u00b1 10.0\n\n### 6.2.5 Screening for Opioid Intake\n\nQuantitative cholescintigraphy is frequently used in the diagnosis of biliary dyskinesia, which consists of two disease entities: cystic duct syndrome (CDS) or chronic acalculous cholecystitis (CAC) and sphincter of Oddi spasm (SOS). The most consistent quantitative functional abnormality in patients with biliary dyskinesia is a reduction in gallbladder ejection fraction in the case of cystic duct syndrome and bile reflux into the hepatic duct followed by a rapid refilling of the gallbladder in the case of sphincter of Oddi spasm [9]. Because of the spasmodic effect on the sphincter of Oddi, it is critical to ensure that the patient is not on any opioids prior to performing a quantitative cholescintigraphy [10]. This issue becomes even more complex in outpatients where many patients are unaware that a non-steroidal anti-inflammatory drug they take for various indications (arthritis, headache, peptic ulcer, or primary or metastatic cancer) may also contain an opioid. This problem is relatively easy to recognize in hospitalized patients by careful review of charts for a list of current medications.\n\nAs only about 60-75% of the administered dose of morphine is excreted in 24-72 h urine, a safe rule is to allow a minimum of 24 h for inpatients and 48 h for outpatients to be off of opioids before performing a quantitative cholescintigraphy for the diagnosis of biliary dyskinesia [2]. If the ejection fraction is within normal range in a patient who has received an opioid, then there is no need to repeat the test. The test should be repeated if the ejection fraction is low and the patient has received an opioid within the last 48 h. The ejection fraction measured after discontinuation of an opioid for longer than 48 h often shows a dramatic increase in value when compared to the value before discontinuation (Fig. 6.2.3).\n\nFig. 6.2.3\n\nEffect of CCK-8 on gallbladder ejection fraction with and without opioids. Note an ejection fraction of 21.16% while on hydrocodone and a value of 41.88% while off of hydrocodone\n\n### 6.2.6 Morphine or Cholecystokinin: One, Neither, or Both?\n\nVarieties of protocols are used in the performance of a Tc-99 m HIDA study. The clinical indication for a Tc-99 m-HIDA study is established first in order to determine when to give or not to give morphine or cholecystokinin [11, 12]. In patients with suspected acute cholecystitis, giving morphine before or during cholescintigraphy is appropriate. When the gallbladder is not seen in the clinical setting of acute cholecystitis, giving morphine at 60 min reduces the total time required for final diagnosis. In a patient with suspected biliary dyskinesia, however, it is inappropriate to give morphine or cholecystokinin prior to cholescintigraphy. In suspected biliary dyskinesia, it is better to wait and take delayed images at 2-4 h than to give morphine at 60 min after injection of Tc-99 m-HIDA. If the gallbladder fills late without morphine, then cholecystokinin is given to measure the gallbladder ejection fraction to rule out biliary dyskinesia. Poor emptying of the gallbladder is a characteristic feature of biliary dyskinesia. The gallbladder also empties poorly in patients given an opioid (Fig. 6.2.3). Questions often arise about whether one should measure the ejection fraction with CCK when the gallbladder appears after morphine administration. In some patients given morphine, the gallbladder empties normally with CCK and thus excludes biliary dyskinesia [13]. Once the gallbladder ejection fraction reduces below the normal value, it never regains its normal function unless the reduction was due to prior opioid administration. Dual studies have confirmed that the ejection fraction is highly reproducible in both normal subjects and patients with biliary dyskinesia [14].\n\nReferences\n\n1.\n\nIvy AC, Oldberg E. A hormone mechanism for gallbladder contraction and evacuation. Am J Physiol 1928;86:599-613\n\n2.\n\nIvy AC, Kloster Gl, Lueth HC, Drewyer GE. On the preparation of \"cholecystokinin.\" Am J Physiol 1929;91:336-344\n\n3.\n\nRehfeld JF. Four basic characteristics of the gastrin-cholecystokinin system. Am J Physiol 1981;240:G255-G266PubMed\n\n4.\n\nSjolund K, Sanden G, Hakanson R, Sundler F. Endocrine cells in human intestine: an immunocytochemical study. Gastroenterology 1983;85:1120-1130PubMed\n\n5.\n\nRehfeld JF, Lindholm J, Andersen BN, Bardram L, Cantor P, Fenger M, Ludecke DK. Pituitary tumors containing cholecystokinin. N Engl J Med 1987;316:1244-1247PubMedCrossRef\n\n6.\n\nWilding PPH, Ghatei MA, Bloom SR. Hormones of the gastrointestinal tract. In: DeGroot LJ (ed) Endocrinology. WB Saunders, Philadelphia, 1995, vol. 3, pp 2870-2894\n\n7.\n\nElyseelein VE, Reeve JR Jr, Shively JE, Hawke D, Walsh JH. Partial structure of a large canine cholecystokinin (CCK58): amino acid sequence. Peptides 1982;3:687-691CrossRef90171-1)\n\n8.\n\nBasso N, Bagarani M, Materia A, Gizzonio D, DePaolis C, Praga C, Speranza V. Effect of caerulein in patients with biliary colic. Gastroenterology 1985;89:605-609PubMed\n\n9.\n\nLow-Beer TS, Harvey RF, Davies ER, Read AF. Abnormalities of serum cholecystokinin and gallbladder emptying in celiac disease. N Engl J Med 1975;292:961-963PubMedCrossRef\n\n10.\n\nWiener I, Inoue K, Fagan CJ, Lilja P, Watson LC, Thompson JC. Release of cholecystokinin in man: correlation of blood levels with gallbladder contraction. Ann Surg 1981;194:321-327PubMedCrossRef\n\n11.\n\nThompson JC, Fender HR, Ramus NI, Villar HV, Rayford PL. Cholecystokinin metabolism in man and dogs. Ann Surg 1975;182:496-504PubMedCrossRef\n\n12.\n\nWank SA, Pisegna JR, deWeerth A. Brain and gastrointestinal cholecystokinin receptor family: structure and functional expression. Proc Natl Acad Sci 1992;89:8691-8695PubMedCrossRef\n\n13.\n\nTang C, Biemond I, Lamers CB. Cholecystokinin receptors in human pancreas and gallbladder muscle: a comparative study. Gastroenterology 1996;111:1621-1626PubMedCrossRef70025-2)\n\n14.\n\nFornai M, Colucci R, Antonioli L, Crema F, et al. Cholecystokinin CCK-2 receptors mediate the peptide's inhibitory actions on the contractile activity of human distal colon via the nitric oxide pathway. Brit J Pharmacology 2007;151:1246-1253CrossRef\n\n15.\n\nWright M, Woodrow G, O'Brien S, Armstrong E, et al. Cholecystokinin and leptin: their influence upon the eating behaviour and nutrient intake of dialysis patients. Nephrol Dial Transplant 2004;19:133-140PubMedCrossRef\n\n16.\n\nBurton-Freeman B, Davis PA, Schneeman BO. Plasma cholecystokinin is associated with subjective measures of satiety in women. Am J Clin Nutrition 2002;76:659-667\n\n17.\n\nHewson G, Leighton GE, Hill RG, Hughes J. The cholecystokinin receptor antagonist L364,718 increases food intake in the rat by attenuation of the action of endogenous cholecystokinin. Br J Pharmacol 1988;93:79-84PubMed\n\n18.\n\nTachibana I, Kanagawa K, Yamamoto Y, Otsuki M. Pharmacological profile of a new serine derivative cholecystokinin receptor antagonist TP-680 on pancreatic, biliary and gastric function. J Pharmacol Exp Ther 1996;279:1404-1412PubMed\n\n19.\n\nMutt V. Cholecystokinin: Isolation, structure, and function. In: Glass GBJ (ed) Gastrointestinal hormones. Raven, New York, 1980, pp 169-221\n\n20.\n\nHarper AA, Raper HS. Pancreozymin, a stimulant of the secretion of pancreatic enzymes in extracts of the small intestine. J Physiology 1943;103:115-125\n\n21.\n\nJorpes E, Mutt V. Cholecystokinin and pancreozymin, one single hormone? Acta Physiol Scand 1966;66:196-202PubMedCrossRef\n\n22.\n\nGrossman MI. Gastrin, Cholecystokinin and secretin act on one receptor (hypothesis). Lancet 1970;1(7656):1088-1089PubMedCrossRef92758-3)\n\n23.\n\nBehar J, Biancani P. Pharmacologic characterization of excitatory and inhibitory cholecystokinin receptors of the cat gallbladder and sphincter of Oddi. Gastroenterology 1987;92:764-770PubMed\n\n24.\n\nIvy AC, Drewyer GE, Orndoff BH. The effects of cholecystokinin on the human gallbladder. Endocrinology 1930;14:343-348CrossRef\n\n25.\n\nSteigerwalt RW, Goldfine ID, Williams JA. Characterization of cholecystokinin receptors on bovine gallbladder membranes. Am J Physiol 1984;247:G709-G714PubMed\n\n26.\n\nBehar J, Biancani P. Effects of cholecystokinin and the octapeptide of cholecystokinin on the feline sphincter of Oddi and gallbladder. Mechanisms of action. J Clin Invest 1980;66:1231-1239PubMedCrossRef\n\n27.\n\nSarles JC, Bidart JM, Devaux MA, Echinard C, Castagnini A. Action of cholecystokinin and caerulein on the rabbit sphincter of Oddi. Digestion 1976;14:415-423PubMedCrossRef\n\n28.\n\nWetzner SM, Vincent ME, Robbins AH. Ceruletide-assisted cholecystography: a clinical assessment. Radiology 1979;131:23-26PubMed\n\n29.\n\nHedner P, Rorsman G. On the mechanism of action for the effect of cholecystokinin on the choledochoduodenal junction in the cat. Acta Physiol Scand 1969;76:248-254PubMedCrossRef\n\n30.\n\nCourtney DF, Clanachan AS, Scott GW. Cholecystokinin constricts the canine cystic duct. Gastroenterology 1983;85:1154-1159PubMed\n\n31.\n\nTorsoli A, Romarino ML, Alessandrini A. Motility of the biliary tract. Rendic R Gastroenterol 1970;2:67\n\n32.\n\nUpp JR Jr, Nealon WH, Singh P, Fagan CJ, Jonas AS, Greeley GH Jr, Thompson JC. Correlation of cholecystokinin receptors with gallbladder contractility in patients with gallstones. Ann Surg 1987;205:641-648PubMedCrossRef\n\n33.\n\nSturdevant RA, Stern DH, Resin H, Isenberg JI. Effect of graded doses of octapeptide of cholecystokinin on gallbladder size in man. Gastroenterology 1973;64:452-456PubMed\n\n34.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Optimization of octapeptide of cholecystokinin (OP-CCK) dose for gallbladder emptying. In: Raynaud C (ed) Proceedings of the III World Congress of Nuclear Medicine and Biology. Paris, France. Pergamon Press, 1982, pp 2244-2247\n\n35.\n\nKrishnamurthy GT, Turner FE, Mangham D, Bobba VR, White SA, Langrell K. Ceruletide intravenous dose-response study by a simplified scintigraphic technique. AJR Am J Roentgenol 1985;144:733-737PubMed\n\n36.\n\nKrishnamurthy S, Krishnamurthy GT. Gallbladder ejection fraction: a decade of progress and future promise (editorial). J Nucl Med 1991;32:542-544\n\n37.\n\nZeissman HA, Fahey FH, Hixson DJ. Calculation of a gallbladder ejection fraction: advantage of continuous sincalide infusion over the three-minute infusion method. J Nucl Med 1992;33:537-541\n\n38.\n\nToftdahl DB, Hojgaard L, Winkler K. Dynamic cholescintigraphy: induction and description of gallbladder emptying. J Nucl Med 1996;37:261-266PubMed\n\n39.\n\nValenzuela JE, Defilippi C. Inhibition of gastric emptying in humans by secretin, the octapeptide of cholecystokinin, and intraduodenal fat. Gastroenterology 1981;81:898-902PubMed\n\n40.\n\nFraser R, Fone D, Horowitz M, Dent J. Cholecystokinin octapeptide stimulates phasic and tonic pyloric motility in healthy humans. Gut 1993;34:33-37PubMedCrossRef\n\n41.\n\nKrishnamurthy GT, Bobba VR, Kingston E, Turner FE. Measurement of gallbladder emptying sequentially using a single dose of 99mTc-labeled hepatobiliary agent. Gastroenterology 1982;83:773-776PubMed\n\n42.\n\nSostre S, Canto MI, Kalloo AN. Gallbladder response to a second dose of cholecystokinin during the same imaging study. Eur J Nucl Med 1992;19:964-965PubMedCrossRef\n\n43.\n\nTorsoli A, Romarino ML, Colagrande C, Demaio G. Experiments with cholecystokinin. Acta Radiologica 1961;55:193-206PubMedCrossRef\n\n44.\n\nOddi R. D'une disposition a sphincter speciale del'ouverture du canal cholique. Arch Ital Biol 1887;8:317-322\n\n45.\n\nBoyden EA. The sphincter of Oddi in man and certain representative mammals. Surgery 1937;1:25-37\n\n46.\n\nBoyden EA. The anatomy of the choledochoduodenal junction in man. Surg Gynecol Obstet 1957;104:641-652PubMed\n\n47.\n\nGeenen JE, Hogan WJ, Dodds WJ, Stewart ET, Arndorfer RC. Intraluminal pressure recording from the human sphincter of Oddi. Gastroenterology 1980;78:317-324PubMed\n\n48.\n\nCarr-Locke DL, Gregg JA. Endoscopic manometry of pancreatic and biliary sphincter zones in man. Basal results in healthy volunteers. Dig Dis Sci 1981;26:7-15PubMedCrossRef\n\n49.\n\nThune A, Scicchitano J, Roberts-Thomson IC, Toouli J. Reproducibility of endoscopic sphincter of Oddi manometry. Dig Dis Sci 1991;36:1401-1405PubMedCrossRef\n\n50.\n\nToouli J, Roberts-Thompson C, Dent J, Lee J. Manometric disorders in patients with suspected sphincter of Oddi dysfunction. Gastroenterology 1985;88:1243-1250PubMed\n\n51.\n\nToouli J, Hogan WJ, Geenen JE, Dodds WJ, Arndorfer RC. Action of cholecystokinin-octapeptide on sphincter of Oddi basal pressure and phasic wave activity in humans. Surgery 1982;92:497-503PubMed\n\n52.\n\nChoi M, Moschetta A, Bookout AL, Peng L, Umetani M, Holstrom SR, et al. Identification of a hormonal basis for gallbladder filling. Nat Med 2006;12:1253-1255PubMedCrossRef\n\n53.\n\nPortincasa P, DiCaula A, Wang HH, Palasciano G, van Erpecum KJ, Moschetta A, Wang DQH. Coordinate regulation of gallbladder motor function in the gut-liver axis. Hepatology 2008;47:2112-2126PubMedCrossRef\n\n54.\n\nHogan WJ, Geenen JE. Biliary dyskinesia. Endoscopy 1988;20:179-183PubMedCrossRef\n\n55.\n\nKrishnamurthy S, Krishnamurthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder, and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n56.\n\nKonturek JW, Hengst K, Konturek SJ, Sito E, Stachura J, Domschke W. Physiological role of cholecystokinin in gastroprotection in humans. Am J Gastroenterol 1998;93:2385-2390PubMedCrossRef\n\n57.\n\nBoeckxstaens GE, Hirsch DP, Fakhry N, Holloway RH, D'Amato M, Tytgat GNJ. Involvement of cholecystokinin-A receptors in transient lower esophageal sphincter relaxations triggered by gastric distension. Am J Gastroenterol 1998, 93:1823-1828PubMedCrossRef\n\n58.\n\nMurphy JA, Criddle DN, Sherwood M, Chvanov M, Mukherjee R, McLaughlin E, Booth D, et al. Direct activation of cytosolic Ca2 + signaling and enzyme secretion by cholecystokinin in human pancreatic acinar cells. Gastroenterology 2008;135:632-641PubMedCrossRef\n\n59.\n\nSaluja A, Longsdon C, Garg P. Direct versus indirect action of cholecystokinin on human pancreatic acinar cells: is it time for a judgment after a century of trial? Gastroenterology 2008;135:357-360PubMedCrossRef\n\nReferences\n\n1.\n\nJaffe JH, Martin WR. Opioid analgesics and antagonists. In: Gilman AG, Rall TW, Niles AJ, Taylor P (eds) Goodman and Gilman's: The pharmacological basis of therapeutics, 8th edn. Pergamon, New York, 1990, pp 485-521\n\n2.\n\nPatwardhan RV, Johnson RF, Hoyumpa A Jr, Sheehan JJ, Desmond PV, Wilkinson GR, Branch RA, Schenker S. Normal metabolism of morphine in cirrhosis. Gastroenterology 1981;81:1006-1011PubMed\n\n3.\n\nChoy D, Shi EC, McLean RG, Hoschl R, Murray IPC, Ham JM. Cholescintigraphy in acute cholecystitis: use of intravenous morphine. Radiology 1984;151:203-207PubMed\n\n4.\n\nHelm JF, Venu RP, Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Arndorfer RC. Effects of morphine on the human sphincter of Oddi. Gut 1988;29:1402-1407PubMedCrossRef\n\n5.\n\nVenu R, Toouli J, Geenen JE, Hogan WJ, Helm J, Dodds WJ, Arndorfer RC. Effect of morphine on motor activity of the human sphincter of Oddi. Gastroenterology 1982;84:1342 (Abstract)\n\n6.\n\nJones RM, Fiddian-Green R, Knight PR. Narcotic induced choledochoduodenal sphincter spasm reversed by glucagon. Anesth Analg 1980;59:946-947PubMed\n\n7.\n\n7. Hopton DS, Torrance HB. Action of various new analgesic drugs on the human common bile duct. Gut 1967;8:296-300PubMedCrossRef\n\n8.\n\nChessick KC, Black S, Hoye SJ. Spasm and operative cholangiography. Arch Surg 1975;110:53-57PubMedCrossRef\n\n9.\n\nKrishnamurthy S, Krishnamurthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder, and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n10.\n\nJoehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg 1984;147:134-138PubMedCrossRef90047-3)\n\n11.\n\nWestlake PJ, Hershfield NB, Kelly JK, Kloiber R, Lui R, Sutherland LR, Shaffer EA. Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy? Am J Gastroenterol 1990;85:986-990PubMed\n\n12.\n\nKrishnamurthy S, Krishnamurthy GT. Cholecystokinin and morphine pharmacological intervention during 99mTc-HIDA cholescintigraphy: a rational approach. Semin Nucl Med 1996;26:16-24PubMedCrossRef80013-4)\n\n13.\n\nAchong DM, Oates E. Normal gallbladder ejection fraction after morphine augmentation. Clin Nucl Med 1999;24:837-841PubMedCrossRef\n\n14.\n\nKrishnamurthy GT, Krishnamurthy S, Brown PH. Constancy and variability of gallbladder ejection fraction: impact on diagnosis and therapy. J Nucl Med 2004;45:1872-1877PubMed\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_7(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 7. Intrahepatic Cholestasis\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nCholestasis is retention of bile within the hepatobiliary system resulting in an accumulation of bile products in the body fluids. It is divided into intrahepatic and extrahepatic types, depending upon the location of the pathology. Intrahepatic cholestasis is defined traditionally as bile retention within the hepatocytes, bile canaliculi, cholangioles, small or large bile ducts down to and including the proximal two thirds of the right hepatic and left hepatic ducts. Extrahepatic cholestasis is bile stasis due to a pathology located at the distal third of the right hepatic and left hepatic ducts and beyond, down to and including the sphincter of Oddi. The previous classification into obstructive and non-obstructive jaundice is no longer popular clinically [1].\n\nCholestasis is retention of bile within the hepatobiliary system resulting in an accumulation of bile products in the body fluids. It is divided into intrahepatic and extrahepatic types, depending upon the location of the pathology. Intrahepatic cholestasis is defined traditionally as bile retention within the hepatocytes, bile canaliculi, cholangioles, small or large bile ducts down to and including the proximal two thirds of the right hepatic and left hepatic ducts. Extrahepatic cholestasis is bile stasis due to a pathology located at the distal third of the right hepatic and left hepatic ducts and beyond, down to and including the sphincter of Oddi. The previous classification into obstructive and non-obstructive jaundice is no longer popular clinically [1].\n\nBile secretion: Formation of bile is an osmotic pressure-dependent uptake and secretory process that occurs along the basolateral and canalicular domains of the hepatocyte, respectively. Of a total of approximately 600 ml of bile produced by the liver per day, 450 ml is secreted by the hepatocytes and the remaining 150 ml by cells lining the bile canaliculi and bile ducts (Chap. 2, Fig. 1). About 50% of bile secreted by the hepatocytes (225 ml) is bile acid dependent, and the remaining 50% (225 ml) is independent of bile acid secretion. The uptake of bile acids, non-bile acid organic anions, cations, and other solutes by the hepa-tocytes from blood in the space of Disse occurs along the basolateral border. Of the several mechanisms utilized for the solute uptake, Na+-K+ ATPase pump, Na+-BS\u2212 (bile salt) co-transport, sodium-hydrogen exchange, Na-HCO3 \u2212 symporter, and organic anion endocytosis play the major roles [2]. Bile salts (taurocholate) are the most important and abundant solutes in bile. Transport of bile salts from blood into hepatocytes is mediated by the sodium-taurocholate co-transporter (NTCP) system [3]. ATPase of the basolateral border regulates the extracellular and intracellular ion concentration gradient [4].\n\n## 7.1 Imaging with Tc-99m HIDA\n\nActive transport of solutes across the canalicular membrane is the rate-limiting step in the amount of bile produced per day. The tight junction between the two adjacent hepatocytes is functionally leaky (a leaky tight junction) and allows passage of water and electrolytes from blood into the canalicular lumen. The canalicular lumen situated between two adjacent hepatocytes is about 0.75 \u03bcm in diameter, and the wall contains microvilli of 500-1,000 nm in length and 100 nm in diameter. The canaliculi and their microvilli contract and propel bile towards larger bile ducts. Secretion of large lipophilic cations (anticancer drugs, calcium-channel blockers, cyclosporin A, and other drugs) is mediated by a transporter protein called multidrug-resistance-1 P-glycoprotein (MDR1). Secretion of phosphatidylcholine is facilitated by another protein called multidrug-resistance-3 P-glycoprotein, called MDR3. Transport of organic anions, including bromosulphalein, glucuronides, and possibly Tc-99m HIDA, across the canalicular membrane is attributed to multidrug resistance protein 2 (MRP2). Endotoxin lipopolysaccharide induces cholestasis by an early retrieval followed by down-regulation of MRP2, which moves from the canalicular membrane to the interior of the cell [5]. Inhibition of contraction of the canalicular wall and microvilli results in atony and dilatation of the canaliculi, leading to intrahepatic cholestasis (Fig. 7.1.1). Tc-99m-HIDA is secreted into canalicular bile in free form, without undergoing any biotransformation during its intracellular transit. This free status can be confirmed by reinjecting Tc-99m-HIDA-labeled gallbladder bile intravenously into the same animal, reproducing the original biokinetic parameters [6]. Reduction in uptake and slow transit through the hepatocytes, and collection in the dilated canaliculi produced a low hepatic extraction fraction and prolongation of excretion half-time in a Tc-99m HIDA study.\n\nFig. 7.1.1\n\nPathogenesis of intrahepatic cholestasis. Normal canaliculi and microvilli contract and propel bile forwards. Infections, drugs, and other toxins cause bile stasis by inactivating contractile function of the bile canaliculi and microvilli\n\n### 7.1.1 Etiology of Intrahepatic Cholestasis\n\nThree types of injury are recognized as being responsible for cholestasis: (1) direct injury, (2) immunologic, and (3) cholestatic. These injuries are caused by microorganisms, poisons, drugs, and metabolic, granulomatous, veno-occlusive, ischemic, and other diseases (Fig. 7.1.2). The injury may involve the endoplasmic reticulum, lysosomes, mitochondria of the hepatocytes or the canalicular cells. In the case of drugs, the injury may be caused directly by the offending agent or by one of its metabolic products [7].\n\nFig. 7.1.2\n\nLocation of intrahepatic vs. extrahepatic cholestasis. Intrahepatic cholestasis occurs between the hepatocyte and the proximal right hepatic and left hepatic ducts. Pathology of the extrahepatic cholestasis lies between the proximal right hepatic and left hepatic ducts and the sphincter of Oddi\n\n### 7.1.2 Viral Hepatitis\n\nAll types of viral hepatitis (A, B, C, D, E, and G) cause intrahepatic cholestasis, and all produce an identical image pattern. The diagnosis is usually made by getting a detailed clinical history and by obtaining a serum hepatitis profile. Bacterial and fungal infections and toxins (mushroom poisoning) also cause intrahepatic cholestasis primarily by affecting the hepatocytes and cholangioles. The bile secretion rate is reduced, hence bile ducts and the gallbladder appear late in a Tc-99m HIDA study (Fig. 7.1.3).\n\nFig. 7.1.3\n\nHepatitis A. Diffuse radiotracer retention with no bile secretion for 1 h in a patient with hepatitis A. Gallbladder is seen at 18 h, and the intestinal activity has moved away from the field of view of the gamma camera\n\n### 7.1.3 Drugs\n\nDrugs are the most common cause of intrahepatic cholestasis, which is classified into two major types [8]: (1) hypersensitive (exudative) and (2) canalicular. The hypersensitive type is characterized by fever, anorexia, marked eosinophilia, and increased levels of serum cholesterol and alkaline phosphatase. The canalicular type is characterized by intense pruritus, associated with a normal eosinophil count and serum alkaline phosphatase level [9]. Sulfonamides, quinidine, and allopurinol are incriminated in the hypersensitivity type of intrahepatic cholestasis. Sex hormones, phenothiazines, antibiotics, (erythromycin), and nitrofurantoin are common causes of the canalicular type of intrahepatic cholestasis. The drug or one of its metabolite secreted into bile canaliculi interferes with canalicular contraction, causing intrahepatic cholestasis [10].\n\nIt is estimated that about 2% of hospitalized patients in the USA suffer from some form of intrahepatic cholestasis related to a prescription drug. Up to 1% of patients receiving chlorpromazine develop intrahepatic cholestasis [9]. Various drugs that cause intrahepatic cholestasis are listed in Table 7.1.1. Most of the drugs react with cytochrome p450 and undergo conjugation with glucuronic acid, sulfate, amino acids, or glutathione prior to elimination from the body. The cytochrome p450 system is under genetic control and produces cytotoxic effects mainly through formation of electrophiles and free radicals [11, 12]. A detailed drug history aids in identifying the offending agent responsible for intrahepatic cholestasis. A cholescintigraphic image pattern remains non-specific in intrahepatic cholestasis [13].\n\nTable 7.1.1\n\nLocalization of drug-induced intrahepatic cholestasis [9]\n\nHepatocyte (A) | Canaliculus (B) | Hepatocyte and canaliculus (A + B) | Ducts (C)\n\n---|---|---|---\n\nCarbon tetrachloride | Estrogens | Phenytoin | Benoxyprofen\n\nHalothane | Testosterone | Quinidine | Ascending cholangitis\n\nChloroform | Phenothiazine | Allopurinol | Floxuridine\n\nAmiodarone | Erythromycin | Butazolidine | -\n\nMethyldopa | Nitrofurantoin | Thiobendozole | -\n\nIsoniazide | Azathioprine | Furasemide | -\n\nKetoconazol | Cyclosporin A | Sulfonamide | -\n\nAcetaminophen | Tranquillizers | - | -\n\nRifampin | Antipsychotic agents | - | -\n\nIndomethacin | - | - | -\n\nTetracycline | - | - | -\n\nValproic acid\n\n|  |  |\n\nFlexin\n\n|  |  |\n\nNovobiocin\n\n|  |  |\n\nCocaine\n\n|  |  |\n\nFlutamide\n\n|  |  |\n\n### 7.1.4 Metabolic Causes\n\nHemochromatosis due to iron overload, Wilson's disease due to copper overload, and fatty infiltration and deficiency of several enzymes are known metabolic causes of intrahepatic cholestasis [14, 15].\n\n### 7.1.5 Alcoholic Hepatitis\n\nAlcohol is metabolized primarily in the liver and converted into acetaldehyde through the enzyme alcohol dehydrogenase. Acetaldehyde in turn is converted into acetate by the enzyme aldehyde dehydrogenase. Each gram of alcohol produces seven calories of energy. Most of the liver injury from alcohol occurs primarily due to its metabolite, acetaldehyde, whose accumulation exerts a toxic effect on the plasma membrane, tubulin, and other cytoskeletons of the hepatocyte [16]. When alcohol intake continues for many years, other toxic effects are manifested in the form of fatty infiltration, fibrosis, and ultimately cirrhosis of the liver and portal hypertension.\n\n### 7.1.6 Primary Biliary Cirrhosis (PBC)\n\nIt is a disease of unknown etiology and affects primarily the canaliculi, cholangioles, and small bile ducts. Clinically, PBC presents with pruritus and malaise accompanied by elevation of serum liver enzymes and lipoproteins. It is more common in middle-aged women than men. Serum anti-mitochondrial antibody is found in almost 100% of the patients [17]. Both planar and SPECT cholescintigraphy with Tc-99m-HIDA shows diffuse parenchymal retention with uniform prolongation of excretion half time from all regions of the liver. The extrahepatic biliary tree remains normal, a common feature for all intrahepatic cholestasis. Cholescintigraphic features enable differentiation of PBC from primary sclerosing cholangitis, where the parenchymal retention is non-uniform [18]. The gallbladder remains normal in size, but shows a reduction of CCK-8 stimulated ejection fraction. In a middle-aged woman with a positive serum antimitochondrial antibody who clinically presents with pruritus and malaise, a Tc-99m-HIDA study is confirmatory for PBC if it shows a diffuse prolongation of excretion half time and no obstruction of the extrahepatic biliary tree. A normal extrahepatic biliary tree may even preclude the need for a contrast cholangiogram to exclude primary sclerosing cholangitis, which PBC often clinically mimics [18]. Characteristic cholescintigraphic features of primary sclerosing cholangitis and primary biliary cirrhosis enable differentiation between two relatively rare conditions [18, 19].\n\n### 7.1.7 Benign Recurrent Intrahepatic Cholestasis (BRIC)\n\nBRIC is a rare disorder affecting patients in their 30s and is often found in several members of the same family. Intense pruritus with elevation of liver enzymes, accompanied by spontaneous recovery, is its characteristic feature. The extrahepatic biliary tree is normal [20]. There are no identifiable serum markers for BRIC. The hepatocytes are unable to get rid of bile acids and other organic anions from the body [21]. Uptake of Tc-99m-HIDA by the hepatocyte is normal, but secretion into bile is delayed or absent, resulting in nondelineation of the entire biliary system, often mimicking total acute common bile duct obstruction. The image pattern appears much like a radiocolloid scan without the spleen.\n\n### 7.1.8 Total Parenteral Nutrition (TPN)\n\nThe major liver enzyme abnormalities in patients with TPN are elevation of gamma glutamyl transferase, ALT, and alkaline phosphatase. Peak enzyme elevation occurs 1-4 weeks after initiation of TPN. Early pathological changes include fatty infiltration in adults and intrahepatic cholestasis in children. When TPN is continued for many years, fibrosis and cirrhosis set in [22]. Uptake of Tc-99m-HIDA by the hepatocyte is maintained, but secretion is markedly delayed or even absent, mimicking total CBD obstruction. The gallbladder is often non-visualized [23].\n\n### 7.1.9 Ischemic Hepatitis\n\nThis condition is often due to an acute reversible hypotension or cardiac failure. Following the ischemic episode there is a rapid rise in aspartate amino transferase and lactic dehydrogenase, and mild elevation of bilirubin and glucose. Liver enzyme abnormality returns to normal, usually within 8-10 days [24]. Functional abnormalities tend to be much more severe in intrahepatic cholestasis than in patients with early partial obstruction of the common bile duct [25].\n\n### 7.1.10 Acute Cholangitis\n\nAcute cholangitis clinically presents as a Charcot triad, which consists of fever with chills, jaundice, and abdominal pain, as described originally by Charcot in 1877 [26]. Obstruction of the common bile duct first initiates the process and then sustains acute cholangitis. Obstruction leads to bacterial overgrowth and reflux of infected bile from the liver into the blood stream. Up to 90% of patients may remain asymptomatic when the obstruction of the common bile duct is not critical or complete [27, 28]. Charcot triad sets in mostly when the obstruction becomes complete. Both gram-positive and gram-negative organisms are found with equal frequency. Serum bilirubin rises above 5 mg% in more than 50% of the patients. Leucocytosis is frequent (63%), and elevation of serum amylase occurs in 30% of the patients [29]. Elevation of serum bilirubin above 5 mg% is a common feature of acute cholangitis, but not of acute cholecystitis (Table 7.1.2).\n\nTable 7.1.2\n\nClinical and laboratory findings in acute cholangitis vs. acute cholecystitis [29]\n\nParameter | Acute cholangitis | Acute cholecystitis\n\n---|---|---\n\nClinical features:\n\nMean age (years) | 60 | 50\n\nMale:female | 1:1 | 3:2\n\nFever (%) | 90 | 90\n\nChills (%) | 75 | 50\n\nJaundice (%) | 95 | 30\n\nRUQ pain (%) | 80 | 95\n\nRUQ tenderness (%) | 80 | 95\n\nLaboratory findings:\n\nWBC >10,000 (%) | 70 | 70\n\nWBC >20,000 (%) | 10 | 5\n\nBilirubin >1.5 mg (%) | 95 | 30\n\nBilirubin >5.0 mg (%) | 55 | 5\n\nElevation of alkaline phosphatase (%) | 90 | 40\n\nIncrease in SGOT and SGPT (%) | 95 | 50\n\nIncrease in serum amylase (%) | 35 | 15\n\nIn the past, choledocholithiasis and postoperative stricture were the most common causes of acute cholangitis. In series reported prior to 1980, stone or postoperative stricture accounted for almost 90% of acute cholangitis; now they account for only 26%. Instru-mentation (ERCP) of the biliary tract is now the most common cause of acute cholangitis (35%), indicating a shift in the etiology of acute cholangitis in more recent years [29].\n\n### 7.1.11 Scintigraphic Features of Intrahepatic Cholestasis\n\nInjury to the hepatocyte, bile canaliculi, and small bile ducts produces a nonspecific image pattern in a Tc-99m-HIDA study. Location of the exact site of injury among these three cannot be made from the images. An etiologic diagnosis, therefore, requires a thorough knowledge of clinical presentation, liver function tests, and a serum viral profile for hepatitis. The diseases that combine the features of both intrahepatic and extrahepatic cholestasis (e.g., sclerosing cholangitis) have a very characteristic image presentation and often enable an etiologic diagnosis [18, 19].\n\nThe dose of Tc-99m-HIDA for imaging is increased to 5 and 10 mCi to compensate for a decrease in hepatocyte uptake secondary to a high serum bilirubin, which competes with Tc-99m-HIDA. The hepatic extraction fraction decreases and excretion half time increases in direct proportion to an elevation of serum bilirubin (Fig. 7.1.4). Delayed images at 4 or 24 h are necessary to show intestinal activity, which establishes patency of the bile duct. In a patient who presents clinically with a Charcot triad, nonvisualization of the gallbladder with features of intrahepatic cholestasis in a TC-99m-HIDA study suggests acute cholangitis (Fig. 7.1.5).\n\nFig. 7.1.4\n\nCholescintigraphic features of intrahepatic cholestasis. Hepatocytes show decreased extraction and delayed excretion of Tc-99m-HIDA. Images are shown between 20 and 36 min (a). Hepatic extraction is only 28% (normal, 92-100%), and T 1\/2 excretion is 278 min (normal, 11-33 min) (b)\n\nFig. 7.1.5\n\nAcute cholangitis secondary to acute cholecystitis. The gallbladder is non-visualized due to obstruction of the cystic duct, and there is diffuse retention at 4 and 16 h. Common bile duct is patent and allows bile entry into small intestine\n\n## 7.2 Imaging with Tc-99m Galactosyl Human Serum Albumin\n\nIdentification of unique asialoglycoprotein (ASGP) receptors on the plasma membrane of the hepatocyte [1] and introduction of technetium-99m-DTPA-galactosyl-human-serum albumin (Tc-99m GSA), which binds to it, allow non-invasive functional imaging and quantification. Asialoglycoprotein receptor concentration on the plasma membrane is an indicator of the functional integrity of the hepatocyte. The quantity of Tc-99m GSA uptake correlates inversely with blood retention of indocyanin green [2]. Liver uptake of Tc-99 GSA decreases in patients with chronic hepatitis, cirrhosis, cholangiocarcinoma, hepatocellular cancer, metastasis, fulminant hepatic failure, and space-occupying benign lesions of the liver [2-5].\n\nData collection and analysis: Most of the clinical studies reported in the literature are from Japan, and the agent is not available in most other countries, including the United States. Functional imaging and quantification require standardization to keep the variables to a minimum. Patient fasting, which is not necessary during imaging with Tc-99m-S-colloid, is very essential for imaging with Tc-99m GSA, because the uptake may be variable due to postprandial hyperperfusion of the GI tract. After 4-6 h of fasting, the patient is positioned supine underneath a gamma camera (single, double, or a triple head) fitted with a low-energy, high-resolution, parallel-hole collimator that is positioned anterior to the liver. Sequential anterior planar images (128 \u00d7 128) at one frame per 30 s for 20 min are obtained immediately after a bolus injection of 5 mCi Tc-99m GSA (185 MBq) into the antecubital vein. Immediately after the planar images, SPECT data are acquired on a 128 \u00d7 128 \u00d7 16 computer matrix for 64 stops at 10 s per stop at 5.6\u00b0 intervals [2]. The spectrometer is set for 140 keV at a 20% window. The liver uptake index at 15 min is calculated as described in Chap. 5.\n\nSome authors express uptake as hepatic GSA clearance using the Patlak plot method and generate functional images of clearance [3, 4]. The receptor index decreases in patients with chronic hepatitis and cirrhosis (Fig. 7.2.1). Since the cells other than the hepatocytes do not take up any Tc-99m GSA, preoperative imaging allows accurate measurement and prediction of residual liver function postoperatively after resection of hepatocellular carcinoma, cholangiocarcinoma, and metastatic liver tumors (Fig. 7.2.2). It is not known at this time if this functional parameter can serve as an ideal marker for end-stage liver disease and timing of liver transplantation.\n\nFig. 7.2.1\n\nRelationship between Tc-99m GSA receptor index and liver disease. Normal hepatocytes rich in ASGP receptors show high index. Reduction of Tc-99m GSA receptor index occurs in patients with chronic hepatitis and cirrhosis of liver [4]. GSA galactosyl human serum albumin\n\nFig. 7.2.2\n\nAbsence of Tc-99m GSA uptake by tumors. CT with contrast shows dilatation of bile ducts in the left lobe (a, b, arrow) of a patient with cholangiocarcinoma. T2-weighted MR shows hyper-intensity of left lobe bile ducts (c, d, arrow). Liver SPECT shows no uptake of Tc-99m GSA (e) by the left lobe of. GSA galactosyl human serum albumin [3]\n\nReferences\n\n1.\n\nSherlock S, Dooley J (1997) Cholestasis. In: Diseases of the liver and biliary system, 10th edn. Blackwell Science Inc, Malden, MA, pp 217-237\n\n2.\n\nTrauner M, Meier PJ, Boyer JL. Molecular pathogenesis of cholestasis. N Eng J Med 1998;339:1217-1227CrossRef\n\n3.\n\nHagenbuch B, Meier PJ. Sinusoidal (basolateral) bile salt uptake system of hepatocytes. Semin Liver Dis 1996;16:129-136PubMedCrossRef\n\n4.\n\nSellinger M, Barrett C, Malle P, Gordon ER, Boyer JL. Cryptic Na+, K(+ ) -ATPase activity in rat liver canalicular plasma membrane: evidence for its basolateral origin. Hepatology 1990;11:223-229PubMedCrossRef\n\n5.\n\nKubitz R, Wettstein M, Warskulat U, Haussinger D. Regulation of the multidrug resistance protein 2 in the rat liver by lipopolysaccharide and dexamethasone. Gastroenterology 1999;116:401-410PubMedCrossRef70138-1)\n\n6.\n\nLoberg MD, Cooper M, Harvey E, Callery P, Faith W. Development of new radiopharmaceuticals based on N-substitution of iminodiacetic acid. J Nucl Med 1976;17:633-638PubMed\n\n7.\n\nSherlock S. Patterns of hepatic injury in man. Lancet 1982;1(8275):782-786PubMedCrossRef91822-0)\n\n8.\n\nLee WM. Drug-induced hepatotoxicity. N Engl J Med 1995;333:1118-1128PubMedCrossRef\n\n9.\n\nSherlock S, Dooley J (1997) Drugs and the liver. In: Diseases of the liver and biliary system, 10th edn. Blackwell Science Inc, Malden, MA, pp 337-369\n\n10.\n\nCorcoran GB, Racz WJ, Smith CV, Mitchell JR. Effects of N-acetylcysteine on acetaminophen covalent binding and hepatic necrosis in mice. J Pharmacology Exp Ther 1985;232:864-872\n\n11.\n\nSmith CV, Hughes H, Mitchell JR. Free radicals in-vivo. Covalent binding to lipids. Mol Pharmacol 1984;26:112-116PubMed\n\n12.\n\nSeeff LB, Cuccherini BA, Zimmerman HJ, Adler E, Benjamin SB. Acetaminophen hepatotoxi-city in alcoholics. Ann Intern Med 1986;104:399-404PubMed\n\n13.\n\nLieberman DA, Krishnamurthy GT. Intrahepatic versus extrahepatic cholestasis. Discrimination with biliary scintigraphy combined with ultrasound. Gastroenterology 1986;90:734-743PubMed\n\n14.\n\nPowell LW, Halliday JW, Cowlishaw JL. Relationship between serum ferritin and total body iron stores in idiopathic hemochromatosis. Gut 1978;19:538-542PubMedCrossRef\n\n15.\n\nBearn AG. Wilson's disease. An inborn error of metabolism with multiple manifestations. Am J Med 1957;22:747-753PubMedCrossRef90125-0)\n\n16.\n\nLauterburg BH, Bilzer H. Mechanisms of acetaldehyde hepatotoxicity. J Hepatol 1988;7:384-390PubMedCrossRef80012-6)\n\n17.\n\nWalker JG, Doniach D, Roitt IM, Sherlock S. Serological tests in diagnosis of primary biliary cirrhosis. Lancet 1965;1:827-831PubMedCrossRef91372-3)\n\n18.\n\nKeeffe EB, Lieberman DA, Krishnamurthy S, Krishnamurthy GT, Gilbert SA. Primary biliary cirrhosis: Tc-99m-HIDA planar and SPECT scanning. Radiology 1988;166:143-148PubMed\n\n19.\n\nRodman CA, Keeffe EB, Lieberman DA, Krishnamurthy S, Krishnamurthy GT, Gilbert SA, Eklem MJ. Diagnosis of sclerosing cholangitis with Tc-99m-labeled iminodiacetic acid planar and single photon emission computed tomographic scintigraphy. Gastroenterology 1987;92:777-785PubMed\n\n20.\n\nLesser PB. Benign familial recurrent intrahepatic cholestasis. Am J Dig Dis 1973;18:259-264PubMedCrossRef\n\n21.\n\nMinuk GY, Shaffer EA. Benign recurrent intrahepatic cholestasis. Evidence for an intrinsic abnormality in hepatocyte secretion. Gastroenterology 1987;93:1187-1193PubMed\n\n22.\n\nQuigley EM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complications of total parenteral nutrition. Gastroenterology 1993;104:286-301PubMed\n\n23.\n\nShuman WP, Gibbs P, Rudd TG, Mack LA. PIPIDA scintigraphy for cholecystitis: False-positives in alcoholism and total parenteral nutrition. Rm J Roentgenol 1982;138:1-5\n\n24.\n\nGitlin N, Serio KM. Ischemic hepatitis: Widening horizons. Am J Gastroenterol 1992;87:831-836PubMed\n\n25.\n\nLima J, Brown R, Krishnamurthy S, Krishnamurthy GT. Reliability of quantitative Tc-99m-mebrofenin scintigraphy (QMS) in the diagnosis of intrahepatic cholestasis(IHC). J Nucl Med 1991;32:976-977\n\n26.\n\nCharcot JM: Lecons sur les maladies du foie des voies biliaires at des veins. Paris Faculte' de medecine. Recueilleies et publices. Bournelle et Senestre, 1877\n\n27.\n\nFlemma RJ, Flint LM, Osterhout S. Bacteriologic studies of biliary tract infection. Ann Surg 1967;166:563-572PubMedCrossRef\n\n28.\n\nPitt HA, Postier RG, Cameron JL. Biliary bacteria: significance and alterations after antibiotic therapy. Arch Surg 1982;117:445-450PubMedCrossRef\n\n29.\n\nPitt HA, Cameron JL. Acute cholangitis. In: Way LW, Pelligrini CA, eds. Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 295-313\n\nReferences\n\n1.\n\nSteer CJ. Receptor-mediated endocytosis: mechanisms, biologic function, and molecular properties. In: Zakim D, Boyer TD (eds) Hepatology. A textbook of liver disease. WB Saunders, Philadelphia, 1996, pp 149-214\n\n2.\n\nUetake M, Koizumi K, Yagawa A, Nogata H, Tezuka T, Kono H, Ozawa T, Kusano T, Miyaburuko M, Hosaka M. Use of Tc-99m DTPA galactosyl human serum albumin to predict postoperative residual liver function. Clin Nucl Med 1999;24:428-434PubMedCrossRef\n\n3.\n\nHwang E, Taki J, Shuke N, Nakajima K, Kinuya S, Konishi S, Michigishi T, Aburano T, Tonami N. Preoperative assessment of residual hepatic functional reserve using Tc-99m-DTPA-galactosyl-human-serum albumin dynamic SPECT. J Nucl Med 1999;40:1644-1651PubMed\n\n4.\n\nSasaki N, Shiomi S, Iwata Y, Nishiguchi S, Kuroki T, Kawabe J, Ochi H. Clinical usefulness of scintigraphy with Tc-99m-galactosyl-human serum albumin for prognosis of cirrhosis of the liver. J Nucl Med 1999;10:1652-1656\n\n5.\n\nKoizumi K, Monzawa S, Shindo C, Hosaka M. Primary hepatic amyloidosis well delineated by Tc-99m DTPA galactosyl HSA liver SPECT. Clin Nucl Med 1999;24:271-273PubMedCrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_8(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 8. Extrahepatic Cholestasis\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nExtrahepatic cholestasis is the retention of bile products within the body secondary to a pathology located outside of the liver parenchyma, usually beyond the middle third of the right and left hepatic ducts, including the common hepatic and common bile ducts. Causes of extrahepatic cholestasis can be divided into four major categories depending upon the exact site of location of the pathologic process: (1) intraluminal, (2) wall thickening, (3) extrinsic compression, and (4) combined intrahepatic and extrahepatic causes (Table 8.1.1). The mode of clinical presentation depends very much upon the duration, degree of obstruction, and exact site of pathology\n\nExtrahepatic cholestasis is the retention of bile products within the body secondary to a pathology located outside of the liver parenchyma, usually beyond the middle third of the right and left hepatic ducts, including the common hepatic and common bile ducts. Causes of extrahepatic cholestasis can be divided into four major categories depending upon the exact site of location of the pathologic process: (1) intraluminal, (2) wall thickening, (3) extrinsic compression, and (4) combined intrahepatic and extrahepatic causes (Table 8.1.1). The mode of clinical presentation depends very much upon the duration, degree of obstruction, and exact site of pathology.\n\nTable 8.1.1\n\nCauses of extrahepatic cholestasis\n\n(1) Intraluminal causes\n\n---\n\n(a) Gallstones (choledocholithiasis)\n\n(b) Hemobilia (blood clots)\n\n(c) Parasites (round worm)\n\n(d) Inspissated bile or concretions\n\n(e) Miscellaneous causes\n\nTumor emboli\n\nPapilloma\n\nAdenomyoma\n\nFibroma\n\nCystedenoma\n\n(2) Wall thickening\n\n(a) Benign (stricture)\n\n(b) Malignant (cholangiocarcinoma)\n\n(3) Combined intrahepatic and extrahepatic cholestasis\n\nSclerosing cholangitis\n\n(4) Extrinsic compression\n\nNormally, the biliary structures appear in a sequential pattern on a Tc-99m HIDA study; the right and left hepatic ducts appear first, followed by the common hepatic duct, gallbladder, common bile duct, and duodenum. Quantitative parameters show the normal hepatic extraction fraction and excretion half-time (Fig. 8.1.1). Ducts proximal to the right and left hepatic ducts are not usually seen clearly. They become prominent only when there is obstruction to bile flow distally.\n\nFig. 8.1.1\n\nNormal cholescintigraphy. Liver shows excellent uptake and excretion of Tc-99 HIDA. The right hepatic duct and left hepatic ducts, common hepatic duct, and gallbladder are seen early (top left), followed by the common bile duct and duodenum (top right). Hepatic extraction fraction (HEF) and excretion values are normal (bottom)\n\n## 8.1 Intraluminal Causes\n\n### 8.1.1 Clinical Presentation\n\nIntraluminal obstruction is usually caused by gallstones, inspissated bile, parasites, blood clots, or pedunculated tumors arising from the wall (Table 8.1.1). The onset of signs and symptoms depends upon the degree and duration of obstruction. A patient with acute complete obstruction of the common bile duct usually presents with sudden onset of epigastric or right upper quadrant pain, which often radiates to the chest, shoulder, or interscapular region in the back. When complete obstruction persists for longer than 3 days, acute cholangitis may set in with onset of clinical Charcot triad, which consists of fever with chills, jaundice, and biliary colic. The time for the serum liver function tests to become abnormal after the onset of obstruction depends upon the presence or absence of the gallbladder; in the absence of the gallbladder, the liver function tests become abnormal within 4-6 h, whereas they may take as long as 48-72 h with an intact gallbladder. In presence of the gallbladder, the liver function tests become abnormal much earlier when the level of obstruction lies proximal to the junction of the cystic duct with the common hepatic duct than when the obstruction lies distal to their junction. Patients with partial bile duct obstruction usually make a benign clinical presentation.\n\n### 8.1.2 Choledocholithiasis\n\nFormation of gallstones is initiated with secretion of lithogenic bile, which is the first indication of a breakdown of normal mechanisms responsible for keeping bile solutes in solution [1]. The majority of gallstones are composed of cholesterol, and few consist of bile pigments. The stone may form de novo within the common bile duct (primary stone), or it may originate in the gallbladder or liver and then move down into the common bile duct (secondary stone). About 85-90% of all stones are secondary, and the rest are primary. Secondary stones are more common in western China, Hong Kong, and other Asian countries. In certain ethnic groups, as much as 50% of the CBD stones are primary [2].\n\n### 8.1.3 Pathophysiology of Bile Duct Obstruction\n\nThe pathophysiologic changes that follow bile duct obstruction depend upon several factors, of which the mode of onset (sudden vs. gradual) and severity (partial vs. complete) are the most important. Much of our knowledge about post-obstructive pathophysiologic changes is derived from ligation of the common bile duct in experimental animals. Following complete ligation of the common bile duct in the rat, the serum alkaline phosphatase and alanine aminotransferase (ALT) levels begin to rise rapidly within 5 h, reach peak levels by 20 h, and later begin to decline to reach a steady state by 4 days. Serum bilirubin begins to rise by 5 h, reaches peak levels by 4 days, and then begins to decline to reach a new steady state level, which is often set at a much lower level than the peak. The serum alkaline phosphatase level begins to rise and reach peak levels much earlier than the serum bilirubin level. The number of bile canaliculi doubles in 5 h and then begins to decrease after 4 days. The hepatocytes shrink in size and reach a steady state by 2 days. Post-obstructive shrinkage of the hepatocytes and swelling of bile canaliculi together lead to a bile leak into the blood stream [3]. Bile flow decreases to 65% of the basal value when the pressure within the ducts exceeds 16-17 cm of water, and the bile secretion ceases completely when the pressure rises above 20-30 cm of water [4, 5].\n\nIn piglets, the serum levels of aspartate aminotransferase (AST), ALT, alkaline phosphatase, total bilirubin, and direct bilirubin more than double by 24 h after ligation of the common bile duct. Elevation of bile duct pressure occurs much faster than the dilatation of the common bile duct. Common bile duct pressure rises from a basal 7.2 cm H2O to 19.0 cm H2O, whereas the duct diameter increases from a basal 5.6 mm to 9.8 mm, and the bile concentration of ciprofloxacin reduces to one-seventh of the original concentration, emphasizing the importance of pressure changes on the rate of secretion of bile and bile components [6].\n\nIn dogs, liver function tests may remain normal for up to 3 h, but become abnormal by 24 h following the complete ligation of the common bile duct. The hepatocyte uptake and secretion into bile of Tc-99m-HIDA continue for up to 3 h post-ligation, enabling cholescintigraphic delineation of the gallbladder and hepatobiliary tree, proximal to the site of obstruction. The hepatobiliary tree often simulates features seen in a physiologically tight sphincter of Oddi, where all of the hepatic bile may be diverted into the gallbladder, and none enters the duodenum. By 24 h, the hepatocytes continue to concentrate Tc-99m-HIDA, but are unable to secrete it into bile, which results in total non-visualization of the entire biliary tree [7]. Scintigraphy then appears much like a radiocolloid liver scan without the spleen.\n\n### 8.1.4 Cholescintigraphic Features of Total Obstruction of the Common Bile Duct\n\nThe cholescintigraphic features merely reflect the pathophysiological changes that follow obstruction of the common bile duct as described above. The normal mean secretory pressure of the hepatocytes in humans is about 35 cm of water, the mean pressure within the gallbladder is 10 cm, in the common bile duct (CBD) is 12 cm, and in the sphincter of Oddi is 15 cm of water [8]. Bile secretion continues at a normal rate as long as all these normal pressure differentials are maintained. Bile secretion begins to decrease when CBD pressure begins to rise, and the secretion ceases completely when CBD pressure equals or exceeds the secretory pressure of the hepatocytes [9]. Normally about 30% of the hepatic bile that enters the duodenum during fasting enables cholescintigraphic visualization of the small intestine within 60 min in about 80% of the subjects. In the remaining 20% of normal subjects, the duodenum is not seen due to entry of all of the hepatic bile into the gallbladder [10-12]. The flow of the entire hepatic bile into the gallbladder and none into the duodenum during fasting in normal subjects is simply a reflection of an increase in the tonus of the sphincter of Oddi.\n\nAfter 6-8 h of fasting, a normal gallbladder is usually filled to its full capacity of 50 ml, and its ability to accommodate a constant inflow of hepatic bile (about 0.3 ml min-1) is due to absorption of an equal volume of water through the wall. When only the gallbladder is seen by 60 min, but not the duodenum, the reasons for non-visualization may include a physiologically tight sphincter of Oddi or a complete obstruction of the common bile duct. After CCK-8 infusion, the gallbladder contracts and empties bile normally into the duodenum in the case of a physiologically tight sphincter of Oddi [10], but no bile enters the duodenum in the case of complete obstruction of the CBD [13, 14].\n\n### 8.1.5 Bile Duct Obstruction for Less than 48 Hours (Hyper Acute)\n\nA gallstone dislodged from either the gallbladder or intrahepatic ducts or an acute edematous acute pancreatitis is the most common cause of acute complete obstruction of the CBD. A dislodged gallstone usually gets trapped just above or within the sphincter of Oddi, the narrowest part of the CBD. The time interval between the onset of acute CBD obstruction and cessation of hepatic bile secretion is variable, depending upon the level (below or above the entrance of the cystic duct into the common hepatic duct), degree (complete or partial), and presence or absence of the gallbladder. Following acute complete obstruction of the CBD, the liver continues to secrete bile slowly for 24-48 h. The uptake of Tc-99m-HIDA remains relatively high (Fig. 8.1.2a), but the secretion slows, resulting in delayed visualization of biliary structures (Fig. 8.1.2b, c). The gallbladder and bile ducts (proximal to the level of obstruction) are seen, but not the duodenum. Quantitative parameters show a normal hepatic extraction fraction and prolongation of the excretion half-time (Fig. 8.1.3). Administration of CCK-8 increases bile secretion and flow by the intrahepatic bile ducts and forces the hepatic bile to enter the gallbladder; also, there is no bile entry into the duodenum. Due to high pressure in the common bile duct, the gallbladder fails to empty in response to CCK-8 infusion. Some patients show an immediate bile flow into the gallbladder, while others may take a few more minutes after CCK-8 (Fig. 8.1.4). Filling of the gallbladder in response to CCK-8 is a physiological paradox and confirmatory feature for acute total obstruction of the common bile duct. The only other condition that shows a similar feature is spasm of the sphincter of Oddi (Chap. 10).\n\nFig. 8.1.2\n\nHyperacute CBD obstruction (less than 48 h). Obstruction of less than 48 h shows excellent uptake of Tc-99m-HIDA by the hepatocytes. Bile secretion is delayed (a). The gallbladder is seen at 4.5 h (b). Cholangiogram confirms obstruction due to stone at distal end of non-dilated CBD (c)\n\nFig. 8.1.3\n\nEffect of acute complete duct obstruction on functional parameters. In acute obstruction, hepatic extraction fraction (HEF) remains normal, but excretion half-time increases. Gallbladder appears late and fills more after CCK-8. There no bile entry into the duodenum\n\nFig. 8.1.4\n\nParadoxical filling of the gallbladder. Cholecystokinin administration in patients with hyperacute complete CBD obstruction increases bile secretion by intrahepatic ducts and forces the hepatic bile to enter the gallbladder, instead of eliciting its emptying. In patient no. 1, gallbladder fills in immediately, and it takes few more minutes to fill in patient no. 2. Gallbladder size and counts increase after CCK-8\n\n### 8.1.6 Obstruction for More than 48 Hours\n\nExtraction of Tc-99m-HIDA by the hepatocytes is maintained at a relatively high level, but the secretion into bile ceases completely. Cholescintigraphy obtained after 48 h of obstruction, therefore, shows good liver uptake without delineation of any of the biliary structures (Fig. 8.1.5a). Hepatic extraction fraction values in the range of 50-85% are common between 2 and 5 days, and the values fall below 50% when total obstruction persists for more than 5 days (Fig. 8.1.5b). Cholescintigraphic images and quantitative parameters accurately reflect histopathological changes of bile duct obstruction as described above in experimental animals. In the rat, for example, a mean HEF value of 97% before bile duct ligation falls to 70% by 2 h and 16% by 48 h after complete ligation of the common bile duct. Long-standing CBD obstruction ultimately compromises hepatocyte functioning and results in a low HEF value [15-17].\n\nFig. 8.1.5\n\nComplete obstruction of the duct for more than 48 h. There is uptake by the hepatocytes, but no secretion of the radiotracer into bile. The entire biliary tree and the small intestine are nonvisualized for up to18 h (top). Hepatic extraction fraction (HEF) is reduced to 28% and excretion half-time shows infinity (bottom)\n\nBoth bilirubin and Tc-99m-HIDA share a common organic anion receptor-mediated endocytosis for uptake by the hepatocyte. When serum levels are high, bilirubin occupies most of the available receptor sites and blocks the uptake of Tc-99m-HIDA by the hepatocytes and produces a low HEF value. Technetium-99m mebrofenin competes with bilirubin for hepatocyte uptake much better than Tc-99m-labeled diisopropyl IDA (DISIDA), diethyl IDA, para-isopropyl-IDA (PIPIDA), or para-butyl IDA. The reciprocal relationship between Tc-99m-HIDA uptake and serum bilirubin level is well documented in both animal and human studies [17, 18]. In a patient with acute onset of biliary pain, a HEF value above 65% combined with cessation of bile secretion (non-visualization of the bile ducts and gallbladder) is a reliable indicator of a pure biliary disease (complete CBD obstruction), whereas an HEF value below 50% under similar circumstances indicates accompanying severe hepatocellular damage [19, 20].\n\n### 8.1.7 Partial Obstruction\n\nPatients with a partial bile duct obstruction usually present with mid-abdominal or right upper quadrant pain. Elevation of serum alkaline phosphatase or gamma glutamyl transferase is the earliest biochemical abnormality. Cholescintigraphic features of partial CBD obstruction include normal hepatic extraction fraction, bile stasis in ducts proximal to obstruction, and prolongation of excretion half-time values (Fig. 8.1.6a). Intestinal acti-vity may be seen within 60 min or delayed slightly in a few of the patients. Diagnosis of obstruction of the common bile duct can neither be excluded nor confirmed solely on the basis of the appearance or non-appearance of the duodenum, respectively.\n\nFig. 8.1.6\n\nPartial obstruction of the common bile duct. The uptake of the radiotracer remains normal, but the excretion is slowed. Common bile duct is poorly visualized. There is bile pooling in the intrahepatic ducts. The gallbladder and small intestine are seen (top). Hepatic extraction fraction (HEF) remains normal, but the excretion half-time increases to 237 min (bottom)\n\nQuantitative parameters indicate the severity of the disease, and an etiological diagnosis (biliary vs. hepatocellular) is usually made in combination with the image pattern. A mean HEF value of 94% was obtained in 14 patients with isolated partial CBD obstruction and a value of 96% in 13 patients with sclerosing cholangitis. In contrast, 14 patients with cirrhosis had a mean HEF of 60%. Hepatic extraction values below 30% are more common in patients with Child class C than class A and B cirrhosis [20]. Complete CBD obstruction of longer than 5-day duration, however, compromises hepatocyte function and lowers HEF values to levels seen in patients with cirrhosis [15]. Excretion half-time values begin to increase immediately after the onset of CBD obstruction and reach values as high as 200-300 min (Fig. 8.1.6b). Many patients with critical obstruction may show only an up-slope to the curve with T1\/2 value of infinity [15, 20]. Cholescintigraphic features of partial CBD obstruction are non-specific, and an etiological diagnosis (stone vs. stricture) can be made only in a few of the patients based solely on an image pattern. A gallstone lodged in the CBD may cause a filling defect with a convex superior border enabling an etiological diagnosis in a few of the patients [21].\n\n### 8.1.8 Functional Recovery Pattern\n\nThe liver recovers its function rapidly after relief of CBD obstruction. Generally, serum bilirubin values decline much more rapidly than serum alkaline phosphatase levels, a feature that is the reverse of what takes place during the onset of obstruction [3]. Serum bilirubin levels decline by 50% of the preoperative value within 2 days, reach 25% by 1 week, and 10% by 3 weeks (Fig. 8.1.7). By 10 days after the relief of obstruction, the serum bilirubin level declines to 25%, whereas the alkaline phosphatase level may decline to only 60% of the preoperative value [9].\n\nFig. 8.1.7\n\nRecovery of liver function. After relief of bile duct obstruction, bilirubin level declines much more rapidly than serum alkaline phosphatase. Serum bilirubin declines to 50% of preoperative value in 2 days, to 25% value by 1 week, and to less than 10% by 3 weeks. Alkaline phosphatase level, however, remains above 50% of the preoperation value at the end of 1 week [8]\n\n### 8.1.9 Hemobilia\n\nThis is a unique name that combines both Greek (haima, meaning blood) and Latin (bilis, meaning bile) to convey the exact meaning of the pathologic process: a mixture of blood and bile. Blunt and penetrating liver trauma is the most common cause, followed by iatrogenic factors secondary to instrumentation or surgery on or around the biliary tract. Liver biopsy, endoscopic retrograde cholangiopancreatography (ERCP), or transhepatic cholangiography is the most common iatrogenic cause [22]. Gunshot injury is becoming a more common cause in recent years because of the rapid rise in gun-related crimes. Penetrating injury may rupture an artery or a vein and the accompanying bile duct, establishing a direct communication between blood and bile.\n\n### 8.1.10 Parasites\n\nObstruction of the common bile duct due to parasites is usually caused by migration of the round worm (Ascaris Lumbricoids) through the sphincter of Oddi. A female round worm is about 25-35 cm in length and 3-6 mm in diameter. A male worm is slightly smaller in size, measuring 15-30 in length and 2-4 mm in diameter. The upper small intestine is the usual habitat, and often live worms are passed in the stool. When the worm migrates into the common bile duct, the usual symptoms of bile duct obstruction (right upper quadrant pain, vomiting, fever, and jaundice) occur. A history of passing the parasites in the stool is the most helpful diagnostic clue. Ova are found on the microscopic examination of the stool specimen [23]. The appearance of a \"bull's eye\" sign in an ultrasound study of the common bile duct suggests a round worm, especially in countries with a high prevalence of ascariasis [24].\n\n### 8.1.11 Miscellaneous Causes\n\nTumor emboli from cholangiocarcinoma (near the bifurcation), foreign bodies, inspissated bile, papilloma, adenomyoma, fibroma, cystedenoma, and giant cell tumors are some of the rare causes of intraluminal obstruction [25].\n\n### 8.1.12 Segmental Biliary Obstruction\n\nAn intraluminal segmental or lobar bile duct obstruction produces a characteristic scintigraphic pattern. Obstruction due to a gallstone is more common in China, Hong Kong, and other Far Eastern countries than in the western hemisphere [26]. The scintigraphic pattern depends upon whether the obstruction is partial or complete. In the case of a partial segmental bile duct obstruction, the uptake and excretion of Tc-99m-HIDA by the hepatocytes into hepatic bile continues manifesting a bile pool within the duct, proximal to the level of obstruction [27]. A focal retention is seen over the involved segment, while the rest of the normal liver clears most of its radioactivity in the images obtained between 45 and 60 min after injection [28]. In the right lobe, where the segmental ducts are positioned anterior and posterior, a right lateral view is necessary to identify the obstructed duct. In the case of the left lobe, where the segmental ducts are positioned medial and lateral, an anterior view image alone will suffice to identify the obstructed duct. When the segmental or area duct obstruction is complete and persists for a longer duration, uptake of Tc-99m-HIDA decrease or ceases completely, resulting in a filling defect.\n\n### 8.1.13 Measurement of Duct Size on Cholescintigraphy\n\nMeasurement of actual duct size from the cholescintigraphic images is prone to inaccuracy due the effect of specific activity, scatter, and pooling of radiolabeled bile within the biliary system. An in-vitro experiment (Fig. 8.1.8) clearly illustrates the effect of changing of the dose or intensity of image settings on duct size. A 4-mm internal diameter tube is measured in different sizes when the dose and\/or intensity settings are changed. High specific activity hepatic bile in a normal subject or bile pooling within the duct in a patient with distal bile obstruction increases the photon scatter, depicting the duct as though it is dilated when in actuality it is not. Ultrasound is far superior for measurement of ductal dilatation. Cholescintigraphy supplements contrast cholangiopancreatography (ERCP) when it fails to identify the intrahepatic segmental duct obstruction primarily because of lack of retrograde flow of the contrast [26, 29]. Magnetic resonance cholangiopancreatography (MRCP) is an emerging new technology that may eventually replace ERCP in some patients with obstruction of the extrahepatic biliary tree. Magnetic resonance does not require any contrast agent to visualize the bile ducts, but depends upon ductal dilatation to be able to detect the level of obstruction [30, 31].\n\nFig. 8.1.8\n\nEffect of bile pooling on duct size. Measurement of duct size from cholescintigraphy is subject to error due to the effect of the scatter and image intensity (I). Numbers 1-4 denote increase in radioactivity. A 4-mm internal diameter tube appears at various sizes depending upon activity and intensity (I) settings\n\n## 8.2 Wall Thickening\n\nWall thickening occurs gradually over weeks or months before causing impediments to bile flow because of narrowing of the lumen. Wall thickening may be caused by a benign or malignant cause.\n\n### 8.2.1 Benign Causes\n\n#### 8.2.1.1 Stricture\n\nMany conditions that cause benign stricture are listed in Table 8.2.1. Wall injury that leads to benign stricture occurs more commonly following a diagnostic or therapeutic instrumentation of the biliary tree. Most strictures occur at the middle of the common hepatic duct, which lies directly across the point of ligation of the cystic duct during an open or laparoscopic cholecystectomy [1]. Laparoscopic cholecystectomy, which has almost replaced open surgical cholecystectomy, is the most common cause of benign stricture [2]. Small gallstones migrating from either the gallbladder or liver may temporarily lodge in the common bile duct and cause constant irritation and subsequent stricture formation. Ischemia [3], infusion of chemotherapy agents [4], infection, radiation [5], chronic pancreatitis [6], and liver transplantation [7] are other well-established causes of benign stricture.\n\nTable 8.2.1\n\nCauses of benign stricture of the bile duct\n\n(1) Open cholecystectomy\n\n---\n\n(2) Laparoscopic cholecystectomy\n\n(3) Migrating stones\n\n(4) Ischemia\n\n(5) Hepatic intra-arterial chemotherapy\n\n(6) Radiation\n\n(7) Infection\n\n(8) Chronic pancreatitis\n\n(9) Liver transplantation\n\n(10) Blunt or penetrating trauma\n\n#### 8.2.1.2 Pathophysiology\n\nThe pathophysiological changes that follow a benign stricture are quite different from those that occur after an intraluminal obstruction. In contrast to an intraluminal obstruction, which occurs suddenly, stricture formation takes months or years after the initiating injury. Post-transplant CBD stricture occurs at or just above the anastomotic site in 10-20% of patients with liver transplantation. Duct ischemia prior to transplantation is responsible for the stricture [7]. The cause of benign stricture in non-transplant patients often remains unknown.\n\n#### 8.2.1.3 Clinical Features\n\nThe clinical presentation of benign stricture often remains vague for many weeks or months because of its slow progression. Intermittent upper abdominal pain is the most common presenting symptom. Elevation of serum alkaline phosphatase or transaminase is the earliest liver function abnormality, followed by elevation of serum bilirubin, especially when the stricture becomes critical with dilatation of the bile duct.\n\n#### 8.2.1.4 Cholescintigraphic Diagnosis\n\nEarly in the course of benign stricture, the uptake (HEF) and excretion of Tc-99m-HIDA by the hepatocytes are maintained within normal range, but the bile flow through the stricture is reduced (Fig. 8.2.1a). The reduction in bile flow leads to bile stasis within the intra-hepatic ducts with delineation of the segmental and area ducts (Fig. 8.2.1b). There is an increase in excretion half-time, which serves as a quantitative measure of the degree of obstruction (Fig. 8.2.1c). The delay in gallbladder filling may indicate an increase in its intra-luminal pressure. The distal common bile duct initially shows a smooth tapering towards the stricture, but this appearance changes when the duct above the stricture dilates (Fig 8.2.1d). The stricture of the common bile duct diverts most of the hepatic bile to enter the gallbladder, and very little bile enters the duodenum [8]. The hepatic extraction fraction remains high in early stricture, but begins to fall when the obstruction becomes severe and persists for a longer duration [9].\n\nFig. 8.2.1\n\nEarly benign stricture. Liver shows excellent uptake, but slightly delayed secretion of Tc-99m HIDA into bile (a). Later, there is intense bile pooling within the intrahepatic ducts (b, c). Common bile duct and the gallbladder appear late, indicating high pressure within them. There is smooth tapering of the CBD towards the stricture (d)\n\nLow extraction fraction with complete cessation of bile secretion occurs in critical stenosis with serum bilirubin levels above 10 mg% (Fig. 8.2.2.).\n\nFig. 8.2.2\n\nCBD critical stricture. Bile secretion ceases and the bile ducts, gallbladder, and intestine are not seen even at 24 h (top). The hepatic extraction decreases and excretion T1\/2 increases (bottom left). Cholangiogram confirms critical stenosis of the common bile duct (bottom right)\n\nUltrasound is used frequently for the diagnosis, and its accuracy depends very much upon the presence or absence of ductal dilatation [10]. A normal common bile duct usually measures up to 10 mm in diameter, and the ultrasound is unable to detect the stricture when the dust size remains within the normal range (Fig. 8.2.3). Ultrasound accuracy, however, increases when the diameter of the common bile duct exceeds 10 mm, serum bilirubin level raise above 10 mg%, and jaundice persists for longer than a week [11]. Dilatation of the extrahepatic ducts occurs much earlier than dilatation of the intrahepatic ducts, as dictated by the law of Laplace, which states that the stress is directly proportional to the internal diameter of the tubing [12]. Because of their larger internal diameter, the extrahepatic ducts sustain more stress and dilate much earlier than the intrahepatic ducts, which are much smaller in size.\n\nFig. 8.2.3\n\nRelationship of common bile duct size with serum bilirubin and duration of jaundice. There is usually no dilatation of the common bile duct (CBD) with bilirubin levels below 5 mg%; dilatation occurs when serum bilirubin rises above 10 mg%; dilatation is variable between 5 and 10 mg% (a). Diameter of the CBD increases (b) as the duration of jaundice increases [11]\n\nStricture impedes bile flow and reduces gallbladder emptying in response to CCK-8 infusion. There may be prolongation of the latent period with a reduction in gallbladder ejection fraction [8]. The bile emptied from the gallbladder may reflux into the common hepatic duct and right and left hepatic ducts, instead of flowing forward into the duodenum. Bile reflux into the common hepatic and right and left hepatic duct is one of a reliable signs of obstruction and is referred to as Krishnamurthy-Bobba sign [13, 14]. Refluxed bile reenters the gallbladder immediately after cessation of CCK-8 infusion, and the gallbladder curve often shows a rapid refilling. In patients with right upper quadrant pain, mild elevation of serum alkaline phosphatase, and normal bilirubin, cholescintigraphy maintains a much higher sensitivity for the detection of obstruction than ultrasound. Ultrasound, however, becomes a preferred modality for diagnosis in cases with high serum bilirubin and dilatation of ducts [11, 15, 16].\n\nIn normal subjects, the mean time of appearance of the common bile duct is 16 min, of the gallbladder 20 min, and of the duodenum 24 min. The gallbladder ejection fraction of 35% or higher is obtained in response to a 3-min infusion of 10 ngm kg-1 (3.3 ngm min-1 for 3 min) of CCK-8. The latent period is less than 3 min, and the ejection period is between 8 and 12 min. The curve over the common bile duct may show a peak corresponding to the second half of the gallbladder ejection period. The common hepatic duct curve usually does not show any peak as the bile emptied from the gallbladder flows antegrade through the sphincter of Oddi and enters the duodenum [17-19]. Because of forward bile entry into the duodenum, there is no rapid refilling of the gallbladder.\n\nDuring quantitative cholescintigraphy, patients with bile duct obstruction often experience a mild to moderate degree of abdominal pain because of either contraction of the gallbladder or distension of the common bile duct. Pain is experienced mostly during the gallbladder ejection period. Pain experienced after completion of the gallbladder ejection is considered non-biliary in origin. Since cholecystokinin increases intestinal peristalsis, late onset abdominal pain (after the gallbladder ejection period) is considered to indicate pain of intestinal origin due to increased peristalsis. A precise documentation of the temporal relationship between the onset of pain and the phase of gallbladder emptying is essential for defining the exact origin of abdominal pain [20, 21].\n\n#### 8.2.1.5 Cholescintigraphic Accuracy of Biliary Obstruction\n\nOf a total of 214 patients with well-documented biliary obstruction (Table 8.2.2), cholescintigraphy accurately detected obstruction in 200 patients, for a sensitivity of 93% [12, 19, 22-28]. Differentiation between functional vs. anatomic obstruction is made by using either amyl nitrite or a calcium channel blocker, nifedapine. These drugs, which relieve functional but not anatomic obstruction, promote smooth passage of bile only in case of a functional obstruction [29, 30]. The quantitative cholescintigraphic parameters are technically simple to measure, reliable, and easily reproducible within and between indi-viduals and among institutions [31, 32]. Simultaneous quantification provides an objective parameter that may alter patient management strategy as to the timing of therapy and also allows later testing for whether or not the chosen therapy has achieved its intended goals. In most patients, nuclear hepatology studies supplement morphological imaging studies; however, in patients where functional alterations precede morphological changes, one may have to depend mostly on the findings of cholescintigraphy [33]. An etiological diagnosis of biliary obstruction, whether it is intraluminal, wall thickening, or extrinsic compression, often cannot be made from cholescintigraphy alone. An ultrasound, CT ERCP, or MRCP is required for an etiological diagnosis. An ERCP may be ideal for confirmation of an intraluminal obstruction, ultrasound for wall thickening, and CT for an extrinsic compression.\n\nTable 8.2.2\n\nSensitivity of Tc-99m-HIDA cholescintigraphy in the detection of biliary obstruction\n\nAuthor (ref.) | Number of patients with biliary obstruction | Obstruction identified with cholescintigraphy\n\n---|---|---\n\nZeman [22] | 60 | 59\n\nKrishnamurthy [19] | 14 | 13\n\nLecklitner [24] | 25 | 23\n\nLieberman [26] | 19 | 14\n\nDarweesh [23] | 15 | 10\n\nBrown [12] | 14 | 14\n\nJuni [25] | 10 | 10\n\nLieberman [27] | 13 | 13\n\nLee [28] | 44 | 44\n\nTotal | 214 | 200 (93%)\n\n### 8.2.2 Malignant Causes\n\n#### 8.2.2.1 Cholangiocarcinoma\n\nCholangiocarcinoma is the most common malignancy of the biliary system, causing wall thickening and obstruction to bile flow. Incidence of cholangiocarcinoma appears to have been rising in recent years, which is partly related to the higher frequency of its detection by using more sophisticated diagnostic methods [34]. Cholangiocarcinoma occurs more commonly in the 6th decade of life and affects men more frequently than women in the ratio of 1.2:1. The proximal common hepatic duct or one or both of its bifurcating branches are the most common locations [35]. About 58% of cholangiocarcinomas occur in the proximal third, 17% in the middle third, 18% in the distal third, and the remaining 7% are distributed diffusely throughout the common hepatic and common bile duct (Fig. 8.2.4). The site and frequency of occurrence of cholangiocarcinoma has changed in the more recent reports, probably reflecting early diagnosis by non-invasive imaging methods and early confirmation by cholangiopancreatography [36, 37].\n\nFig. 8.2.4\n\nLocation of cholangiocarcinoma. Most occur in the common hepatic duct at its bifurcation [37]\n\n#### 8.2.2.2 Clinical Presentation\n\nPresenting symptoms and signs include weight loss, jaundice, and pruritus. Serum bilirubin levels may fluctuate, but the general trend is one of sustained increase. Patients usually seek medical attention late in the course of the disease, many after the onset of jaundice. By this time there is dilatation of the bile duct proximal to the site of cancer, and it is readily detected on ultrasound or CT examination [38]. Bismuth classifies cholangiocarcinoma into four types based on its location and extent (Fig. 8.2.5). Type I involves the common bile duct or the distal common hepatic duct. The proximal common hepatic duct and the right hepatic and left hepatic ducts are free of cancer. In type II, the carcinoma extends up to the level of the junction of the right and left hepatic ducts, but the proximal part of both the right and left hepatic ducts are free of cancer. In type III, the cancer involves either the right hepatic (IIIa) or the left hepatic duct (IIIb). One of the lobar ducts is free of cancer. Type IV extends to both the right and left hepatic ducts and their segmental branches, and the cancer is unresectable [39].\n\nFig. 8.2.5\n\nStaging of cholangiocarcinoma. In stage I, only the common duct is involved; both the right hepatic duct (RHD) and left hepatic duct (LHD) are free of cancer. In stage II, both the proximal hepatic duct and distal RHD and LHD are involved. Stage III involves the common hepatic duct along with either the right hepatic duct (IIIA) or the left hepatic duct (IIIB). In stage IV, entire extrahepatic biliary tree is involved, including both the right and left hepatic ducts along with their segmental branches\n\n#### 8.2.2.3 Carcinoma of the Ampulla of Vater\n\nOf the 18% of the cholangiocarcinoma arising from the distal third of the common bile duct (Fig. 8.2.5), 75% are less than 4 mm from the ampulla of Vater [36]. The clinical presentation of the peri-ampullary cholangiocarcinoma is distinctly different from those arising from the common hepatic duct and its bifurcation. Periampullary carcinoma presents more often as painless jaundice. Courvoisier first made the observation in 1890 that a palpable, painless gallbladder in a patient with jaundice has either a periampullary or a pancreatic cancer [40]. Periampullary cholangiocarcinoma accounts for less than 1-3% of obstructive jaundice. The common age group is between 55 and 65 years, with equal prevalence between men and women. There is frequent association with primary sclerosing cholangitis [41].\n\nAbout 50% of patients with cholangiocarcinoma already have intra-abdominal and intrahepatic metastases at the time of their first presentation to a clinician [42]. Obstruction manifests as two types of image pattern on Tc-99m-HIDA study, depending upon the degree (partial vs. complete obstruction) and duration of obstruction. Early segmental duct partial obstruction may show a normal or slightly reduced Tc-99m-HIDA uptake with bile stasis proximal to obstruction [43]. Complete obstruction, however, shows marked reduction or no uptake at all in the region affected by the tumor [44]. Involvement of the left hepatic duct, for example, may show no uptake at all over the entire left lobe.\n\nMost patients with cholangiocarcinoma present late, after the onset of jaundice, when hyperbilirubinemia and ductal dilatation are evident. A typical pattern consists of bile pooling in the duct proximal to the site of obstruction and increased liver to duodenal transit time, often as long as 24 h. Multimodality imaging, including ultrasonography, cholescintigraphy, CT, ERCP, and MRCP, are complementary imaging modalities [45]. Biopsy is required prior to deciding on a definitive therapeutic strategy.\n\n#### 8.2.2.4 Stent Patency\n\nPlacement of a palliative endo-prosthesis to relieve bile duct obstruction due to malignancy is now a standard treatment [46]. Endo-prosthesis relieves the obstruction promptly and establishes bile flow immediately. The plastic stents tend to occlude prematurely or move ferred, and they function much better and for a longer period of time than the plastic variety [47, 48]. The stent patency is easily documented with Tc-99m-HIDA cholescintigraphy.\n\nSurgery is recommended for early stages. Some prefer surgery even for tumors located proximally at the bifurcation (Klatskin tumor). Pylorus-preserving partial pancreatoduodenectomy or the Kausch-Whipple resection is the preferred surgical procedure [49, 50]. Insertion of an endo-prosthesis is now a popular therapeutic option, especially in the terminal stage. Migration, infection, and occlusion are frequent complications of the endo-prosthesis. Recent progress in stent design and improvements in stent insertion techniques have contributed towards longer duration of stent function, for up to 3-4 months. Occluded stents are easily replaced, and it is currently not a one-time procedure [51].\n\n## 8.3 Combined Intrahepatic and Extrahepatic Cholestasis (Sclerosing Cholangitis)\n\nBy involving both intrahepatic and extrahepatic ducts sequentially, or simultaneously, sclerosing cholangitis is a typical example of a disease that combines features of both intrahepatic and extrahepatic cholestasis. Sclerosing cholangitis (SC) is a slowly progressive disease of unknown etiology characterized by chronic inflammation, fibrosis, and narrowing of both intrahepatic and extrahepatic ducts at multiple levels [1]. Several contributing factors have been identified (Table 8.3.1). Multiple strictures with normal duct in between give the characteristic beaded appearance on the contrast cholangiogram. The term \"primary\" is used when all other possible causes of cholangitis have been excluded. Cholangitis associated with choledocholithiasis, biliary tract surgery, carcinoma, chemotherapy, or acquired immunodeficiency syndrome (AIDS) is called secondary sclerosing cholangitis. Only after exclusion of these secondary causes is the term primary applied.\n\nTable  8.3.1\n\nCholescitigraphic features of primary sclerosing cholangitis, isolated common bile duct obstruction, and primary biliary cirrhosis\n\nParameter | Primary sclerosing cholangitis | Isolated common bile duct obstruction | Primary biliary cirrhosis\n\n---|---|---|---\n\nLevel of CBD obstruction | Proximal | Distal | None\n\nNumber of obstructions | Multiple | Single | None\n\nBeading of the ducts | Common | Rare | None\n\nBile pooling proximal to obstruction | Uncommon | Very common | Uncommon\n\nCystic duct obstruction | Common | Rare | Rare\n\nLiver clearance half time | Marked increase | Moderate increase | marked increase\n\nRegional variations in clearance half time | Wide variation from region to region | Uniform increase from all regions | Uniform increase from all regions.\n\n### 8.3.1 Primary Sclerosing Cholangitis\n\nPrimary sclerosing cholangitis usually affects patients in their 40s, and men more often (75%) than women [2]. An association with inflammatory bowel disease is found in 75% of the patients [3, 4]. The clinical onset is insidious, with fatigue, pruritus, and malaise. Biochemical changes are characterized by moderate elevation of serum alkaline phosphatase and mild elevation of alanine amino transferase. Elevation of serum bilirubin is a late event. Urinary copper excretion is increased [3]. Unlike primary biliary cirrhosis, there is no specific serological marker for primary sclerosing cholangitis.\n\n### 8.3.2 Pathophysiology\n\nHistologically, four stages are identified. Stage I represents the initial degenerative changes in the duct-lining epithelial cells and infiltration by lymphocytes and neutrophils. Stage II is characterized by peri-portal necrosis, stage III consists of portal to portal fibrous septa and disappearance of bile ducts, and stage IV represents the end stage with cirrhosis and onion skin appearance on biopsy, a characteristic histological finding. The cholangiogram shows a typical beaded appearance of the extrahepatic ducts. Both intrahepatic and extrahepatic ducts are involved, but the contrast cholangiogram is often incapable of detecting the involvement of the intrahepatic ducts [5]. In 100 patients with primary sclerosing cholangitis, 87% had involvement of both intrahepatic and extrahepatic ducts, 11% had involvement of only the intrahepatic ducts, and 2% had involvement of only the extrahepatic ducts [4].\n\nThe disease progresses slowly over 10-15 years before reaching the stage of cirrhosis, portal hypertension, liver failure, and death. The median survival is 12 years [5]. The course of the disease is reversible during stage I, may be reversible in stage II, but is irreversible at stages III and IV. The following criteria are required for the diagnosis: (1) alkaline phosphatase increased by more than 1.5 times the normal amount for at least 6 months and (2) multiple strictures or beading of the ducts on the cholangiogram. Characteristic planar and SPECT images on Tc-99m-HIDA study may be included as one of the required criteria [6].\n\n### 8.3.3 Secondary Sclerosing Cholangitis\n\nSecondary sclerosing cholangitis follows an identifiable cause, such as surgery on the biliary tract, choledocholithiasis, intra-arterial infusions of chemotherapeutic agents [8], cholangiocarcinoma [9], acquired immunodeficiency syndrome [10], and congenital biliary abnormalities. The diagnosis of primary sclerosing cholangitis is made only after excluding all of the above causes. Inflammatory bowel disease (ulcerative colitis or Crohn's disease) is now considered an accompaniment of primary sclerosing cholangitis, and when found either before or in association with cholangitis, the condition is still labeled primary sclerosing cholangitis. The scintigraphic findings of secondary sclerosing cholangitis have not been studied as thoroughly as primary sclerosing cholangitis. The ERCP findings of secondary sclerosing cholangitis are indistinguishable from those of the primary sclerosing cholangitis.\n\n### 8.3.4 Cholescintigraphic Diagnosis\n\nCholescintigraphic planar images are obtained for 60 min with 3-5 mCi of Tc-99m-HIDA. SPECT images are obtained between 60-90 min [6, 11]. Early planar images (within 10 min) show patchy uptake by the liver (Fig. 8.3.1). Late images show a typical pattern of beading of the right hepatic, left hepatic, common hepatic, or common bile ducts, depending upon the extent of the disease (Fig. 8.3.1). The hepatic extraction fraction remains within the normal range early in the course of the disease and begins to decrease in advanced stages [6, 11]. The excretion half time increases from the very beginning. Due to multiple duct involvement at various levels, the excretion half time varies widely from region to region, often reaching values as high as six to seven times the normal value. The gallbladder is often not visualized due to obstruction of the cystic duct (Table 8.3.1).\n\nFig. 8.3.1\n\nSclerosing cholangitis. Planar image shows beading of right hepatic, left hepatic duct, common hepatic and common bile ducts. Gallbladder is not seen due to obstruction of the cystic duct\n\nSPECT images show characteristic features of varying parenchymal retention among the different regions. Liver parenchyma with normal bile ducts shows rapid clearance, while the parenchyma drained by obstructed bile ducts shows retention, giving the characteristic scintigraphic images (Fig. 8.3.2). The involvement and extent of cholangitis as indicated by cholescintigraphy may be more critical and much larger than the disease shown on the contrast cholangiogram. This underestimation of severity and extent by the cholangiogram is due to the inability of the contrast to enter most of the intrahepatic ducts. Several features characteristic of primary sclerosing cholangitis that help to differentiate it from primary biliary cirrhosis and isolated common bile duct obstruction are shown in Table 8.3.1. Magnetic resonance cholangiopancreatography is an emerging new technique that is capable of demonstrating involvement of both intrahepatic and extra-hepatic ducts [12, 13].\n\nFig. 8.3.2\n\nSPECT in sclerosing cholangitis. Transaxial (a) and coronal (b) slices, obtained between 60-90 min, show multiple areas of focal parenchymal retention over the involved ducts along with regions of complete clearance from ducts not affected\n\n### 8.3.5 Therapy\n\nThe medical therapy for primary sclerosing cholangitis includes such drugs as D-penicillamine, cyclosporine, methotrexate, corticosteroids, azathioprine, colchicine, or cholesteramine. Antibiotics are prescribed when there is superimposed infection [5]. Endoscopic stenting is shown to be safe and effective, and it works for several years until end-stage liver disease sets in [14]. Liver transplantation is recommended for end-stage liver disease when medical therapy fails.\n\n## 8.4 Extrinsic Compression\n\nExtrinsic compression of the bile duct can occur at any point along their course from the small intrahepatic duct to the termination of the common bile duct (Table 8.4.1). Compression due to an enlarged lymph node occurs more frequently at the porta hepatis where there are many lymph nodes. Lymphosarcoma, reticulum cell sarcoma, and Hodgkin's disease account for the majority of such obstructions [1]. Acute edematous pancreatitis is a frequent cause. Carcinoma of the stomach, pancreas, and gallbladder may invade the bile duct directly, whereas cancer of other distant organs spreads via a hematogenous route [2]. Chronic pancreatitis, which causes obstruction due to thickening of the intraduodenal portion of the duct wall, may also cause obstruction by an extrinsic compression due to fibrosis around the distal common bile duct [3]. Duodenal diverticulae are found along the medial duodenal wall, very close to the ampulla of Vater, in about 2% of patients undergoing barium meal examination [4]. On rare occasions, the ampulla of Vater may be found within the diverticulum. Acute cholecystitis and acute pancreatitis often co-exist and cause non-visualization of the gallbladder during a Tc-99m-HIDA study [5, 6]. Non-visualization of the gallbladder in a patient with a marked elevation of serum lipase or amylase may indicate acute biliary pancreatitis. Elevation of serum lipase and amylase aids in differentiating pancreatitis from acute cholecystitis. Cancer of the head of the pancreas is a well-recognized cause of extrinsic compression (Fig 8.4.1).\n\nFig. 8.4.1\n\nExtrinsic compression. Common bile duct obstruction because of extrinsic compression by cancer of the head of the pancreas. Uptake is excellent (left). Distal common bile duct ends abruptly (middle), and the gallbladder is seen late (middle) and does not empty even at 24 h (right)\n\nTable 8.4.1\n\nCauses of bile duct obstruction due to extrinsic compression\n\n(1) Peri-ductal lymph node enlargement\n\n---\n\n(2) Carcinoma of head of the pancreas\n\n(3) Chronic pancreatitis\n\n(4) Acute edematous pancreatitis\n\n(5) Annular pancreas\n\n(6) Duodenal diverticula\n\n(7) Pseudocyst of the pancreas.\n\n(8) Mirizzi syndrome\n\n### 8.4.1 Mirizzi Syndrome\n\nThis is a rare type of common bile duct obstruction resulting from extrinsic compression from a large gallstone impaction in the Hartmann's pouch or at the neck of the gallbladder. Patients with Mirizzi syndrome usually have a long cystic duct that runs parallel to the common hepatic duct before joining it to form the common bile duct [7, 8]. Two types of Mirizzi syndrome are described. Type I Mirizzi syndrome consists of extrinsic compression of the common hepatic duct by the stone in the gallbladder neck or in Hartmann's pouch. In type II Mirizzi syndrome, the stone erodes into the common hepatic duct forming a cholecystocholedochal fistula. Recent studies have shown a role for non-invasive diagnosis with MR imaging [9]. Laparoscopic cholecystectomy is the preferred initial approach in uncomplicated cases, and open cholecystectomy is recommended when anomalies exist around the Callot triangle [10].\n\nReferences\n\n1.\n\nAdmirand WH, Small DM. The physiological basis of cholesterol gallstone formation in man. J Clin Invest 1968;47:1043-1052PubMedCrossRef\n\n2.\n\nMadden J. Common duct stones. Their origin and surgical management. Surg Clin North Am 1973;53:1095-1113PubMed\n\n3.\n\nVital A, Bioulac-Sage P, Iron A, Balabaud C. Morphologic structure of bile canaliculi after bile duct ligation in the rat. A time-course study. Arch Pathol Lab Medicine 1982;106:464-467\n\n4.\n\nAccatino L, Contreras A, Fernandez S, Quintana C. The effect of complete biliary obstruction on bile flow and bile acid secretion: post-cholestatic choleresis in the rat. J Lab Clin Med 1979;93:706-717PubMed\n\n5.\n\nJohnson G, Sundman L. Bile and dry matter output at elevated liver secretion pressure. Acta Clin Scand 1964;128:153\n\n6.\n\nChen C, Shiesh S, Wu M, Lin X. The effect of bile duct obstruction on the biliary secretion of ciprofloxacin in piglets. Am J Gastroenterol 1999;94:2408-2411PubMedCrossRef\n\n7.\n\nKlingensmith WC III, Whitney WP, Spitzer VM, Klintmalm GB, Koep LM, Kuni CC. Effect of complete biliary-tract obstruction on serial hepatobiliary imaging in an experimental model: concise communication. J Nucl Med 1981;22:866-868PubMed\n\n8.\n\nOster MJ, Csendes A, Funch-Jensen P, Skjoldborg H. Intra-operative pressure measurements of the choledocho-duodenal junction, common bile duct, cystico-choledochal junction, and gallbladder in humans. Surg Gynecol Obstet 1980;150:385-389PubMed\n\n9.\n\nPelligrini CA. Pathophysiology of biliary obstruction. In: Way LW, Pelligrini CA (eds). The surgery of the gallbladder and bile ducts. Philadelphia, WB Saunders, 1987, pp 103-117\n\n10.\n\nWilliams W, Krishnamurthy GT, Brar HS, Bobba VR. Scintigraphic variations of normal biliary physiology. J Nucl Med 1984;25:160-165PubMed\n\n11.\n\nKrishnamurthy GT, Bobba VR, McConnell D, Turner F, Mesgarzadeh M, Kingston E. Quantitative biliary dynamics: introduction of a new non-invasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n12.\n\nDoo E, Krishnamurthy GT, Eklem MJ, Gilbert S, Brown PH. Quantification of hepatobiliary function as an integral part of imaging with technetium-99m-mebrofenin in health and disease. J Nucl Med 1991;32:48-57PubMed\n\n13.\n\nBlue PW. Hyperacute complete common bile duct obstruction demonstrated with Tc-99m-IDA cholescintigraphy. Nucl Med Commun 1985;6:275-279PubMedCrossRef\n\n14.\n\nLee AW, Ram MD, Shin WJ, Murphy K. Technetium-99m BIDA biliary scintigraphy in the evaluation of the jaundiced patient. J Nucl Med 1986;27:1407-1412PubMed\n\n15.\n\nJuni JE, Reichle R. Measurement of hepatocellular function with deconvolutional analysis: application in the differential diagnosis of acute jaundice. Radiology 1990;177:171-175PubMed\n\n16.\n\nLima J, Shankaran H, Krishnamurthy GT, et al Evaluation of hepatocyte function following acute common bile duct obstruction (ACBDO) by Tc-99m-mebrofenin scintigraphy in rats. Eur J Nucl Med 1992;19:687 (abstract)\n\n17.\n\nLima J. Quantifica\u00e7ao em hepatologia nuclear. Thesis submitted to the University of Coimbra as partial fulfillment for a doctoral degree. University of Coimbra, Portugal, 1997\n\n18.\n\nKrishnamurthy S, Krishnamurthy GT. Technetium-99m-iminodiacetic acid organic anion: Review of biokinetics and clinical application in hepatology. Hepatology 1989;9:139-153PubMedCrossRef\n\n19.\n\nLecklitner ML, Austin AR, Benedetto AR, Growcock GW. Positive predictive value of cholescintigraphy in common bile duct obstruction. J Nucl Med 1986;27:1403-1406PubMed\n\n20.\n\nBrown PH, Juni JE, Lieberman DA, Krishnamurthy GT. Hepatocyte versus biliary disease: a distinction by deconvolutional analysis of technetium-99m-IDA time-activity curve. J Nucl Med 1988;29:623-630PubMed\n\n21.\n\nKrishnamurthy GT, Lieberman DA, Brar HS. Detection, localization and quantitation of degree of common bile duct obstruction by scintigraphy. J Nucl Med 1985;26:726-735PubMed\n\n22.\n\nSandblom P. Hemobilia. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. Philadelphia, WB Saunders, 1987, pp 643-654\n\n23.\n\nLouw JH, Rode H. Ascariasis. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile duct. Philadelphia, WB Saunders, 1987, pp 539-555\n\n24.\n\nCremin BJ. Ultrasonic diagnosis of biliary ascariasis, \"a bull's eye in the triple O.\" Br J Radiol 1982;55:683-684PubMed\n\n25.\n\nSherlock S, Dooley J. Diseases of the liver and biliary system. Blackwell Science, Inc. Malden, MA, 10th edn, 1997, pp 641-649\n\n26.\n\nYeh SH, Liu OK, Huang MJ. Sequential scintigraphy with technetium-99m-pyridoxylideneglutamate in the detection of intrahepatic lithiasis: concise communication. J Nucl Med 1980;21:17-21PubMed\n\n27.\n\nZeman RK, Gold JA, Gluck L, Caride VJ, Burrell M, Hoffer PB. Tc-99m-HIDA scintigraphy in segmental biliary obstruction. J Nucl Med 1981;22:456-458PubMed\n\n28.\n\nGupta S, Owshalimpur D, Cohen G, Margules R, Herrera N. Scintigraphic detection of segmental bile-duct obstruction. J Nucl Med 1982;23:890-891PubMed\n\n29.\n\nGibney RG, Cooperberg PL, Scudamore CH, Nagy AG. Segmental biliary obstruction: false-negative diagnosis with direct cholangiography without US guidance. Radiology 1987;164:27-30PubMed\n\n30.\n\nLee MG, Lee HJ, Kim MH, Kang EM, Kim YH, Lee SG, Kim PN, Ha HK Auh YH. Extrahepatic biliary diseases: 3D MR cholangiopancreatography compared with endoscopic retrograde cholangiopancreatography. Radiology 1997;202:663-669PubMed\n\n31.\n\nAsselah T, Ernst O, Sergent G, L'hermine C, Paris JC. Caroli's disease: a magnetic resonance cholangiopancreatography diagnosis. Am J Gastroenterology 1998;93:109-110CrossRef\n\nRefrences\n\n1.\n\nAndren-Sandberg A, Alinder G, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. Pre- and perioperative factors of importance. Ann Surg 1985;201:328-332PubMedCrossRef\n\n2.\n\nThe Southern Surgeons' Club. A prospective analysis of 1,518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073-1078CrossRef\n\n3.\n\nTerblanche J, Allison HF, Northover JM. An ischemic basis for biliary strictures. Surgery 1983;94:52-57PubMed\n\n4.\n\nMueller PR, van Sonnenberg E, Ferrucci JT Jr, et al. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology 1986;160:17-22PubMed\n\n5.\n\nMartenson JA Jr, Gunderson LL, Buskirk SJ, et al. Hepatic duct stricture after radical radiation therapy for biliary cancer: recurrence or fibrosis? Mayo Clin Proc 1986;61:530-536PubMed\n\n6.\n\nItoh H, Shimono R, Hamamoto K. Evaluation of common bile duct stenosis in chronic pancreatitis using cholescintigraphy. Eur J Nucl Med 1988;14:137-140PubMedCrossRef\n\n7.\n\nWard EM, Kiely MJ, Maus TP, Wiesner RH, Kron RA. Hilar biliary strictures after liver transplantation: cholangiography and percutaneous treatment. Radiology 1990;177:259-263PubMed\n\n8.\n\nKrishnamurthy GT, Bobba VR, McConnell D, Turner F, Mesgarzadeh M, Kingston E. Quantitative biliary dynamics: introduction of a new non-invasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n9.\n\nBrown PH, Juni JE, Lieberman DA, Krishnamurthy GT. Hepatocyte vs. biliary disease: a distinction by deconvolutional analysis of technetium-99m-HIDA time-activity curve. J Nucl Med 1988;29:623-630PubMed\n\n10.\n\nHonickman SP, Mueller PR, Wittenberg J, et al. Ultrasound in obstructive jaundice: prospective evaluation of site and cause. Radiology 1983;147:511-515PubMed\n\n11.\n\nLapis JL, Orlando RC, Mittlesteadt CA, Staab EV. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978;89:61-63PubMed\n\n12.\n\nCompton RA. Bursting forces within the human body. Radiology 1973;107:77-80PubMed\n\n13.\n\nItoh H, Murase K, Hamamoto K. Reflux sign in cholescintigraphy after administration of a gallbladder contracting agent. J Nucl Med 1989;30:1192-1197PubMed\n\n14.\n\nBrar HS. Scintigraphic cholecystokinin-induced bile reflux named as Krishnamurthy-Bobba sign. J Nucl Med 1990;31:248-249PubMed\n\n15.\n\nCooperberg PL, Burhenne HJ. Real-time ultrasonography. Diagnostic technique of choice in calculous gallbladder disease. N Engl J Med 1980;302:1277-1279PubMedCrossRef\n\n16.\n\nLaing FC, Jeffrey RB Jr. Choledocholithiasis and cystic duct obstruction: difficult ultrasonographic diagnosis. Radiology 1983;146:475-479PubMed\n\n17.\n\nKrishnamurthy S, Krishnamurthy GT. Quantitative assessment of hepatobiliary diseases with Tc-99m-HIDA scintigraphy. In: Freeman LM, Weissman HS (eds). Nuclear medicine. Annual Raven Press, New York, 1988, pp 309-330\n\n18.\n\nDoo E, Krishnamurthy GT, Eklem MJ, Gilbert S, Brown PH. Quantification of hepatobiliary function as an integral part of imaging with technetium-99m-mebrofenin in health and disease. J Nucl Med 1991;32:48-57PubMed\n\n19.\n\nKrishnamuthy GT, Lieberman DA, Brar HS. Detection, localization, and quantitation of degree of common bile duct obstruction by scintigraphy. J Nucl Med 1985;26:726-735\n\n20.\n\nKrishnamurthy S, Krishnamurthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n21.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical entity. J Nucl Med Technol 1995;23(suppl):35S-45S\n\n22.\n\nZeman RK, Lee C, Jaffe MH, Burrell MI. Hepatobiliary scintigraphy and sonography in early biliary obstruction. Radiology 1984;153:793-798PubMed\n\n23.\n\nDarweesh RMR, Dodds WJ, Hogan WJ, et al. Efficacy of quantitative hepatobiliary scintigraphy and fatty meal sonography for evaluating patients with suspected partial common bile duct obstruction. Gastroenterology 1988;94:779-786PubMed\n\n24.\n\nLecklitner ML, Austin AR, Benedetto AR, Growcock GW. Positive predictive value of cholescintigraphy in common bile duct obstruction. J Nucl Med 1986;27:1403-1406PubMed\n\n25.\n\nJuni JE, Reichle R. Measurement of hepatocellular function with deconvolutional analysis: Application in the differential diagnosis of acute jaundice. Radiology 1990;177:171-175PubMed\n\n26.\n\nLieberman DA, Krishnamurthy GT. Intrahepatic vs extrahepatic cholestasis. Discrimination with biliary scintigraphy combined with ultrasound. Gastroenterology 1986;90:734-743PubMed\n\n27.\n\nLieberman DA, Brown PH, Krishnamurthy GT. Improved scintigraphic assessment of severe cholestasis with the hepatic extraction fraction. Dig Dis Sci 1990;35:1385-1390PubMedCrossRef\n\n28.\n\nLee AW, Ram MD, Shih WJ, Murphy K. Technetium-99m-BIDA biliary scintigraphy in the evaluation of the jaundiced patient. J Nucl Med 1986;27:1407-1412PubMed\n\n29.\n\nMadacsy L, Velosy B, Lonovics J, Csernay L. Differentiation between organic stenosis and functional dyskinesia of the sphincter of Oddi with amyl nitrite-augmented quantitative hepatobiliary scintigraphy. Eur J Nucl Med 1994;21;203-208PubMedCrossRef\n\n30.\n\nBhatnagar A. Nifedipine interventional cholescintigraphy: a new method for assessing sphincter of Oddi? Indian J Nucl Med 1997;12:93-96\n\n31.\n\nGilbert SA, Brown PH, Krishnamurthy GT. Quantitative nuclear hepatology. J Nucl Med Technol 1987;15:38-43\n\n32.\n\nSpackman J, Bartlett ME, Ryals L, et al. Reproducibility of technetium-99m-mebrofenin hepatic functional parameters obtained with semiautomatic software. J Nucl Med Technol 1991;19:228-231\n\n33.\n\nKrishnamurthy S, Krishnamurthy GT. Functional imaging in nuclear hepatology. Indian J Nucl Med 1997;12:216-232\n\n34.\n\nTomkins RK, Saunders KD, Roslyn JJ, Longmire WP Jr. Changing patterns in diagnosis and management of bile duct cancer. Ann Surg 1990;211:614-620\n\n35.\n\nKlatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatic. An unusual tumor with distinctive clinical and pathologic features. Am J Med 1965;38:24CrossRef90178-6)\n\n36.\n\nWise L, Pizzimbono C, Dehner LP. Periampullary cancer. A clinicopathologic study of 62 patients. Am J Surg 1976;131:141-148PubMedCrossRef90087-8)\n\n37.\n\nSherlock S, Dooley J. Diseases of the liver and biliary system, 10th edn, Blackwell Science, Malden, MA, 1997, pp 641-649\n\n38.\n\nReiman TH, Balfe D, Weyman PJ. Suprapancreatic biliary obstruction: CT evaluation. Radiology 1987;163:49-56PubMed\n\n39.\n\nBismuth H, Nakache R, Diamond R. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 1992;215:31-38PubMedCrossRef\n\n40.\n\nCourvoisier LG. Kasuistisch-statistiche Beitrage zur Pathologie und Chirurgie der Gallenwege. Leipzig FCV, Vogel, 1890\n\n41.\n\nDeGroen PC, Gores GJ, LaRusso NF, Gunderson LL, Nagorney DM. Biliary tract cancers. N Engl J Med 1999;341:1368-1378CrossRef\n\n42.\n\nBurke EC, Jarnagin WR, Hochwald SN, Pisters PWT, Fong Y, Blungart LH. Hilar cholangiocarcinoma. Pattern of spread, the importance of hepatic resection for curative operation, and a pre-surgical staging system. Ann Surg. 1998;228:385-394PubMedCrossRef\n\n43.\n\nZeman RK, Gold JA, Gluck L, Caride VJ, Burrell M, Hoffer PB. Tc-99m-HIDA scintigraphy in segmental biliary obstruction. J Nucl Med 1981;22:456-458PubMed\n\n44.\n\nGupta S, Owshalimpur D, Cohen G, Margules R, Herrera N. Scintigraphic detection of segmental bile-duct obstruction. J Nucl Med 1982;23:890-891PubMed\n\n45.\n\nZeman RK, Lee C, Stahl RS, Cahow CE, Viscomi GN, Neumann RD, Gold JA, Burrell MI. Ultrasonography and hepatobiliary scintigraphy in the assessment of biliary-enteric anastomoses. Radiology 1982;145:109-115PubMed\n\n46.\n\nMueller RR, Ferrucci JT Jr, Teplick SK, van Sonnenberg E, Haskin PH, Butch RJ, Papanicolaou N. Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology 1985;156:637-639PubMed\n\n47.\n\nMathieson JR, McLoughlin RE, Cooperberg PL, Prystai CC, Stordy SN, MacFarlane JK, Schmidt N. Malignant obstruction of the common bile duct: long-term results of Gianturco-Rosch metal stents used as initial treatment. Radiology 1994;192:663-667PubMed\n\n48.\n\nBoguth L, Tatalovic S, Antonucci F, Heer M, Susler H, Zollikofer CL. Malignant biliary obstruction: clinical and histopathologic correlation after treatment with self-expanding metal prostheses. Radiology 1994;192:669-674PubMed\n\n49.\n\nBeger HG, Treitschke F, Gansauge F, Harada N, Hiki N, Mattfeldt T. Tumor of the ampulla of Vater. Experience with local or radical resection in 171 consecutively treated patients. Arch Surg 1999;134:526-532PubMedCrossRef\n\n50.\n\nLaunois B, Terblanche J, Lakehal M, Catheline JM, Bardaxoglou E, Landen S, Campion JP, Sutherland F, Meunier B. Proximal bile duct cancer: high resectability rate and 5 year survival. Ann Surg 1999;230:266-275PubMedCrossRef\n\n51.\n\nLee MJ, Mueller PR, Saini S, Morrison MC, Brink JA, Hahn PF. Occlusion of biliary endoprosthesis: presentation and management. Radiology 1990;176:531-534PubMed\n\nReferences\n\n1.\n\nLaRusso NF, Wiesner RH, Ludwig J, MacCarty RL. Current concepts. Primary sclerosing cholangitis. N Eng J Med 1984;310:899-903CrossRef\n\n2.\n\nWiesner RH, Grambsch PM, Dickson ER, Ludwig J, MacCarty RL, Hunter EB, Fleming TR, Fisher LD, Beaver SJ, LaRusso NF. Primary sclerosing cholangitis: natural history, prognostic factors, and survival analysis. Hepatology 1989;10:430-436PubMedCrossRef\n\n3.\n\nGross JB Jr, Ludwig J, Wiesner RH, McCall JT, LaRusso NF. Abnormalities in tests of copper metabolism in primary sclerosing cholangitis. Gastroenterology 1985;89:272-278PubMed\n\n4.\n\nLee YM, Kaplan MM. Primary sclerosing cholangitis. N Eng J Med 1995;332:924-933CrossRef\n\n5.\n\nWiesner RH. Current concepts in primary sclerosing cholangitis. Mayo Clin Proc 1994;69:969-982PubMed\n\n6.\n\nRodman CA, Keeffe EB, Lieberman DA, Krishnamurthy S, Krishnamurthy GT, Gilbert S, Eklem MJ. Diagnosis of sclerosing cholangitis with technetium 99m-labeled iminodiacetic acid planar and single photon emission computed tomographic scintigraphy. Gastroenterology 1987;92:777-785PubMed\n\n7.\n\nAment AE, Bick RJ, Miraldi FD, Haaga JR, Wiedenmann SD. Sclerosing cholangitis: cholescintigraphy with Tc-99m-labeled DISIDA. Radiology 1984;151:197-201PubMed\n\n8.\n\nPien EH, Zeman RK, Benjamin SB, Barth KH, Jaffe MH, Choyke PL, Clark LR, Paushter  DM. Iatrogenic sclerosing cholangitis following hepatic arterial chemotherapy infusion. Radiology 1985;156:329-330PubMed\n\n9.\n\nShea WJ Jr, Demas BE, Goldberg HI, Hohn DC, Ferrell LD, Kerlan RK. Sclerosing cholangitis associated with hepatic arterial FUDR chemotherapy: radiographic-histologic correlation. AJR Am J Roentgenol 1986;146:717-721PubMed\n\n10.\n\nMacCarty RL, LaRusso NF, May GR, Bender CE, Wiesner RH, King JE, Coffey RJ. Cholangiocarcinoma complicating primary sclerosing cholangitis: cholangiographic appearances. Radiology 1985;156:43-46PubMed\n\n11.\n\nDolmatch BL, Laing FC, Federle MP, Jeffrey RB, Cello J. AIDS- related cholangitis: radiographic findings in nine patients. Radiology 1987;163:313-316PubMed\n\n12.\n\nLee MG, Lee HJ, Kim MH, Kang EM, Kim YH, Lee SG, Kim PN, Ha NK, Auh YH. Extrahepatic biliary diseases: 3D MR cholangiopancreatography compared with endoscopic retrograde cholangiopancreatography. Radiology 1997;202:663-669PubMed\n\n13.\n\nAsselah T, Ernst O, Sergent G, L'hermine C, Paris J. Caroli's disease: a magnetic resonance cholangiopancreatography diagnosis. Am J Gastroenterol 1998;93:109-110PubMedCrossRef\n\n14.\n\nPonsioen CY, Lam K, van Milligen de Wit AWM, Huibregtse K, Tytgat GNJ. Four years experience with short-term stenting in primary sclerosing cholangitis. Am J Gastroenterol 1999;94:2403-2407PubMedCrossRef\n\nReferences\n\n1.\n\nLeuitan R, Diamond HD, Craver LF. Jaundice in Hodgkin's disease. Am J Med 1961;30:99CrossRef90067-5)\n\n2.\n\nPopp JW Jr, Schapiro RH, Warshaw AL. Extrahepatic biliary obstruction by metastatic breast carcinoma. Ann Intern Med 1979;91:568-571PubMed\n\n3.\n\nItoh H, Shimono R, Hamamoto K. Evaluation of common bile duct stenosis in chronic pancreatitis using cholescintigraphy. Eur J Nucl Med 1988;14:137-140PubMedCrossRef\n\n4.\n\nMcSherry CK, Glenn F. Biliary tract obstruction and duodenal diverticula. Surg Gynecol Obstet 1970;130:829-836PubMed\n\n5.\n\nSerafini AN, Al-Sheikh W, Barkin JS, Hourani M, Sfakiankis G, Clarke LP, Ashkar FS. Biliary scintigraphy in acute pancreatitis. Radiology 1982;144:591-595PubMed\n\n6.\n\nAli A, Turner DA, Fordham EW. Tc-99m-IDA cholescintigraphy in acute pancreatitis: concise communication. J Nucl Med 1982;23:867-869PubMed\n\n7.\n\nMirizzi PL. Sindrome del conducto hepatico. J Int Chir 1948;8:731-733 (from Chap. 9)\n\n8.\n\nMontefusco P, Spicer N, Geiss AC. Another facet of Mirizzi's syndrome. Arch Surg 1983;118:1221-1223PubMedCrossRef\n\n9.\n\nKim PN, Outwater EK, Mitchel DG. Mirizzi syndrome: evaluation by MR imaging. Am J Gastroenterol 1999;94:2546-2550PubMedCrossRef\n\n10.\n\nSare M, Gurer S, Taskin V, Aladag M, Hilmioglu F, Gurel M. Mirizzi syndrome: choice of surgical procedure in the laparoscopic era. Surg Laparosc Endosc 1998;8:63-67PubMedCrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_9(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 9. Diseases of the Gallbladder\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nLiver and gallbladder diseases are two of the most common digestive system problems around the world [1]. In the United States, there are about 20.5 million people with gallbladder disease, with an estimated annual cost for medical care of more than 6.4 billion dollars [2]. Gallstones account for the majority of gallbladder problems. Women are affected two to three times as frequently as men [3]. Race, heredity, gender, age, and obesity are some of the important known risk factors for gallstones (Table 9.1.1). Between the ages 60 and 74, the prevalence of gallbladder disease is as high as 25.3% in men and 33.1%% in women (Table 9.1.2), and it is relatively more common among the Mexican Americans (Table 9.1.3). The highest rate among the Americans is found in the Pima Indians of Arizona [4]. By the teenage years, as many as 10-13% of Pima Indian girls develop lithogenic bile, and by 35-44 years, about 71% develop gallstones. Almost 90% of Pima Indian women over the age of 65 develop gallbladder disease, and the prevalence is much higher than in Pima Indian men.\n\nLiver and gallbladder diseases are two of the most common digestive system problems around the world [1]. In the United States, there are about 20.5 million people with gallbladder disease, with an estimated annual cost for medical care of more than 6.4 billion dollars [2]. Gallstones account for the majority of gallbladder problems. Women are affected two to three times as frequently as men [3]. Race, heredity, gender, age, and obesity are some of the important known risk factors for gallstones (Table 9.1.1). Between the ages 60 and 74, the prevalence of gallbladder disease is as high as 25.3% in men and 33.1%% in women (Table 9.1.2), and it is relatively more common among the Mexican Americans (Table 9.1.3). The highest rate among the Americans is found in the Pima Indians of Arizona [4]. By the teenage years, as many as 10-13% of Pima Indian girls develop lithogenic bile, and by 35-44 years, about 71% develop gallstones. Almost 90% of Pima Indian women over the age of 65 develop gallbladder disease, and the prevalence is much higher than in Pima Indian men. Such a high prevalence is also found in Mestizo Hispanics of Chile and the high-altitude rural population of Peru [5, 6]. The incidence of gallbladder disease varies from country to country; the Italians [7], British [8], Scottish [9], and Swedish [10] people have a much higher rate than people from other parts of Europe.\n\nTable 9.1.1\n\nRisk factors for gallstones\n\n(1) Heredity\n\n---\n\n(2) Obesity\n\n(3) Gender\n\n(4) Diabetes\n\n(5) Age\n\n(6) Low socioeconomic status\n\n(7) Parity\n\n(8) Pregnancy\n\n(9) Drugs, e.g., somatostatin analogues (octreotide)\n\nTable 9.1.2\n\nPrevalence of gallstones and gallbladder disease in men and women in the United States [2]\n\nGallstones | Gallbladder disease\n\n---|---\n\nAge (years) | Men (%) | Women (%) | Men (%) | Women (%)\n\n20-29 | 1.3 | 4.4 | 1.3 | 6.5\n\n30-39 | 1.1 | 5.2 | 1.9 | 10.2\n\n40-49 | 5.9 | 8.2 | 7.3 | 15.7\n\n50-59 | 7.3 | 11.9 | 11.7 | 25.0\n\n60-74 | 17.2 | 16.4 | 25.8 | 33.1\n\nMean | 5.5 | 8.6 | 7.9 | 16.6\n\nTable 9.1.3\n\nEffect of gender and ethnicity on the prevalence of gallstones and gallbladder disease in the United States [2]\n\nGender, ethnicity | Gallstones | Gallbladder disease\n\n---|---|---\n\nMen\n\nWhites (non-Hispanics) | 5.8 | 8.6\n\nBlacks (non-Hispanics) | 3.9 | 5.3\n\nMexican Americans | 6.1 | 8.9\n\nWomen\n\nWhites (non-Hispanics) | 8.6 | 16.6\n\nBlacks (non-Hispanics) | 7.9 | 13.9\n\nMexican Americans | 12.8 | 26.7\n\nNatural history of gallstones : Most gallstones initially remain asymptomatic. The frequency of pain developing in an asymptomatic gallstone patient is 10 \u00b1 3% at end of 5 years, 15 \u00b1 4% at 10 years, and 18.4 \u00b1 4% at 15 years (Fig. 9.1.1), which remains unchanged at 20 years [11]. Asymptomatic gallstone patients develop biliary pain (become symptomatic) at an average rate of 2% per year [12, 13]. The frequency of gallstone formation and onset of biliary pain both increase during pregnancy because of elevation of serum estrogens, which induce bile stasis, crystallization, and stone growth within the gallbladder. Gallstones form seven times more frequently in obese women than in non-obese women of comparable age [10]. Stones form more frequently in patients with increased body mass index and less physical activity than in lean people who maintain vigorous physical activity [14]. Stones smaller than 10 mm in size tend to pass through the cystic duct and common bile duct spontaneously during or after delivery [15].\n\nFig. 9.1.1\n\nNatural history of asymptomatic gallstones. Cumulative probability of onset of biliary pain in patients with asymptomatic gallstones increases with time: 10 \u00b1 3%, 15 \u00b1 4%, 18 \u00b1 4%, and 18 \u00b1 4%, at the end of 5,10, 15, and 20 years, respectively [11]\n\nComposition of gallstones: Gallstones are generally classified into two main types: cholesterol and pigment stones [16-18]. The color of the mucosal surface of the gallbladder depends on the nature of the gallstone composition (Fig. 9.1.2). Cholesterol stones are the most common, are soft in consistency, and consist of layers of cholesterol alternating with mucin and glycoproteins (Fig. 9.1.3). Although cholesterol is insoluble in water, it is kept in solution in bile by the formation of micelles, which are composed of cholesterol, bile salts, and phospholipids (lecithin). As the bile cholesterol concentration increases, a large number of multilayered vesicles and crystals are formed, which aggregate and grow into large stones [19, 20]. Pigment stones are more common in patients with cirrhosis or chronic hemolytic anemia. They are black or brown in color, hard in consistency, and contain bilirubin or calcium salts [21]. Stones formed within the common bile duct usually belong to the pigment type. The great majority of gallstones (65-70%) seen on a plain abdominal X-ray are pigment stones [22].\n\nFig. 9.1.2\n\nGallbladder color. Combination of light-colored cholesterol and dark-colored pigment crystals and stones may cast different hues on the surface (left) and inside of a gallbladder (right)\n\nFig. 9.1.3\n\nGallstone color. Cholesterol stones (left) are yellowish and soft, and pigment stones (right) are dark in color and hard in consistency. Pigment stones have multiple facets\n\n## 9.1 Chronic Calculous Cholecystitis\n\n### 9.1.1 Clinical Presentation\n\nPatients with chronic calculous cholecystitis usually present with mild- to moderate- intensity upper abdominal pain without fever or leucocytosis. They ignore pain in the beginning and seek medical aid only when pain becomes intolerable. Pain usually begins 15-30 min after a meal, and this time interval roughly corresponds to the time taken for the serum endogenous cholecystokinin level to rise above the threshold to induce gallbladder contraction and emptying. The site of origin and direction of propagation of biliary pain are variable. The most common location is the epigastrium or the right hypochondrium (Fig. 9.1.4). The pain beginning in the right lower quadrant may mimic an acute appendicitis, or that beginning on the left side of the abdomen may simulate gastritis or diverticulitis. The pain may radiate to the chest and shoulder, mimicking an anginal attack. The pain deep in the abdomen and radiating to the interscapular region may simulate an attack of acute pancreatitis [23]. The pain following dinner usually reaches its peak intensity at midnight [24]. Biliary pain is attributed to distension of the gallbladder or common bile duct wall when they contract against obstruction to bile flow. Pain intensity correlates directly with the degree of wall distension [25]. Stones lying free within the gallbladder lumen do not cause pain. Pain is intermittent, with weeks or months of pain-free intervals between attacks. In a given patient, however, the pain frequency, duration, and intensity remain constant despite wide variations among patients [26].\n\nFig. 9.1.4\n\nLocation and propagation of biliary pain. Epigastrium is the most common location, followed by the right hypochondrium. The pain may radiate to the chest and shoulder, mimicking an anginal attack, or to the back, mimicking pancreatitis. Radiation to the lower quadrants of the abdomen may mimic appendicitis or diverticulitis [22]\n\n### 9.1.2 Biliary Pain Pathway\n\nThe liver and biliary tract receive both somatic and autonomic (sympathetic and parasympathetic) nerve supply. The somatic supply is provided through the thoracic intercostal nerves from spinal segments T8, 9, and 10, which supply the parietal peritoneum. The phrenic nerve (cervical third and fourth segments) supplies the diaphragm and the underlying parietal peritoneum and the gallbladder. Pain originating from the gallbladder, bile ducts, and peritoneum is also carried centrally (afferent) through the branches of the right phrenic nerve. The axons from the sympathetic preganglionic neurons located in thoracic spinal segments T7 to T10 travel along the ventral root and the corresponding sympathetic ganglion to reach the celiac ganglion via the greater and lesser splanchnic nerves. Postganglionic sympathetic fibers from the celiac ganglion supply the liver and the biliary tree (Fig.1.1.7, Chap. 1). Biliary tract pain is carried centrally through these afferent sympathetic fibers. Afferent nerve fibers originating from the corresponding somatotomes and dermatomes join the liver and biliary tract afferent fibers in the spinal cord and serve as a common channel for referred pain. Afferent fibers cross the midline to enter the opposite spino-thalamic tract before reaching the thalamus where pain is processed and sent to higher centers in the cortex.\n\nThe parasympathetic nerve supply is via the right and left vagal nerves, which originate in the medulla. After entering the abdomen, vagal fibers pass through the posterior and anterior hepatic plexus before entering the liver, bile ducts, and gallbladder. The parasympathetic branches to the gallbladder and intrahepatic ducts come mainly from the left (anterior) vagus, and branches to the extrahepatic bile ducts and the sphincter of Oddi arrive mainly from the right (posterior) vagus. The parasympathetic system supplies the efferent nerve fibers and controls motor function of the gallbladder, bile ducts, and sphincter of Oddi. Pain from the gallbladder and common bile duct is referred to the epigastrium, right hypochondrium, right shoulder, or anterior chest (Fig. 9.1.4).\n\n### 9.1.3 Histopathologic Features\n\nThe gallbladder of patients with chronic cholecystitis is often small in size and consists of thickening, fibrosis, and microcalcification of the wall. A single large stone or multiple small stones are common (Fig. 9.1.2). Bile is usually clear, but when it is viscous and contains debris, it settles at the bottom of the fundus of the gallbladder as sludge. The wall shows chronic inflammation and infiltration with lymphocytes, without any hemorrhage or necrosis, which are features of acute cholecystitis. The mucous membrane shows ulceration and scarring. Fibrosis and wall thickening reduce absorption of water through the wall, which accounted for delayed visualization or non-visualization of the gallbladder in the days of oral cholecystogram. Yet most of such non-visualized gallbladders in oral cholecystograms were seen in a Tc-99m-HIDA study, because the entry of even a single drop of high specific activity hepatic bile enables visualization of the gallbladder in a cholescintigram.\n\n### 9.1.4 Diagnosis of Cholelithiasis\n\nUltrasonography is the diagnostic procedure of choice for detection of gallstones. The gallstones are hyperechoic and produce an acoustic shadow beyond the wall (Fig. 9.1.5). A confirmatory diagnosis of cholelithiasis by ultrasound requires demonstration of stone movement with gravity by taking gallbladder images at several different angles [27]. Often a calcified polyp may mimic a gallstone by casting an acoustic shadow, but it does not move with change of patient position. The stones are readily demonstrated in a fully filled gallbladder, but are often missed when the gallbladder is contracted and small in size, incompletely filled with bile, or completely filled with stones. Small stones mixed with sludge settle at the fundus and may fail to produce an acoustic shadow. Bile sludge is a thick, echo-dense fluid containing mucin, protein, calcium bilirubinate granules, and cholesterol monohydrate crystals [28, 29]. Bile sludge produces an irregular dense echo pattern within the gallbladder and does not produce an acoustic shadow (Fig. 9.1.6). Sludge formation increases after prolonged fasting or parenteral nutrition, and it usually clears after a fatty meal. Sludge formed during pregnancy disappears after delivery [15]. The sludge may collect at the dependent part of the gallbladder in a layered fashion and simulate settlement of the contrast agent (Fig. 9.1.7). About 15% of gallstones contain enough calcium to be seen on a plain abdominal X-ray film or on a CT scan [30].\n\nFig. 9.1.5\n\nDetection of gallstone with the ultrasound. Typically, the gallstone appears as hyperechoic within an acoustic shadow beyond the wall. Note one stone in the neck and another in the body of the gallbladder\n\nFig. 9.1.6\n\nBile sludge. On the ultrasound study the sludge appears as an irregular echo-dense mass without an acoustic shadow. Also note thickening of the wall\n\nFig. 9.1.7\n\nLayering of radiocontrast. High-density radiocontrast agent settles at the dependent part of the gallbladder and appears as a separate layer from bile\n\n### 9.1.5 Bile Aspiration\n\nWhen standard imaging procedures fail to show gallstones, duodenal bile aspiration is performed to demonstrate cholesterol crystals, the forerunner of gallstones. After positioning the tip of an orally passed tube in the second part of the duodenum, CCK-8 is infused intravenously to induce contraction and emptying of the gallbladder. The bile emptied from the gallbladder into the duodenum is aspirated through the naso-duodenal tube and examined under the microscope for stones or subjected to biochemical analysis [31]. The test is relatively invasive and expensive and used mostly for research purposes when all other simple methods fail to demonstrate gallstones.\n\n### 9.1.6 Quantitative Cholescintigraphy\n\nCholescintigraphy is used for measuring gallbladder motor function (ejection fraction) and for differentiating symptomatic from asymptomatic gallstones by closely monitoring the temporal relationship between the onset of pain and the phase of gallbladder emptying. A geometric technique for measurement of gallbladder volume by using an oral cholecystogram was first introduced in 1948 by deSilva [32]. A slightly modified method was adopted for volume measurement with the ultrasound [33]. Both oral cholecystogram and ultrasound are geometric methods and require that the gallbladder is of a particular shape (pear) before contraction and that it maintains that shape during and after contraction. It is widely recognized that the gallbladder has many different shapes when it is full and that it changes its shape to different forms during and after its contraction.\n\nTo overcome the theoretical disadvantages of a geometric technique, a counts-based, non-geometric cholescintigraphic method was introduced in 1981 [34]. The cholescintigraphic method does not require that the gallbladder be of a particular shape. Counts originating from the gallbladder accurately represent the bile volume (see Fig. 5.1.4, Chap. 5). Emptying is expressed as an ejection fraction by dividing counts emptied by the total counts before emptying. The technique is highly reproducible either with ingesting a fatty meal or after intravenous administration of cholecystokinin [35, 36]. The short serum half life (2.5 min) of cholecystokinin enables measurement of serial ejection fractions by administering two to four sequential doses of CCK-8 on a single occasion [37]. Such techniques enable the study of the effect of various drugs on the gallbladder or on the sphincter of Oddi function (Fig. 6.1.5, Chap. 6).\n\nCholescintigraphy is usually obtained 6-10 h after fasting (minimum 4 h) to ensure a maximum tightness of the sphincter of Oddi and maximum relaxation of the gallbladder. In patients with serum bilirubin less than 2 mg%, a dose of 2-3 mCi (74-111 MBq) of HIDA will suffice. Larger doses are required in patients with hyperbilirubinemia. During the first 60 min of data collection (hepatic phase imaging), a relatively larger fraction of the hepatic bile enters the gallbladder in both normal subjects and patients with gallstones. A gallbladder count rate of more than 35,000 min-1 by 30 min and more than 70,000 min- 1 by 45 min-1 is usual with a 5-mCi dose of Tc-99m-HIDA (Table 9.1.4). A gallbladder that appears early (within 10-15 min) shows a much higher count rate at 60 min (Fig. 9.1.8) than a gallbladder that visualizes late (between 30 and 60 min). In those 5-10% of the patients in whom the gallbladder appears late (after 50 min), it is necessary to wait 90 min to ensure adequate counts within the gallbladder. Variations in the time of appearance and rate of filling of the gallbladder are common and should be taken into account before proceeding with quantitative cholescintigraphy [38].\n\nFig. 9.1.8\n\nNormal cholescintigram. Gallbladder, intrahepatic and extrahepatic bile ducts, and duodenum all appear within 30 min in one patient (left), whereas the gallbladder appears by 60 min in another patient (right). Distal common bile duct has a convex left margin, and the first part of the duodenum stays closer to the gallbladder\n\nTable 9.1.4\n\nGallbladder counts following intravenous injection of 5 mCi Tc-99-HIDA in normal subjects and patients with gallstones [34]\n\nTime | Normal subject (n = 15) | Gallstone patients (n = 15)\n\n---|---|---\n\n15 min | 5,100 \u00b1 70 | 4,200 \u00b1 60\n\n30 min | 40,600 \u00b1 520 | 38,700 \u00b1 490\n\n45 min | 75,200 \u00b1 680 | 70,800 \u00b1 630\n\n60 min | 72,000 \u00b1620 | 78,100 \u00b1 710\n\n### 9.1.7 Fatty Meal Stimulation\n\nGallbladder emptying is under both nervous and hormonal control [39]. Nervous control is exerted via the cholinergic (vagus) and adrenergic nervous system. Gallbladder emptying in response to a sham feeding occurs via the cholinergic nerve stimulation and can be blocked completely with atropine or after vagotomy [40]. Gallbladder emptying after a meal, however, occurs predominantly through the release of endogenous cholecystokinin (hormonal control), while the nervous control plays a minor role.\n\nIt can take 10-20 min after a meal for the serum CCK level to rise above a threshold to induce contraction and emptying of the gallbladder. The mean latent period (time from fatty meal ingestion to the beginning of gallbladder emptying) is 15.5 min. Post-prandial serum CCK levels stay above the threshold for 2-3 h post-meal [41, 42], and the gallbladder emptying is maintained as long as the serum CCK levels remain above the threshold for contraction (Fig. 9.1.9).\n\nFig. 9.1.9\n\nRelationship between serum cholecystokinin (CCK) level and gallbladder emptying. Serum CCK level begins to rise soon after a meal, peaks by 10-30 min, and the level is maintained above the threshold for contraction for more than 90 min. Gallbladder maintains its emptying as long as the post-prandial serum CCK level remains above the threshold for contraction (modified from [41])\n\n### 9.1.8 Effect of Nutrients on Gallbladder Emptying\n\nThe degree of gallbladder emptying post-meal is dependent upon various factors, including the quality, quantity, total calorie intake, and the proportion of proteins, fats, and carbohydrates in the meal. A mean ejection fraction of 82% has been reported with a liquid meal consisting of 300 ml meritene, 15 ml lipomul with 36 g carbohydrates, 29 g of fats, and 10 g of proteins, and an ejection fraction of 64% with half-and-half milk [40, 43]. These results clearly show that one must strictly follow the investigator's protocol, while adopting values reported in the literature, or must establish local values if a different type of meal is used.\n\n### 9.1.9 Causes of Gallbladder Low Ejection Fraction\n\nMany conditions associated with a gallbladder low ejection fraction are listed in Table 9.1.5. A decrease in emptying is attributed to various factors, including wall fibrosis, a decrease in the total number of CCK receptors in the gallbladder wall, or inactivation of cholecystokinin by anti-cholecystokinin peptides in the serum [44]. The total number of CCK receptors in the gallbladder smooth muscle shows a direct correlation with the degree of emptying; the higher the receptor number, the greater is the ejection fraction, and vice versa [41]. Although a decrease in gallbladder emptying is a common feature of patients with cholelithiasis, a normal or even an exaggerated emptying has been reported in a few selected patients with cholelithiasis [45].\n\nTable 9.1.5\n\nCauses of gallbladder low ejection fraction\n\n(1) Cystic duct syndrome (chronic acalculous cholecystitis)\n\n---\n\n(2) Diabetes\n\n(3) Chronic calculous cholecystitis\n\n(4) Obesity\n\n(5) Common bile duct obstruction\n\n(6) Sphincter of Oddi spasm\n\n(7) Opiates\n\n(8) Somatostatin analogues (octreotide)\n\n(9) Anticholinergic drugs (atropine)\n\n(10) Congenital anomalies (septum, bilobed, etc.)\n\nA delay in the appearance of the gallbladder or low ejection fraction in response to CCK stimulation indicates a functional abnormality [46, 47]. The efficiency with which the wall absorbs water, sodium, and other electrolytes from the lumen is a reflection of the concentration function of the gallbladder and determines the time of appearance of the gallbladder in a Tc-99m-HIDA study. It has been argued in the past whether the abnormal concentration and contraction functions of the gallbladder precede or follow the development of the gallstones. Most of the conditions associated with a decrease in gallbladder emptying are also associated with a higher incidence of gallstones (Table 9.1.5). Patients with ulcerative colitis, for example, show a lower gallbladder ejection fraction and a higher incidence of gallstones when compared to a control group [48]. Treatment with octreotide, a somatostatin analogue, which decreases gallbladder emptying, also increases the incidence of cholelithiasis and cholecystitis [49]. Octreotide decreases gallbladder emptying by interfering with the release of both acetylcholine (cholinergic stimulation) and cholecystokinin (hormonal stimulation), and also by directly blocking the effect of cholecystokinin on the gallbladder wall [50]. The recent literature, therefore, appears to support the hypothesis that the functional abnormalities precede the development of gallstones by months or years.\n\nSome of the investigators suggest using ultrasound for measurement of both the gallbladder volume and emptying, and claim that it can substitute cholescintigraphy for measurement of emptying [51]. Ultrasound emptying measurements are subject to error due to change of shape, shift of axis, and other technical artifacts introduced during contraction and emptying of the gallbladder. Combining the geometric ultrasound technique for measurement of the resting volume (after making necessary volume correction) and non-geometric cholescintigraphy for measurement of gallbladder emptying overcomes many of the theoretical limitations of a geometric method. Combination offers the best features of both techniques for evaluation of gallbladder morphology and function [52].\n\n## 9.2 Chronic Acalculous Cholecystitis\n\nChronic acalculous cholecystitis (CAC), also known as cystic duct spasm or cystic duct syndrome, is one of two diseases that come under the broad category of 'biliary dyskinesia,' the other one being spasm of the sphincter of Oddi (Chap. 10). Biliary dyskinesia is a purely functional abnormality without an easily identifiable morphologic abnormality. The term cystic duct syndrome merely indicates the major site of functional abnormality. The syndrome was first described by Cozzolino et al. in 1961, but did not receive much clinical recognition until a reliable and easily reproducible diagnostic procedure became available for measurement of the gallbladder ejection fraction [1].\n\n### 9.2.1 Clinical Presentation\n\nPatients with chronic acalculous cholecystitis usually present with symptoms very similar to those with chronic calculous cholecystitis. Intermittent mild to moderate intensity right upper quadrant or epigastric pain is the most common presenting symptom. Pain begins 30-60 min after a meal and is often associated with nausea and vomiting. Post-prandial pain after dinner reaches its peak intensity at midnight. Women in their 30s and 40s are affected three to four times more frequently than men of similar age. The physical examination, liver function tests, blood counts, and serum amylase and lipase levels are normal. Gallbladder morphology remains normal, and no gallstones are found within the gallbladder.\n\n### 9.2.2 Histopathologic Features\n\nHistopathologic abnormalities are confined mostly to the cystic duct. There is kinking and narrowing of the cystic duct lumen due to thickening and fibrosis of the wall [2]. Adhesion and angulation of the infundibulum are common. The connection of the cystic duct with the common hepatic duct normally shows wide variations (Fig. 9.2.1). About 50% of cystic ducts join with the common hepatic duct along its right margin at a 45 degree angle, 18% pass behind the common hepatic duct before joining it along its left margin, and the remaining 32% show a spiral form before joining the common hepatic duct either in front or behind [3]. Microscopic examination of the cystic duct shows infiltration with chronic inflammatory cells, concentric thickening, and fibrosis of the media and adventitia with narrowing of the duct lumen (Fig. 9.2.2).\n\nFig. 9.2.1\n\nVariations in the union of the cystic duct with the common hepatic duct. The cystic duct usually joins the common hepatic duct at 45\u00b0 angle along its right margin (50%). It may pass behind the common hepatic duct before joining it on the left side (18%). A spiral cystic duct joins in front in 33% of the patients [3]\n\nFig. 9.2.2\n\nCystic duct histopathology in normal subjects and patients with cystic duct syndrome (CDS). Normal cystic duct wall shows thin mucosa, muscular layer, and adventitia. All three layers show inflammation and concentric thickening with narrowing of the lumen in CDS\n\n### 9.2.3 Functional Abnormality\n\nThe major abnormality pertains to the concentration and contraction functions of the gallbladder. Bile aspirated from the duodenum in patients with CAC shows a lower concentration of bile salts and phospholipids than in normal subjects [4]. Hepatic bile enters the gallbladder slowly through the narrowed cystic duct. Although the gallbladder may appear within 30 min in a Tc-99m-HIDA study (Fig. 9.2.3), a delayed appearance (after 40 min) is more common (Fig. 9.2.4). Some of the gallbladders may take as long as 2-3 h for their appearance. Late appearance is attributed to delayed and decreased entry of hepatic bile into the gallbladder primarily due to slow absorption of water and electrolytes through the wall. Gallbladder low ejection fraction in response to intravenous cholecystokinin or after a fatty meal ingestion is the characteristic feature. Low ejection fraction is due to a combination of several factors, of which wall fibrosis, a decrease in the total number of CCK receptors in the gallbladder wall, and a decrease in the cystic duct threshold for CCK are considered very important contributing factors (Fig. 9.2.5). A decrease in the cystic duct threshold with a paradoxical contraction is attributed to an activation of inhibitory CCK receptors, which induce contraction of the cystic duct instead of normal relaxation [5, 6]. A decrease in the smooth muscle threshold for CCK induces cystic duct contraction before the contraction of the fundus and body, with subsequent non-emptying of the gallbladder [7]. Unable to empty bile against a spasmodic cystic duct, the gallbladder contracts and assumes many different shapes, with globular being the most common form. Usually there is no bile reflux into the common hepatic duct or to the right and left hepatic ducts [8].\n\nFig. 9.2.3\n\nNormal bile formation and flow. Bile flow into the gallbladder may remain normal in some of the patients with cystic duct syndrome. The gallbladder, intrahepatic ducts, extrahepatic ducts, and small intestine are seen within 40 min. Radioactivity clears almost completely from the liver and enters the gallbladder at 60 min\n\nFig. 9.2.4\n\nDelayed gallbladder appearance. Gallbladder that does not appear by 30 min fills in by 60 min with fewer counts than normal. Intrahepatic and extrahepatic ducts are normal\n\nFig. 9.2.5\n\nGallbladder cholecystokinin (CCK) receptors in health and disease. A normal gallbladder rich with CCK receptors produces almost complete emptying, while the gallbladder with chronic cholecystitis elicits poor emptying because of paucity of CCK receptors\n\nDuring fasting, the serum endogenous cholecystokinin reaches its lowest level, which promotes the maximum increase in the tone of the sphincter of Oddi and maximum relaxation of the gallbladder wall. An increase in sphincter tone raises the sphincter of Oddi mean basal pressure to 15 cmH2O. The common bile duct and the gallbladder pressure are maintained at 12 cmH2O and 10 cmH2O, respectively. The pressure differences at these three levels promote preferential entry of the hepatic bile into the gallbladder as the bile seeks the path of the least resistance. During cholescintigraphy, Tc-99m-HIDA simply follows the path taken by the hepatic bile [8].\n\nAfter 4-6 h of fasting, a normal gallbladder is completely filled to its maximum capacity of 50 ml, but it continues to receive hepatic bile at the rate of 0.3 min. A completely filled gallbladder is able to accommodate an additional 0.3 ml of hepatic bile per minute simply by absorbing an equal volume of water through the wall. Absorption of water takes place along the lateral intercellular channels situated between the columnar cells of the mucosa (see Fig. 2.5, Chap. 2). These lateral intercellular channels are open widely during fasting when the gallbladder is completely relaxed, but they close tightly when the gallbladder contracts after a meal. These two factors, an increase in sphincter tone and absorption of water through the wall, are the primary mechanisms by which the gallbladder sequesters most bile salts during fasting. The process by which the gallbladder concentrates bile salts during fasting by selective absorption of water and electrolytes through the wall is called the concentration function of the gallbladder [9]. The concentration function can be measured quantitatively and non-invasively with cholescintigraphy using Tc-99m HIDA as described in Chap 2.\n\n### 9.2.4 Measurement of Gallbladder Ejection Fraction\n\n#### 9.2.4.1 Imaging Procedure\n\nThe patient preparation and data acquisition and analysis are monitored carefully. The patient fasts for a minimum of 4 h, preferably for 8-10 h. Detailed drug history is taken to ensure that the patient is not currently taking any medications that act either on the gallbladder or sphincter of Oddi. Opioids, calcium channel blockers, nitrates, sympathetic and parasympathetic agonists or antagonists, and other drugs that are known to act on the gallbladder or the sphincter of Oddi are withdrawn for a day or two before scheduling the patient for measurement of the gallbladder ejection fraction.\n\nThe data are collected with the large field of view gamma camera interfaced to an online computer in two separate phases: the hepatic phase between 0 and 60 min and gallbladder phase between 61 and 90 min. The hepatic phase data are collected on a 64 \u00d7 64 matrix as one frame per minute for 60 min, following intravenous injection of 2-3 mCi of Tc-99m-HIDA. After ascertaining the adequacy of counts within the gallbladder (Table 9.1.4), the gallbladder phase data are acquired. When the gallbladder appears late and does not contain adequate counts at the end of 60 min, a second dose of Tc-99m-HIDA is given at 60 min, and the gallbladder phase data collection is delayed for an additional 30-60 min. This delay ensures adequate counts within the gallbladder for measurement of the ejection fraction. Images are carefully scrutinized in cine display to check for superimposition of structures over one another, especially the superimposition of the gallbladder and duodenal radioactivity. In the supine position, the gallbladder fundus lies anteriorly and the neck posteriorly. Small gallstones often gravitate to the dependent posterior part and settle in the neck, blocking bile entry into the gallbladder. Changing the patient position to a right lateral decubitus position or asking the patient to walk for few minutes usually dislodges the stones from the neck and allows bile entry into the gallbladder. A septum at the neck may allow filling of the proximal segment and delay entry of radiolabeled bile into the distal segment (Fig. 9.2.6).\n\nFig. 9.2.6\n\nSepta at the neck (S). Bile enters the small proximal segment at the neck first (left) followed by delayed filling of the body and fundus (right) forming the distal segment (A). Ultrasound shows septa at the neck\n\n#### 9.2.4.2 Gallbladder Phase Data Acquisition and Analysis\n\nThis data collection usually occurs between 61 and 90 min after Tc-99m-HIDA injection, unless there is a delay in filling of the gallbladder [10-12]. If there is a superimposition of structures during the hepatic phase data collection, the gamma camera angle is changed to the position that maximally separates the gallbladder from the common bile duct and the duodenum. When the gallbladder and duodenum are superimposed, drinking a glass of water moves the duodenal radioactivity away from the gallbladder region of interest [13]. The data are collected at one frame per minute for 30 min. Beginning at 3 min, 3 ng kg-1min-1 of cholecystokinin-8 (sincalide, Bracco Diagnostics Inc., Princeton, NJ) is infused over 10 min through an infusion pump [8, 14].\n\nBefore the test begins, the patient is instructed to raise a hand when pain is experienced and raise the hand again when pain is relieved. The time of onset and relief of pain are noted on the gallbladder time\/activity curve to critically establish the temporal relationship between pain and the phase of gallbladder emptying. Biliary pain typically occurs during the gallbladder ejection period. Pain experienced after the ejection period is considered non-biliary in origin [8]. Saline may be infused as a placebo prior to cholecystokinin infusion. The gallbladder ejection fraction depends upon various factors, including the dose, dose rate, and the duration of infusion of sincalide. These variables are controlled strictly to obtain a consistent result. The gallbladder ejection fraction is calculated using the counts before and after emptying [14, 15]. The normal gallbladder ejection fraction is 35% and higher when 3 ng kg-1 min-1 CCK-8 is infused over 3 min, and 50% and higher when the identical dose rate is infused over 10 min. Large bolus doses of sincalide produce a non-physiological response and should be avoided.\n\nContraction and emptying of the gallbladder are initiated when sincalide binds to its receptors located in the smooth muscle, which are distributed irregularly in the wall (Fig. 9.2.7). The smooth muscle is much thicker in the fundus and neck than in the body and cystic duct. Cholecystokinin receptors located in the smooth muscle of the body, fundus, and cystic duct show varied thresholds for contraction. In dogs, for example, the smooth muscle in the cystic duct shows a much higher threshold (is less sensitive) than the smooth muscle in the fundus [5]. The cystic duct, therefore, does not contract when the fundus and body contract in response to a physiologic dose of sincalide. A dose rate within a physiologic range causes smooth, sustained, and coordinated contraction and emptying of the gallbladder.\n\nFig. 9.2.7\n\nValentine gallbladder. A bi-lobed gallbladder high in position fills with bile (top left). Each segment empties at different rate in response to CCK-8 infusion, with a total ejection fraction of 47.5% (top right). Cholangiogram (bottom) shows the septa in between two segments [18]\n\n#### 9.2.4.3 Sincalide Dose\n\nA low ejection fraction is often obtained in normal subjects when a large, non-physiologic dose rate of sincalide is given rapidly. In the package insert, the manufacturer of sincalide (Bracco Laboratory, Princeton, NJ) recommends a dose of 0.02 \u03bcg kg-1 (20 ng kg-1) given in 30-60 s. The recommended dose in the package insert for sincalide originally was developed for an oral cholecystogram or for stimulation of pancreatic enzyme secretion. This dose rate is too large for cholescintigraphy and often causes a low ejection fraction in normal subjects and should be avoided [7, 16, 17]. An optimal dose rate for cholescintigraphy is 3.0 ng kg-1 min-1 infused over 3 or 10 min. This dose rate (3 ng kg-1 min-1) is much lower than the dose recommended in the package insert. Currently, we have standardized the sincalide dose as 3 ng kg-1 min-1 for 10 min and consider GBEF of 50% or greater as normal. We hope that others will follow this procedure in total such that it becomes a universal standard. Local normal values should be established when a different sincalide dose rate or duration of infusion is chosen.\n\n#### 9.2.4.4 Congenital Abnormalities of the Gallbladder\n\nCongenital folds or septa often cause abnormalities in filling and emptying of the gallbladder [18]. An intrahepatic gallbladder may cause a filling defect in the liver in the early images (within 10 min) that fills later with radiolabeled bile and may not empty normally in response to CCK because of adhesion of its wall to the liver parenchyma. Often a gallbladder is divided into two segments of equal or unequal size (Valentine gallbladder) by a fold, and each segment may fill differently and empty at different rates in response to sincalide (Fig. 9.2.7). An epithelial fold or septa near the neck creates a pouch-like compartment (Hartmann pouch) where gallstones may lodge and delay or prevent bile entry into the distal compartment (Fig. 9.2.8). Septa in the middle of the gallbladder may allow normal filling of the proximal segment but delay the filling of the distal segment for 10-15 min. In such instances, only the proximal segment may empty bile normally, while the distal segment is prevented from emptying by the septa, which acts as a one-way valve (Fig. 9.2.9). Imaging at a shorter frame rate (one frame\/minute) enables easy recognition of such morphologic variations [19, 20]. Failure to recognize such morphologic abnormalities may provide false functional information. The distal segment, which fills late, may empty bile poorly, while the proximal segment shows a normal ejection fraction. Poor emptying of the distal segment may promote formation of gallstones. When the shape of the gallbladder in the anterior view mimics the duodenal loop, a right lateral view helps to separate them (Fig. 9.2.10). The gallbladder projects at the middle of the anterior liver border, while the common bile duct remains posterior in location. Cholescintigraphy usually does not show gallstones as a filling defect within the gallbladder due to mixing of Tc-99m-HIDA with gallbladder bile. A large gallstone, however, may occasionally become visible within the gallbladder when most of the bile empties in response to CCK-8 (Fig. 9.2.11).\n\nFig. 9.2.8\n\nHartmann pouch. Anterior (Ant) and posterior (Post) view cholescintigrams (top) show a pouch (H) at the neck (Hartmann pouch) of the gallbladder (GB). An ultrasound of the gallbladder (bottom) confirms the pouch at the neck\n\nFig. 9.2.9\n\nSepta in the body of the gallbladder. An ultrasound study shows a prominent septa in the body (top left).The proximal segment fills in by 58 min (top right), whereas the distal segment takes 3 h to fill in the cholescintigram (bottom). After CCK-8, mostly the proximal segment empties, with a total ejection fraction of 31%\n\nFig. 9.2.10\n\nCurved gallbladder. A comma-shaped gallbladder (GB) may mimic first part of the duodenum (DU). A right lateral view (RL) helps to visualize the long axis of the gallbladder and relationship with the common bile duct (CBD)\n\nFig. 9.2.11\n\nGallstone within the gallbladder. Radiolabeled hepatic bile enters the gallbladder (35 min), surrounds the gallstones, and obscures it (pre-CCK). The stones become obvious as a filling defect only after CCK-8-induced gallbladder emptying\n\n#### 9.2.4.5 Irritable Bowel\n\nAt the end of the hepatic phase imaging (60 min), most of the bile entering the duodenum moves and collects at the ligament of Trietz, jejunum, and proximal ileum. In a patient with irritable bowel syndrome, the bile moves much more rapidly through the small and large bowel, resulting in the visualization of the distal ileum and proximal colon. Administration of CCK-8 during the gallbladder phase in such patients increases the intestinal peristalsis and moves the bile much further away, resulting in the delineation of the entire ascending, transverse, and descending colon. This recognition of colon appearance is essential in separating the biliary from bowel pain (Fig. 9.2.12).\n\nFig. 9.2.12\n\nIrritable bowel. Bile transit is hastened by CCK-8 infusion. The bile emptied from the gallbladder after CCK-8 mixes with rest of the intestinal bile and moves rapidly through the ascending (AC), transverse (TC), and descending colon\n\n#### 9.2.4.6 Therapeutic Response to Cholecystectomy\n\nLaparoscopic or open cholecystectomy is the most appropriate therapy for cystic duct syndrome (Table 9.2.1). Of a total of 320 patients with cystic duct syndrome who underwent cholecystectomy solely on the basis of a low ejection fraction, 287 patients (90%) had relief of pain [21-27]. Histopathological examination showed evidence of gallbladder or cystic duct disease in 285 patients (89%). Such a high therapeutic success rate, however, is not universal. One report showed pain relief in only 69% of patients with the cystic duct syndrome [28]. Recent studies have identified Helicobacter DNA in both bile and the gallbladder wall of patients with chronic cholecystitis, raising the possibilities of an infection as a forerunner of chronic cholecystitis and of antibiotics having a role in the treatment [29, 30]. These therapeutic options may add new dimensions to the role of quantitative functional imaging in the diagnosis and management of patients with various types of gallbladder disease [31].\n\nTable 9.2.1\n\nCholescintigraphic, histopathologic, and post-cholecystectomy results in patients with cystic duct syndrome (chronic acalculous cholecystitis)\n\nAuthors [Ref] | No. of patients with pain and low EF (cholecystectomy) | No. of abnormal histopathology of the gallbladder | No. of patients with post-cholecystectomy relief of pain\n\n---|---|---|---\n\nPickelman et al. [20] | 19 | 11 | 18\n\nFink-Bennet et al. [21] | 124 | 115 | 105\n\nZack et al. [22] | 59 | 54 | 56\n\nMisra et al. [23] | 67 | 60 | 58\n\nHalverson et al. [24] | 12 | 10 | 10\n\nSorenson et al. [25] | 11 | 11 | 11\n\nKleiger et al. [26] | 28 | 26 | 27\n\nTotal | 320 | 287 (90%) | 285 (89%)\n\n#### 9.2.4.7 Standardization of Technique\n\nIn the literature, many different values have been reported for the post CCK-8 gallbladder ejection fraction. This wide variation is primarily due to differences in methodology. Variations in the dose, dose rate, and duration of infusion of CCK-8 influence the gallbladder ejection fraction. Unlike the left ventricular ejection fraction, which is controlled solely by the ventricle itself through its pace maker, the gallbladder ejection fraction can be controlled to any desired level simply by controlling the dose, dose rate, and duration of infusion of CCK-8.\n\nThe gallbladder contracts and empties bile as long as the serum cholecystokinin level is maintained above the threshold level. After cessation of CCK-8 infusion, the gallbladder emptying continues for an additional 8-12 min and then stops. The emptying resumes upon CCK-8 reinfusion. One can obtain as many as two to four sequential gallbladder ejection fractions following a single dose of Tc-99m-HIDA [14]. The CCK-8 contractile receptors in the cystic duct usually do not respond when the hormonal dose is within the physiologic limit. Large, non-physiologic doses, however, induce cystic duct contraction with subsequent non-emptying of a normal gallbladder [17]. The physiologic dose rate of cck-8 ranges from 1 to 4 ng kg-1 min-1. A steady-state serum cholecystokinin level can be achieved for 1-2 h by continuously infusing doses as low as 0.3 ng kg-1 min-1. A basal serum cholecystokinin level of less than 1 pmol l-1 raises to above 4 pmol l-1 by 10 min, reaches a peak level of 6.5 pmol l-1 by 30 min, and a steady-state level between 5 and 6 pmol l-1 can be maintained for as long as 70 min-1 by a constant infusion [16]. Infusion of a smaller dose over a longer period of time simulates postprandial CCK release and is much more effective than infusion of a larger dose as a bolus [7, 17].\n\n## 9.3 Acute Cholecystitis\n\nAcute cholecystitis is one of the common abdominal emergencies that require immediate diagnosis and therapy. It usually presents with right upper quadrant pain, fever, and leucocytosis. Since gallstones are found in nearly 10% of all Americans, a mere association between gallstone and abdominal pain with fever cannot be equated with a diagnosis of acute cholecystitis [1, 2]. The great majority of gallstones remains silent, and only about 15-20% ever become symptomatic [3]. About 85-90% of acute cholecystitis associated with gallstones is called acute calculous cholecystitis, and the remaining 10-15% without gallstones is called acute acalculous cholecystitis [4].\n\n### 9.3.1 Clinical Presentation\n\nAcute cholecystitis clinically presents as right upper quadrant or epigastric pain and fever, mimicking other abdominal and lower thoracic acute emergencies (Table 9.3.1). Pain may radiate to the right shoulder, mediastinum, or lower anterior chest, mimicking an acute myocardial infarction [5]. The pain radiation to the right lower quadrant may mimic an acute appendicitis or that radiating to the left lower quadrant may mimic an acute diverticulitis. Pain is due to distension of the inflamed gallbladder wall. On deep inspiration when the liver moves downwards, the fundus of the gallbladder extends below the right costal margin and is felt as a soft mass during deep palpation. When the palpating finger touches the inflamed gallbladder wall, the patient experiences pain and abruptly stops breathing. This is called Murphy's sign.\n\nTable 9.3.1\n\nDifferential diagnosis of acute cholecystitis\n\n(1) Acute pancreatitis\n\n---\n\n(2) Acute hepatitis\n\n(3) Gastritis\n\n(4) Acute appendicitis\n\n(5) Acute cholangitis\n\n(6) Acute nephritis\n\n(7) Angina or acute myocardial infarction\n\n(8) Pleurisy\n\n(9) Right lower lobe pneumonia\n\n(10) Acute diverticulitis\n\nAcute cholecystitis is three to four times more common in women than men, and the incidence increases with age. The clinical presentation of a calculous or an acalculous acute cholecystitis is very similar. A combination of fever with chills, right upper quadrant abdominal tenderness, and clinical jaundice is called Charcot triad. The triad is found more frequently when acute cholecystitis occurs in association with obstruction of the common bile duct. The place of maximum tenderness over the gallbladder fundus corresponds to the point where a line drawn between the left superior iliac spine and umbilicus meets the right costal margin when the line is extended upwards (Fig 9.3.1). This point also corresponds to the intersection of the lateral border of the right rectus abdominus muscle with the right ninth costal cartilage. Murphy's sign is readily elicited by deep palpation at this point. Clinical presentation of acute cholecystitis is variable and mimics varieties of other abdominal diseases, and hence, clinical diagnosis alone is not reliable to plan for a definitive therapy. The accuracy of clinical diagnosis alone ranges from 45 to 77% [6].\n\nFig. 9.3.1\n\nClinical location of the gallbladder fundus and Murphy's sign. A straight line drawn between the left anterior superior iliac spine and the umbilicus points to the fundus of the gallbladder when extended upwards to meet the right costal margin. This is also the point of Murphy's sign\n\nAcute cholecystitis is usually accompanied by leucocytosis; about 75% of patients have more than 10,000 white cells dl-1. Liver function tests usually remain normal, especially when the patients present early in the course of the disease. A few of the patients who present late may show a mild elevation of serum alkaline phosphatase and transaminase. An elevation of serum bilirubin indicates a complicated acute cholecystitis, such as acute cholangitis or obstruction of the common bile duct.\n\n### 9.3.2 Pathophysiology\n\nMacroscopic appearance of the gallbladder wall as seen directly by the surgeon just prior to cholecystectomy may reflect the true pathology much more accurately than the histopathological changes seen under the microscope after laparoscopic cholecystectomy. The microscopic findings after laparoscopic cholecystectomy may show changes secondary to tissue damage sustained during surgical manipulation and not necessarily the changes because of acute cholecystitis.\n\nThe histopathologic changes are divided into six evolving stages: (1) edema, (2) congestion, (3) focal necrosis, (4) suppuration, (5) gangrene, and (6) perforation. Edema is the earliest change initiated by infection or a gallstone impaction in the cystic duct or in Hartman's pouch. Edema leads to obstruction of the cystic duct and distension of the gallbladder [7]. When the gallbladder distends, the stone may get dislodged and fall back into the lumen, and the pathologic changes initiated by the stone may then subside completely with spontaneous recovery. When inflammation and edema of the cystic duct continue, a full blown picture of acute cholecystitis sets in, and edema extends to involve the rest of the gallbladder wall. Either wall edema or stone or a combination of both is the most common cause of obstruction of the cystic duct, which prevents entry of hepatic bile into the gallbladder, resulting in its non-visualization in a Tc-99m-HIDA study [8]. Acute inflammation increases the vascularity of the gallbladder wall and infiltration with inflammatory cells: neutrophils and monocytes during the acute phase and lymphocytes as it enters the subacute phase. Edema and infiltration with inflammatory cells produce thickening of the gallbladder wall, which is seen with ultrasonography [9].\n\nAs the focal necrosis progresses and becomes more diffuse, it may lead to the development of suppuration and abscess formation. Inflammation from the superior gallbladder wall, which lies in direct contact with the liver, often spreads to the adjoining liver tissue and causes edema and pericholecystic fluid collection, manifesting a \"rim sign\" of acute cholecystitis on cholescintigraphy [10]. When the necrosis becomes diffuse, the pain receptors often lose their sensation and produce a negative Murphy's sign. A negative Murphy's sign, therefore, is an ominous feature and calls for an immediate therapeutic intervention. Necrosis leads to ulceration and occasional perforation and bile leak. Due to its faraway location from the entrance of the cystic artery, the fundus is more vulnerable to ischemic necrosis, rupture, and bile leak than the body and neck. When the diagnosis and treatment of acute cholecystitis are delayed, the incidence of perforation and bile peritonitis increases to as high as 12% [11].\n\n### 9.3.3 Cholescintigraphic Approach\n\nThe patient should fast for a minimum of 4 h, preferably for 8-10 h, but not more than 24 h. Serum endogenous cholecystokinin reaches its lowest level during fasting, which promotes a maximum increase in the tone of the sphincter of Oddi and maximum relaxation of the gallbladder wall. A wide basal pressure difference between these two structures during fasting promotes preferential bile entry into the gallbladder when the cystic duct is patent, and Tc-99m-HIDA simply follows the path taken by the hepatic bile [12, 13].\n\n### 9.3.4 Hepatic Phase Imaging\n\nWith the patient in the supine position, a large field of view dual-head gamma camera fitted with a low-energy all-purpose collimator is positioned anteriorly and posteriorly over the upper abdomen to cover the entire liver. In patients with a normal bilirubin level, a dose of 2-3 mCi (74-111 MBq) Tc-99m-HIDA is injected intravenously, and the data are acquired at 1 frame\/minute for 60 min. Hypervascularity of the acutely inflamed gallbladder wall can be demonstrated by obtaining a radionuclide perfusion study by collecting the first minute data at 1 frame per 2 s [14]. A higher dose (3-6 mCi or 111-222 MBq) is needed when a perfusion study is desired. After completion of 60 min data collection, the images are viewed in cine mode display and reformatted at 2 frames\/image and recorded on X-ray film for interpretation.\n\n### 9.3.5 Delayed Imaging vs. Morphine Administration\n\nTwo options are available when the gallbladder is not seen by 60 min (during hepatic phase imaging) in a patient with clinically suspected acute cholecystitis. One option is to choose a delayed imaging protocol by obtaining images at 3-4 h after injection of Tc-99m HIDA, some times even at 24 h. The other option is to administer morphine (0.04 mg kg-1) intravenously at 60 min and take images immediately for an additional 30 min (total imaging time 90 min). In both cases, a second dose of Tc-99m-HIDA (1-3 mCi) is administered if the radiotracer from the first dose clears almost completely from the liver by 60 min.\n\nThe diagnostic sensitivity, specificity, and accuracy of cholescintigraphy using the delayed imaging protocol vary from 92 to 100% [15-20]. A mean sensitivity of 97%, specificity of 96%, and accuracy of 97% have been reported from a total of 1,426 patients from six reports (Table 9.3.2). The major disadvantage of the delayed imaging protocol is that it simply delays the diagnosis and hence the therapy.\n\nTable 9.3.2\n\nSensitivity, specificity, and accuracy of Tc-99m -HIDA cholescintigraphy in the diagnosis of acute cholecystitis by using a delayed imaging protocol (without using morphine)\n\nAuthors (Ref.) | No. of patients | Sensitivity (%) | Specificity (%) | Accuracy (%)\n\n---|---|---|---|---\n\nFonseca et al. [15] | 113 | 100 | 100 | 100\n\nFreitas et al. [16] | 186 | 97 | 87 | 94\n\nMatolo et al. [17] | 619 | 92 | 97 | 95\n\nMauro et al. [18] | 95 | 100 | 94 | 96\n\nSzlabick et al. [19] | 117 | 100 | 98 | 99\n\nWeissman et al. [20] | 296 | 95 | 99 | 98\n\nTotal | 1,426 | 97% | 96% | 97%\n\n### 9.3.6 Morphine Dose\n\nThe most popular imaging protocol for suspected acute cholecystitis is to administer morphine intravenously at 60 min if the gallbladder is not seen by then. Morphine acts immediately on the sphincter of Oddi and raises the sphincter pressure by increasing the frequency and amplitude of phasic waves [21]. The usual dose of morphine is 0.04 mg kg-1, infused intravenously over 1 min. A standard 70-kg weight patient would require a minimum total dose of 2.8 mg. Since morphine sulfate for intravenous use is packaged in a 2-mg unit dose, it is convenient to dispense a 4-, 6-, or 8-mg dose for adults. When the cystic duct is patent, morphine increases the sphincter of Oddi pressure and forces the hepatic bile entry the gallbladder [22-30]. Hepatic bile does not enter the gallbladder, despite morphine, if the cystic duct is obstructed, as is the case in patients with acute cholecystitis. A sensitivity of 96% and a specificity of 94% have been shown with the morphine protocol (Table 9.3.3). The major advantage of intravenous morphine is that it enables an early diagnosis, usually within 90 min, allowing the referring physician to plan for an appropriate therapy strategy immediately. The disadvantage of intravenous morphine is its central sedation. Caution is exercised while giving morphine to outpatients, and the patient is instructed not to drive for at least 8-10 h after receiving morphine.\n\nTable 9.3.3\n\nSensitivity and specificity of Tc-99m HIDA cholescintigraphy in the diagnosis of acute cholecystitis with morphine augmentation\n\nAuthors (Ref.) | Sensitivity | Specificity\n\n---|---|---\n\nChoy et al. [22] | 23\/24 (96%) | 35\/35 (100%)\n\nKim et al. [23] | 11\/11 (100%) | 18\/18 (100%)\n\nKeslar et al. [24] | 19\/19 (100%) | 12\/12 (100%)\n\nMehta et al. [25] | 18\/18 (100%) | 13\/13 (100%)\n\nVasquez et al. [26] | 10\/10 (100%) | 22\/26 (85%)\n\nFig et al. [27] | 12\/12 (100%) | 14\/17 (96%)\n\nKistler et al. [28] | 13\/14 (93%) | 14\/18 (78%)\n\nFink-Bennett et al. [29] | 35\/36 (97%) | 115\/117 (98%)\n\nKim et al. [30] | 24\/28 (86%) | 15\/17 (88%)\n\nTotal | 165\/172 (96%) | 258\/273 (94%)\n\n### 9.3.7 Scintigraphic Features of Acute Cholecystitis\n\nObstruction of the cystic duct is the salient pathophysiologic feature of acute cholecystitis (Fig. 9.3.2A). The most common cause of cystic duct obstruction is edema of the wall [7, 8]. Gallstones, which may initiate inflammation, often fall back into the lumen when the gallbladder distends, but the edema continues. A diagnostic test that establishes the status of the cystic duct (patency or obstruction), therefore, carries a much higher sensitivity and specificity than other morphology imaging modalities that only show gallstones, wall thickening, or pericholecystic fluid collection as indicators of acute cholecystitis (Fig. 9.3.2B). Documentation of the cystic obstruction in an appropriate clinical setting confirms the diagnosis of acute cholecystitis with a high degree of certainty [31]. Hypervascularity of an acutely inflamed gallbladder wall is seen in 72% of patients with acute cholecystitis and can be shown by including a Tc-99m-HIDA perfusion study as a part of the imaging protocol. Hypervascularity of the wall correlates with the severity of acute cholecystitis [14, 32].\n\nFig. 9.3.2\n\nAcute cholecystitis. Cholescintigraphic non-visualization of the gallbladder due to obstruction of the cystic duct is the most characteristic feature. Liver shows normal uptake excretion and the bile enters the duodenum (a). Ultrasound shows gallstones in the neck and thickening of the gallbladder wall (b)\n\n### 9.3.8 Pericholecystic Hepatic Retention of Tc-99m-HIDA or \"Rim Sign\"\n\nAn acute inflammation along the superior gallbladder wall often spreads to the adjoining liver parenchyma, causing focal hepatitis where pericholecystitic hepatocytes show a normal pattern of uptake, but a delayed excretion of Tc-99m-HIDA relative to the hepatocytes far away from the gallbladder, manifesting a thin strip of increased radioactivity along the gallbladder fossa in the late images (Fig. 9.3.3A). This is called a \"rim sign\" [33]. The spread of infection from the gallbladder wall into the adjacent liver tissue takes place via a special set of bile ducts called the \"aberrant ducts of Luschka\" [34]. These aberrant ducts connect the pericholecystic hepatocytes with the adventia of the gallbladder wall where they end blindly (Fig. 9.3.3B). An increase in intraluminal pressure because of inflammation produces pseudo-diverticulum in the gallbladder wall. Microorganisms from the superior gallbladder wall travel along these aberrant channels and pseudo-diverticulum and infect the hepatocytes and Kupffer cells of liver parenchyma.\n\nFig. 9.3.3\n\nRim sign of acute cholecystitis. Hepatocytes adjacent to the superior gallbladder wall show normal uptake, but a delayed excretion of Tc-99m-HIDA, resulting in a thin rim of increased radioactivity (arrow) along the gallbladder fossa (a). The gallbladder infection spreads to the liver via the aberrant bile ducts (Luschka) and inflammatory pseudo diverticulum (b), which end blindly in the adventia of the gallbladder wall [34]\n\nOn histopathological examination, the liver tissue from the rim sign region shows edema, sinusoidal congestion, hyperplasia of Kupffer cells, and obliteration of the canalicular lumen, impeding bile flow from the rim sign region [35]. Rim sign is found in 34-60% of patients with acute cholecystitis. Despite a strong positive predictive value, the rim sign alone does not carry a high enough specificity for acute cholecystitis to terminate cholescintigraphy at 60 min when the gallbladder is not seen. Morphine augmentation is necessary to increase the sensitivity, specificity, and overall diagnostic certainty (Table 9.3.3) before planning for a definitive therapeutic strategy [36]. Gangrene, abscess, and perforation of the gallbladder wall with bile leak are some of the complications of acute cholecystitis [37, 38]. Among patients with a definite rim sign, the frequency of complication is often as high as 45%. A gangrenous acute cholecystitis on the ultrasound study shows an edematous wall with thick sludge or pus within the gallbladder (Fig. 9.3.4).\n\nFig. 9.3.4\n\nGangrenous acute cholecystitis. Ultrasound shows edematous gallbladder wall, and the lumen contains hyper-echoic pus or bile sludge\n\n### 9.3.9 Gallbladder Pre-Emptying with CCK\n\nSome advocate intravenous cholecystokinin with the notion that pre-emptying, prior to cholescintigraphy, facilitates rapid gallbladder filling when the cystic duct is patent. Administration of cholecystokinin prior to cholescintigraphy is counterproductive physiologically as it creates conditions that are just the opposite of what is required for diversion of hepatic bile into the gallbladder. By stimulating contraction of the gallbladder and relaxation of the sphincter of Oddi, cholecystokinin promotes free bile flow directly into the duodenum (Chap. 6). Comparison of studies with and without CCK-8 pre-emptying shows a much lower specificity for studies obtained with a CCK-8 pre-emptying protocol. The specificity of cholescintigraphy without CCK-8 pre-emptying is 94%, in contrast to 81% with a CCK-8 pre-emptying protocol. Pre-emptying with CCK-8, however, does not alter the sensitivity (94%) of cholescintigraphy [39]. In a study of 86 patients using a CCK-8 pre-emptying protocol, the gallbladder did not visualize by 60 min in 43 patients. In 18 of these 43 patients, the gallbladder filled in only after the use of intravenous morphine, indicating the necessity of maximizing the tonus of the sphincter of Oddi prior to cholescintigraphy [40]. Pre-emptying is appropriate in patients on hyperalimentation or those who have waited for longer than 24 h (Fig. 9.3.5).\n\nFig. 9.3.5\n\nProtocol for Tc-99m-HIDA study. Four-hour fasting is the minimum, 8-10 h is ideal, and more than 24 h fasting should be avoided. Morphine or CCK-8 use depends upon the clinical situation at hand\n\nThe decision as to when to use morphine vs. cholecystokinin is dependent upon the clinical challenge at hand. Administration of morphine is appropriate in a clinical setting of acute cholecystitis, and its use is inappropriate in a clinical setting of biliary dyskinesia. Administration of cholecystokinin, on the other hand, is appropriate in a clinical setting of biliary dyskinesia, but not in patients with acute cholecystitis [39]. Rarely, there is a need to use both agents sequentially in a given patient [41, 42].\n\n### 9.3.10 Cholangitis\n\nThe superior gallbladder wall not covered by the peritoneum lies directly against the inferior surface of the liver (the bare area). The aberrant ducts of Luschka and inflammatory pseudo-diverticulum serve as the shortest and most direct route for spreading infection from the gallbladder wall to the biliary canaliculi and hepatocytes (Fig. 9.3.3B). The microorganisms responsible for acute cholecystitis travel along these aberrant ducts and cause acute cholangitis. Clinically acute cholangitis is suggested by the onset of the Charcot triad of fever and chills accompanied by gallbladder tenderness and jaundice in the absence of obstruction of the common bile duct. The characteristic features of a combined acute cholecystitis and acute cholangitis on cholescintigraphy include non-visualization of the gallbladder (despite morphine), delayed clearance of Tc-99m-HIDA from the entire liver (intrahepatic cholestasis), leucocytosis, right upper quadrant pain, fever, and jaundice (Fig 9.3.6). Rim sign is typically absent due to diffuse retention of Tc-99m-HIDA by the liver, not just by the pericholecystic hepatocytes.\n\nFig. 9.3.6\n\nAcute cholecystitis and acute cholangitis. The gallbladder is non-visualized, and there is diffuse retention of Tc-99m HIDA by the liver parenchyma. Rim sign is absent, and bile enters the duodenum\n\n### 9.3.11 Differential Diagnosis of Acute Cholecystitis\n\nMany diseases are to be considered in the differential diagnosis in any patient who presents clinically with abdominal pain, fever, and leucocytosis (Table 9.3.1). Pain due to a right renal stone is colicky in nature and very severe in intensity when compared to pain of acute cholecystitis, which tends to be of moderate intensity. A renal stone often causes hematuria as it passes through the ureter. The pain due to viral hepatitis is mild in intensity and is accompanied by abnormal liver function tests. The viral hepatitis profile confirms the diagnosis. Acute pancreatitis and acute cholecystitis often coexist. Non-visualization of the gallbladder in association with a rise in serum amylase or lipase indicates the co-existence of acute cholecystitis and acute pancreatitis [43, 44]. A peptic ulcer may cause epigastric pain mimicking cholecystitis. Infection with Helicobacter pylori is now the most common cause of peptic ulcer. These bacteria produce the enzyme urease that splits C-14 labeled urea in the stomach and liberates C-14-labeled carbon dioxide, which is eliminated in the expired breath. A positive C-14 urea breath test confirms active H. pylori infection. Gallbladder pain radiation upwards into the chest and shoulder may mimic an anginal pain. An abnormal electrocardiogram, elevation of cardiac enzymes, or abnormal Tc-99m pyrophosphate myocardial image helps confirm a cardiac origin of acute pain. A thorough clinical evaluation along with the measurement of an appropriate biochemical profile aids the primary care physician in requesting the most appropriate imaging test to either confirm or rule out each diagnostic possibility.\n\n### 9.3.12 Comparison of Cholescintigraphy and Ultrasound\n\nImmediately after the introduction of Tc-99m-HIDA agents in 1976 and up until 1984, most cholescintigraphic studies were carried out with the first-generation agents using a delayed imaging protocol, which often delayed diagnosis, sometimes for up to 24 h. The diagnostic time interval using the current generation Tc-99m-HIDA agents is now reduced to less than 90 min by administering morphine intravenously at 60 min when the gallbladder is not seen in a patient with suspected acute cholecystitis. A meta-analysis of 2,466 patients from 30 reports revealed cholescintigraphy as the test of choice for acute cholecystitis and ultrasound for cholelithiasis [45]. For acute cholecystitis, the cholescintigraphic sensitivity is 97% (95% confidence interval, 0.96-0.98) and specificity 90% (95% confidence interval, 0.86-0.95). Morphine administration shortens the diagnostic time interval, but does not alter the sensitivity or specificity when compared to delayed imaging protocols (Tables 9.3.2 and 9.3.3). Adjusted sensitivity of ultrasound for acute cholecystitis is 88% (95% confidence interval, 0.74-1.0) and specificity 80% (95% confidence interval, 0.62-0.98). Adjusted sensitivity for detection of cholelithiasis with the ultrasound is 84% (95% confidence limit, 0.76-0.92) and adjusted specificity is 99% (95% confidence interval, 0.97-1.0). Since the salient pathophysiology of acute cholecystitis is cystic duct obstruction, cholescintigraphy, which establishes the status of the cystic duct (patency or obstruction), is much more reliable than ultrasound or CT, both of which depend upon wall thickening as an indicator of acute cholecystitis.\n\n### 9.3.13 Application of Baye's Analysis\n\nClinical diagnosis is often a probability estimate based on the frequency of the disease in the study population. Because it is impossible to study the entire population, the estimates are made from studies comprising a limited number of samples from the population at risk. After the clinical examination, a clinician makes a rough estimate of the disease probability (pre-test probably) based on the frequency of that disease found in that particular population. Imaging tests are requested either to confirm the clinical diagnosis or rule out the disease from consideration with a high degree of certainty. The clinicians feel more comfortable to proceed with a definitive therapeutic strategy after confirmation of acute cholecystitis by an imaging procedure. When the clinical diagnosis is not confirmed by the imaging test, then the clinicians have the option of accepting the results of the imaging test as final or ignore it completely and obtain additional diagnostic tests.\n\nMost imaging procedures are interpreted subjectively, and they provide a dichotomous result in the form of either the disease being present or absent. The probability of a disease being present or absent after an imaging test (post-test probability) depends upon various factors, including the sensitivity, specificity, false-positive, and false-negative ratio of the test, and the prevalence of the disease in the study population. Probabilities are assessed by applying Bayesian analysis [46, 47]. After conducting a thorough clinical evaluation and obtaining a basic biochemical profile, the clinician arrives at a tentative clinical diagnosis and then chooses one of the diagnostic imaging tests for confirmation. In the case of acute cholecystitis, Tc-99m-HIDA cholescintigraphy and ultrasound are two of the most common imaging options, and the clinician may decide to choose either one or both for confirmation.\n\n### 9.3.14 Target Disease | Target disease\n\n---|---\n\nTest Result | Present | Absent\n\nPositive | a | b\n\nNegative | c | d\n\n<<Probability of acute cholecystitis when the imaging test is positive or negative is given by the following formulas.\n\n![\n$$\\\\begin{array}{l}\n{\\\\rm Probability\\\\ of\\\\ acute\\\\ cholecystitis\\\\ when\\\\ the\\\\ testispositive}\\\\left\\( {{\\\\rm abnormal}} \\\\right\\) \\\\\\\\\n= \\\\frac{\\\\left\\[ \\\\begin{array}{c}\n{\\\\rm Sensitivity} \\\\times {\\\\rm Prevalence\\\\ of\\\\ acute}\\\\\\\\\n{\\\\rm cholecystitis\\\\ in\\\\ the\\\\ study\\\\ population}\\\\\\\\\n\\\\end{array}\\\\right\\]}{\\\\left\\[ \\\\begin{array}{l}\n{\\\\rm Sensitivity} \\\\times {\\\\rm Prevalance}\\\\\\\\\n{\\\\rm of\\\\ acute\\\\ cholecystitis}\\\\\\\\\n{\\\\rm in\\\\ the\\\\ study\\\\ population}\\\\\\\\\n\\\\end{array} \\\\right\\] + \\\\left\\[ \\\\begin{array}{l}\n{\\\\rm Falsepositive}\\\\\\\\\n{\\\\rm fraction} \\\\times {\\\\rm Prevalence\\\\ of\\\\ no\\\\ acute}\\\\\\\\\n{\\\\rm cholecystitis\\\\ in\\\\ the\\\\ study}\\\\\\\\\n{\\\\rm population}\\\\\\\\\n\\\\end{array} \\\\right\\]} \\\\\\\\\n\\\\end{array}$$\n](A978-3-642-00648-7_9_Chapter_TeX2GIF_Equ1_9.gif)\n\n![\n$$\\\\begin{array}{l}\n{\\\\rm Probability\\\\ of\\\\ acute\\\\ cholecystitis\\\\ when\\\\ the\\\\ testispositive }\\\\left\\( {{\\\\rm abnormal}} \\\\right\\) \\\\\\\\\n= \\\\frac{{\\\\left\\[ \\\\begin{array}{c}\n{\\\\rm False - negative\\\\ fraction} \\\\times {\\\\rm Prevalence\\\\ of\\\\ actue\\\\ cholecystitis\\\\ in\\\\ the}\\\\\\\\\n{\\\\rm study\\\\ population}\\\\end{array} \\\\right\\]}}{{\\\\left\\[ \\\\begin{array}{l}{\\\\rm False - negativefraction} \\\\times {\\\\rm prevalence}\\\\\\\\\n{\\\\rm of\\\\ acute\\\\ cholecystitis\\\\ in}\\\\\\\\\n{\\\\rm the\\\\ study\\\\ population}\\\\end{array} \\\\right\\] + \\\\left\\[ \\\\begin{array}{l}\n{\\\\rm Specificity} \\\\times\\\\\\\\\n{\\\\rm Prevalence\\\\ of\\\\ no}\\\\\\\\\n{\\\\rm acute\\\\ cholecystitis\\\\ in}\\\\\\\\\n{\\\\rm the\\\\ study\\\\ population}\\\\end{array} \\\\right\\]}} \\\\\\\\ \\\\end{array}$$\n](A978-3-642-00648-7_9_Chapter_TeX2GIF_Equ2_9.gif)\n\nPre-test probability (prevalence): The proportion of patients who have the target disease, as determined before the test is carried out = a + c\/a + b + c + d.\n\nPost-test probability: The proportion of patients with the target disease with a positive test.\n\nLikelihood ratio (LR): It is the ratio of the probability of a test result among the patients with the target disease to the probability of the same test result among patients who do not have the target disease.\n\nThe likelihood ratio for a positive test = sensitivity\/1-specificity.\n\nThe likelihood ratio for a negative test = 1-sensitivity\/specificity\n\nAfter knowing the pre-test (clinical evaluation) and post-test (after an imaging procedure) probability, the clinicians can calculate the Bayes factor or likelihood ratio of the target disease prior to subjecting the patient to a definitive therapy. The Bayes factor is considered more objective and can substitute for a p value of a null hypothesis [48, 49]. By referring to the nomogram (Fig 9.3.7), the post-test likelihood ratio is obtained directly without need for an actual calculation [50, 51]. The likelihood ratio corresponds to the point where a straight line drawn between the pre-test probability and post-test probability intersects the likelihood ratio line in the middle. Let us assume that in a patient with right upper quadrant pain and fever, the pre-test probability of acute cholecystitis (after the clinical examination) is 20%. If the gallbladder is not visualized in a Tc-99m-HIDA study (97% sensitivity), the likelihood ratio of acute cholecystitis is approximately 200. The cost effectiveness of a positive (GB not seen) Tc-99m HIDA test is greater when the pre-test probably is lower, and the cost effectiveness decreases as the pre-test probably increases to a very high level.\n\nFig. 9.3.7\n\nNomogram for likelihood ratio. A line drawn between the pre-test (clinical diagnosis) and post-test (after imaging test) probability intersects the line in the middle and indicates the likelihood ratio [51]\n\nThe discriminating power of a test is the difference in post-test probability between a positive (gallbladder not seen) and a negative test (gallbladder seen) for acute cholecystitis [31]. The wider the difference between positive and negative tests, the greater is the discriminating power (Fig. 9.3.8). Cholescintigraphy, which establishes the patency or obstruction of the cystic duct (the basic pathology of acute cholecystitis), provides a much better discriminating power than ultrasound. Ultrasound, which detects gallstones and thickness of the gallbladder wall but does not establish the status of the cystic duct, therefore, provides a much lower discriminating power for acute cholecystitis (Fig. 9.3.9). The discriminating power of a test works at its best when the prevalence of disease in the study population is around 50%. The discriminating power decreases precipitously when the prevalence is below 20% or above 80% [31].\n\nFig. 9.3.8\n\nRelative merits of imaging tests for acute cholecystitis. Radionuclide imaging (cholescintigraphy) and oral cholecy-stogram, which establish the status of the cystic duct, show a wider difference between a positive (cystic duct not patent) and negative test (cystic duct patent) when compared to ultrasound, which shows only gallstones and wall thickening\n\nFig. 9.3.9\n\nDiscriminating power. The difference between a positive (gallbladder not seen) and a negative test (gallbladder seen) probability is the discriminating power of the diagnostic test. A positive cholescintigraphy and oral cholecystography in an appropriate clinical setting confirm acute cholecystitis. A negative test (gallbladder seen) rules out acute cholecystitis. Ultrasound shows the least discriminating power for acute cholecystitis [31]\n\nApplication of Baysian analysis requires the establishment of true sensitivity and specificity of an imaging test. The ultimate diagnosis of acute cholecystitis, however, is based upon the histopathological criteria chosen by the pathologist. Some pathologists are satisfied with the mere presence of transmural inflammation of the gallbladder wall, while others insist upon the presence of hemorrhage and necrosis before assigning the definitive diagnosis of acute cholecystitis. The best combination of sensitivity and specificity for cholescintigraphy is obtained when the presence of any one of the above two histological criteria is chosen as the basis for the diagnosis of acute cholecystitis [52]. Under an appropriate clinical setting, most clinicians are satisfied with the cholescintigraphic documentation of cystic duct obstruction as sufficient evidence for the diagnosis of acute cholecystitis in planning for a definitive therapy.\n\n### 9.3.15 Acute Acalculous Cholecystitis\n\nClinically, it presents very similarly to acute calculous cholecystitis, but has few unique clinical features of its own. The patients are usually much older and have additional risk factors, such as a recent surgery, crush injury, burns, sepsis, or hyperalimentation. About 10-15% of all acute cholecystitis belongs to the acalculous variety. The incidence of acute acalculous cholecystitis appears to be increasing recently, which may be attributed to increased clinical awareness and sensitivity of the diagnostic tests [53]. The morbidity and mortality of acute acalculous cholecystitis are much higher than in acute calculous cholecystitis. As obstruction of the cystic duct is common for both conditions, the diagnostic sensitivity of cholescintigraphy is similar for both calculous and acalculous acute cholecystitis [54, 55]. Edema (and not the stone) as the primary cause of cystic duct obstruction is easy to appreciate in the case of acute acalculous cholecystitis, as there are no gallstones associated with it.\n\n### 9.3.16 Gallbladder Cancer\n\nGallbladder cancer is a relatively rare, but highly lethal disease. In the United States, about 7,100 new cases per year are found, and 3,500 deaths are attributed to it annually [56]. There are no specific symptoms that draw special attention, and the majority of cancers are advanced at the time of diagnosis. Many are discovered incidentally during microscopic examination of the gallbladder specimen submitted after a routine cholecystectomy for a benign cause (gallstone). Adenocarcinomas account for 80-95% cases, and the rest include squamous cell and undifferentiated or anaplastic type. Cholecystectomy is the initial therapy, but prognosis is poor [57]. The role of chemotherapy and\/or radiation therapy is not well established.\n\n## 9.4 Management of Gallbladder Disease\n\nCholecystectomy is the treatment of choice for most diseases of the gallbladder. The very first cholecystectomy was performed in 1882 by a German surgeon, Langenbach [1]. Today as many as 600,000 cholecystectomies are performed annually in the United States with either laparoscopic or open cholecystectomy. Open cholecystectomy carries a mortality rate ranging from 0 to 2.4% and morbidity ranging from 4.1 to 14.7%. The incidence of bile duct injury varies from 0.06 to 0.45% [2]. Laparoscopic cholecystectomy, which has now almost replaced open cholecystectomy, carries a similar rate of mortality, but a slightly lower morbidity (1.6-12%) than open cholecystectomy [3]. Laparoscopic cholecystectomy in the beginning was restricted mostly to symptomatic cholelithiasis, but now it is performed for varieties of gallbladder diseases, including acute cholecystitis, gangrenous cholecystitis, hydrops, and empyema, etc. [4]. The young as well as the old patients tolerate the laparoscopic cholecystectomy procedure well, and the hospital stay is much shorter than with an open cholecystectomy [5]. Administration of prophylactic antibiotics does not seem to affect the rate of wound infection in case of elective laparoscopic cholecystectomy [6]. Laparoscopic cholecystectomy for symptomatic gallstone disease during pregnancy is considered safe both for the mother and fetus, and is preferred over conservative management for all trimesters [7].\n\n### 9.4.1 Complications\n\nThe complications of acute cholecystitis can occur either before or after treatment. The complications of delayed or untreated acute cholecystitis include acute cholangitis, gallbladder perforation, and bile leak. Post-operative complications include bile leak, cholangitis, infection, and stricture formation. Bile fistula occurs as a chronic complication.\n\n### 9.4.2 Perforation of the Gallbladder\n\nPerforation of the gallbladder is rare and is found in 10% of patients undergoing open cholecystectomy for acute gangrenous cholecystitis [8]. The bile may leak into a small closed space or leak freely into the peritoneum, causing bile peritonitis. Localized leak is the most common type and accounts for 50% of all perforations (Fig. 9.4.1). Most of the localized leaks and those that form fistula remain undiagnosed as they usually do not produce symptoms. Free perforation with bile peritonitis presents with the most disabling symptoms and is responsible for many deaths if not treated immediately. Most perforations into the subhepatic space are walled off and manifest very few symptoms. Perforation near the neck or Hartmann pouch may form a biloma and compress the common bile duct externally, manifesting a Mirizzi syndrome.\n\nFig. 9.4.1\n\nTypes of gallbladder perforation. Subhepatic bed is the most common site, followed by leak into free peritoneum and colon. Perforation near the neck and Hartmann pouch may form a biloma and compress the common bile duct extrinsically, manifesting a Mirizzi syndrome [7]\n\n### 9.4.3 Bile Leak\n\nThe most common complication of laparoscopic cholecystectomy is bile leak through an unligated cystic duct or from an injury to the common hepatic or common bile duct (Fig. 9.4.2). Leak is best defined as bile collection in an unanticipated location or in an anticipated location at an unanticipated time. The common hepatic duct, which lies directly in front of the tip of the laparoscopic instrument, sustains injury more frequently than other bile ducts. The incidence of bile duct injury from laparoscopic cholecystectomy is twice as frequent as from open cholecystectomy. The consequence of bile leak depends upon its volume and location. A small volume subhepatic bile leak (Fig. 9.4.2A) or large volume bile leak into the stomach (Fig. 9.4.2B) causes few of the symptoms. Large volume hepatic subcapsular leak (Fig. 9.4.2C) or leak into the peritoneal cavity (Fig. 9.4.2D) requires treatment. Since the leak prefers the path of least resistance, major bile ducts often are not visualized beyond the point of the leak (Fig. 9.4.2).\n\nFig. 9.4.2\n\nLocations of bile leak. Bile may leak into subhepatic space (top left), stomach (top right), right subdiaphragmatic (bottom left), or peritoneal space (bottom right)\n\n### 9.4.4 Treatment of Bile Leak\n\nSmall volume bile leaks close spontaneously if the tonus of the sphincter of Oddi is maintained at its minimum by treating patients with antispasmodics (Fig. 9.4.3). Use of opioids is avoided. Large volume bile leaks may require sphincterotomy. Sphincterotomy creates the path of least resistance for hepatic bile and promotes closure of the leak (Fig. 9.4.4A, B). Often the leak from the common hepatic or common bile duct may require stents or surgical repair. Malignant strictures usually require stents [9].\n\nFig. 9.4.3\n\nSpontaneous closure of bile leak. Bile leak into the lateral aspect of the right lobe 2 days after cholecystectomy (left) stops spontaneously after 12 days (right). Narcotics that constrict the sphincter of Oddi were discontinued during this time period\n\nFig. 9.4.4\n\nClosure of bile leak after sphincterotomy. A large volume bile leak through an unligated cystic duct (top) required sphincterotomy for its stoppage (bottom)\n\n### 9.4.5 Bile Duct Stricture\n\nThe frequency of postoperative bile duct stricture is much higher after laparoscopic than after open cholecystectomy (Table 9.4.1). Most postoperative strictures occur in the proximal one half of the common hepatic duct, often involving its bifurcation into right and left hepatic ducts. Strictures near the bifurcation are treated with Hepp-Couinaud hepaticojejunostomy using the left hepatic duct [10]. Lately, the design of laparoscopic instruments has improved, and it is now possible to perform cholecystectomy safely with needles as small as 3 mm in diameter [11]. Postoperative strictures commonly occur at the site of ductal injury and are classified into four grades depending upon its location from the bifurcation into left hepatic with right hepatic duct [12]. Grade I strictures are more than 2 cm, grade II less than 2 cm from the union, grade III are at or just below the union, and grade IV at the site of union. Well-designed prospective studies have shown that immediate cholecystectomy is much more cost-effective than delayed elective cholecystectomy [13-16].\n\nTable 9.4.1\n\nComplications of open vs. laparoscopic cholecystectomy [3]\n\nComplication | Open cholecystectomy (%) | Laparoscopic cholecystectomy (%)\n\n---|---|---\n\nCBD injury | 0.1 | 0.2\n\nBile leak | 0.8 | 5.6\n\nPancreatitis | 1.0 | 1.1\n\nJaundice | 1.2 | 1.0\n\nAtelectasis | 10.0 | 5.4\n\nIleus | 12.0 | 5.3\n\nUrinary retention | 17.4 | 6.5\n\nPostoperative subhepatic fluid collection is common and is noted in as many as 25% of the patients following an open cholecystectomy [17], but only about 30-45% of this subhepatic fluid collection is due to bile leak [18]. Bile fistulae as a consequence of acute and chronic complications occur in the subhepatic space, duodenum, stomach, or hepatic flexure of the colon (Fig. 9.4.5).\n\nFig. 9.4.5\n\nCommon sites of biliary fistula. Fistulas occur as a complication of either acute or chronic cholecystitis. Most of them remain asymptomatic\n\n### 9.4.6 Prophylactic Cholecystectomy\n\nPatients with asymptomatic gallstones or diabetes mellitus usually show a decrease in gallbladder emptying, but generally do not require cholecystectomy when either disease exists alone [19, 20]. However, patients with a combination of asymptomatic gallstones and diabetes mellitus develop acute cholecystitis and its complications 2.2 times more frequently than with either disease alone. Based upon such findings, prophylactic cholecystectomy is recommended for asymptomatic gallstone patients with diabetes mellitus [21]. Prophylactic cholecystectomy is also recommended for patients undergoing cardiac transplantation, but not for those undergoing renal transplantation [22, 23]. Newer therapy in the form of oral dissolution, contact dissolution, and extracorporeal biliary lithotripsy has been used less and less frequently in recent years [24]. Some of the preventive measures are known to reduce the incidence of gallstones and accompanying complications. A 30-min exercise five times a week reduces symptomatic gallstones by 34% in men [25], and recreational physical activity (jogging, running, bicycling) reduces the incidence of symptomatic gallstones and cholecystectomy significantly in women [26].\n\nReferences\n\n1.\n\nWilliams R. Global challenges in liver disease. Hepatology 2006;44:521-526PubMed\n\n2.\n\nSandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Goodman C, Gemmen E, Shah S, Avdic A, Rubin R. The burden of selected digestive diseases in the United States. Gastroenterology 2002;122:1500-1511PubMed\n\n3.\n\nEverhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999;117:632-639PubMed\n\n4.\n\nSampliner RE, Bennett PH, Comess LJ, Rose FA, Burch TA. Gallbladder disease in Pima indians. Demonstration of high prevalence and early onset by cholecystography. N Engl J Med 1979;283:1358-1364\n\n5.\n\nMiquel JF, Covarrubias M, Villaroel L, Mingrone G, Greco AV, Puglielli L, Carvallo P, Marshall G, Del Pino G, Nervi F. Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris. Gastroenterology 1998;115:937-946PubMed\n\n6.\n\nMoro PL, Checkley W, Gilman RH, Lescano G, Bonilla JJ, Silva B, Garcia HH. Gallstone disease in high-altitude Peruvian rural population. Am J Gastroenterol 1999;94:153-158PubMed\n\n7.\n\nRome Group for the Epidemiology and Prevention of Cholelithiasis (GREPO). Prevalence of gallstone disease in an Italian adult female population. Am J Epidemiol 1984;119:796-805\n\n8.\n\nGodrey PJ, Bates J, Harrison M, King MB, Padley NR. Gallstones and mortality: a study of all gallstone related deaths in a single health district. Gut 1984;25:1029-1033PubMed\n\n9.\n\nLayde PM, Vessey MP, Yeates D. Risk factors for gall-bladder disease: a cohort study of young women attending family planning clinics. J Epidemiol Community Health 1082;36:274-278\n\n10.\n\nLindstrom CG. Frequency of gallstone disease in a well-defined Swedish population. A prospective necropsy study in Malmo. Scand J Gastroenterol 1977;12:341-346PubMed\n\n11.\n\nGracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth. N Engl J Med 1982;307:798-800PubMed\n\n12.\n\nMcSherry CK, Ferstenberg H, Calhoun WF, Lahman E, Virshup M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann Surg 1985;202:59-63PubMed\n\n13.\n\nThistle JL, Cleary PA, Lachin JM, Hersh T. The natural history of cholelithiasis: the National Co-operative Gallstone Study. Ann Intern Med 1984;101:171-175PubMed\n\n14.\n\nWilliams PT. Independent effects of cardiorespiratory fitness, vigorous physical activity, and body mass index on clinical gallbladder disease risk. Am J Gastroenterol 2008;103:2239-2247PubMed\n\n15.\n\nValdivieso V, Covarrubias C, Siegel F, Cruz F. Pregnancy and cholelithiasis: pathogenesis and natural course of gallstones diagnosed in early puerperium. Hepatology 1993;17:1-4PubMed\n\n16.\n\nDonovan JM, Carey MC. Physical-chemical basis of gallstone formation. Gastroenterol Clin North Am 1991;20:47-66PubMed\n\n17.\n\nHolzbach RJ, Busch N. Nucleation and growth of cholesterol crystals. Kinetic determinates in supersaturated native bile. Gastroenterol Clin North Am 1991;20:67-84PubMed\n\n18.\n\nLaMont JT, Smith BF, Moore JRL. Role of gallbladder mucin in pathophysiology of gallstones. Hepatology 1984;4(Suppl):51S-56SPubMed\n\n19.\n\nAdmirand WH, Small DM. The physicochemical basis of cholesterol gallstone formation in man. J Clin Invest 1968;47:1043-1052\n\n20.\n\nSomjen GJ, Gilat T. Contribution of vesicular and micellar carriers to cholesterol transport in human bile. J Lipid Res 1985;26:699-704PubMed\n\n21.\n\nJohnston DE, Kaplan MM. Pathogenesis and treatment of gallstones. N Engl J Med 1993;328:412-421PubMed\n\n22.\n\nTrotman BW, Petrella EJ, Soloway RD, Sanchez HM, Morris TA 3d, Miller WT. Evaluation of radiographic lucency or opaqueness of gallstones as a means of identifying cholesterol or pigment stones. Correlation of lucency or opaqueness with calcium and mineral. Gastroenterology 1975;68:1563-1566PubMed\n\n23.\n\nGunn A, Kiddie N. Some clinical observations on patients with gallstones. Lancet 1972;2:239-241PubMed\n\n24.\n\nRigas B, Torosis J, McDougall CJ, Vener KT, Spiro HM. The circadian rhythm of biliary colic. J Clin Gastroenterol 1990;12:409-414PubMed\n\n25.\n\nSullivan FJ, Eaton SB Jr, Ferrucci JT Jr, Dreyfuss JR, Sloan RW. Cholangiographic manifestations of acute biliary colic. N Engl J Med 1973;288:33-35PubMed\n\n26.\n\nDoran FS. The sites to which pain is referred from the common bile duct in man and its implications for the theory of referred pain. Br J Surg 1967;54:599-606PubMed\n\n27.\n\nCooperberg PL, Burhenne HJ. Real time ultrasonography. Diagnostic technique of choice in calculous gallbladder disease. N Engl J Med 1980;302:1277-1279PubMed\n\n28.\n\nKo CW, Sekijima JH, Lee SP. Biliary sludge. Ann Intern Med 1999;130:301-311PubMed\n\n29.\n\nPortincasa P, van Erpecum KJ, Jansen A, Renooij W, Gadellaa M, van Berge-Henegouwen GP. Behavior of various cholesterol crystals in bile from patients with gallstones. Hepatology 1996;23:738-748PubMed\n\n30.\n\nBerk RN, Ferrucci JT Jr, Fordtran JS, Cooperberg PL, Weissmann HS. The radiological diagnosis of gallbladder disease. An imaging symposium. Radiology 1981;141:49-56PubMed\n\n31.\n\nDelchier JC, Benfredj P, Preaux AM, Mentreau JM, Dhumeaux D. The usefulness of microscopic bile examination in patients with suspected microlithiasis: a prospective evaluation. Hepatology 1986;6:118-122PubMed\n\n32.\n\ndeSilva GS. A simple method for computing the volume of the human gallbladder. Radiology 1949;52:94-102\n\n33.\n\nEverson GT, Braverman DZ, Johnson MA, Kern F Jr. A critical evaluation of real time ultrasonography for the studies of gallbladder volume and contraction. Gastroenterology 1980;69:40-46\n\n34.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: a technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology 1981;80:482-490PubMed\n\n35.\n\nFisher RS, Stelzer F, Rock E, Malmud LS. Abnormal gallbladder emptying in patients with gallstones. Dig Dis Sci 1982;27:1019-1024PubMed\n\n36.\n\nKrishnamurthy GT, Bobba VR, Kingston E, Turner F. Measurement of gallbladder emptying sequentially using a single dose of 99mTc-labeled hepatobiliary agent. Gastroenterology 1982;83:773-776PubMed\n\n37.\n\nKrishnamurthy GT, Bobba VR, Langrell K. The gallbladder emptying response to sequential exogenous and endogenous cholecystokinin. Nucl Med Commun 1984;5:27-33PubMed\n\n38.\n\nWilliams W, Krishnamurthy GT, Brar HS, Bobba VR. Scintigraphic variations of normal biliary physiology. J Nucl Med 1984;25:160-165PubMed\n\n39.\n\nHopman WPM, Jansen JBMJ, Rosenbusch G, Lamers CBHW. Cephalic stimulation of gallbladder contraction in humans: role of cholecystokinin and the cholinergic system. Digestion 1987;38:197-203PubMed\n\n40.\n\nFisher RS, Rock E, Malmud LS. Gallbladder emptying response to sham feeding in humans. Gastroenterology 1986;90:1854-1857PubMed\n\n41.\n\nUpp JR Jr, Nealon WH, Singh P, Fagan CJ, Jonas AS, Greeley GH Jr, Thompson JC. Correlation of cholecystokinin receptors with gallbladder contractility in patients with gallstones. Ann Surg 1987;205:641-648PubMed\n\n42.\n\nVezina WC, McAlister VC, Wall WJ, Engel CJ, Grant DR, Ghent CN, Hutton LC, King ME, Chey WY. Normal fasting volume and postprandial emptying of the denervated gallbladder in liver transplant recipients. Gastroenterology 1994;107:847-853PubMed\n\n43.\n\nBobba VR, Krishnamurthy GT, Kingston E, Turner FE, Brown PH, Langrell K. Gallbladder dynamics induced by fatty meal in normal subjects and patients with gallstones: concise communication. J Nucl Med 1984;25:21-24PubMed\n\n44.\n\nSarles H, Hags G, Lanier R, Demol P, Bataille D. Present status of the anticholecystokinin hormone. Digestion 1979;19:73-76PubMed\n\n45.\n\nNorthfield TC, Kupfer RM, Maudgal DP, Zenter-Munro PL, Meller ST, Garvie NW, McCready R. Gallbladder sensitivity to cholecystokinin in patients with gallstones. Br Med J 1980;280:143-144PubMed\n\n46.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23:35S-45S\n\n47.\n\nNahrwold DL, Rose RC, Ward SP. Abnormalities in gallbladder morphology and function in patients with cholelithiasis. Ann Surg 1976;184:415-421PubMed\n\n48.\n\nDamiao AO, Sipahi AM, Vezozzo DP, Goncalves PL, Habr-Gama A, Teixeira MG, Fukushima JT, Laudanna AA. Effects of colectomy on gallbladder motility in patients with ulcerative colitis. Dig Dis Sci 1997;42:259-264PubMed\n\n49.\n\nTrendle MC, Moertel CG, Kvols LK. Incidence and mortality of cholethiasis in patients receiving chronic octreotide for metastatic carcinoid and malignant islet cell tumors. Cancer 1997;79:830-834PubMed\n\n50.\n\nFisher RS, Rock E, Levin G, Malmud L. Effects of somatostatin on gallbladder emptying. Gastroenterology 1987;92:885-890PubMed\n\n51.\n\nPallotta N, Corazziari E, Scopinaro F, Bonino R, Schillaci O, Vignoni A, Mangano M, Torsoli AT. Noninvasive estimate of bile flux through the gallbladder in humans. Am J Gastroenterol 1998;93:1877-1885PubMed\n\n52.\n\nKrishnamurthy GT, Krishnamurthy S. Hazards of formulating new theories about gallbladder (GB) function based on ultrasound volume data. Am J Gastroenterol 1999;94:1703-1705PubMed\n\nReferences\n\n1.\n\nCozzolino HJ, Goldstein F, Greening RR, Wirts CW. The cystic duct syndrome. JAMA 1963;185:920-924PubMed\n\n2.\n\nGoldstein F, Grunt R, Margulies M. Cholecystokinin cholecystography in the differential diagnosis of acalculous gallbladder disease. Am J Dig Dis 1974;19:835-849PubMed\n\n3.\n\nShaw MJ, Dorsher PJ, Vennes JA. Cystic duct anatomy: an endoscopic perspective. Am J Gastroenterology 1993;88:2102-2106\n\n4.\n\nVenkataramani A, Strong RM, Anderson DS, Gilmore IT, Stokes K, Hoffman AF. Abnormal duodenal bile composition in patients with acalculous chronic cholecystitis. Am J Gastroenterol 1998;93:434-441PubMed\n\n5.\n\nUpp JR Jr, Nealon WH, Singh P, Fagan CJ, Jonas AS, Greeley GH Jr, Thompson JC. Correlation of cholecystokinin receptors with gallbladder contractility in patients with gallstones. Ann Surg 1987;205:641-648PubMed\n\n6.\n\nCourtney DF, Clanachan AS, Scott GW. Cholecystokinin constricts the canine cystic duct. Gastroenterology 1983;85:1154-1159PubMed\n\n7.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Optimization of octapeptide of cholecystokinin (OP-CCK) dose for gallbladder emptying. In: Raynaud C (ed). Proceedings of the Third World Congress of Nuclear Medicine and Biology. Paris, Pergamon Press, 1982, pp 2244-2247\n\n8.\n\nKrishnamurthy S, Krishnamurthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder, and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n9.\n\nWheeler HO. Concentrating function of the gallbladder. Am J Med 1971;51:588-595PubMed\n\n10.\n\nKrishnamurthy GT, Krishnamurthy S. Hepatic bile entry into and transit pattern within the gallbladder lumen: a new quantitative cholescintigraphic technique for measurement of its concentration function. J Nucl Med 2002;43:901-908PubMed\n\n11.\n\nBalon HR, Fink-Bennett DM, Brill DR, Fig LM, Freitas JE, Krishnamurthy GT, Klingensmith WC 3rd, Royal HD. Procedure guideline for hepatobiliary scintigraphy. J Nucl Med 1997;38:1654-1657PubMed\n\n12.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical speciality. J Nucl Med Technology 1995;24(Suppl):35S-45S\n\n13.\n\nKeller IA, Weissman HS, Kaplun LL, freeman LM. The use of water ingestion to distinguish the gallbladder and duodenum on cholescintigraphy. Radiology 1984;152:811-813PubMed\n\n14.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: a technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology 1981;80:482-490PubMed\n\n15.\n\nKrishnamurthy GT, Bobba VR, Kingston E, Turner F. Measurement of gallbladder emptying sequentially using a single dose of Tc-99m-labeled hepatobiliary agent. Gastroenterology 1982;83:773-776PubMed\n\n16.\n\nToftdahl DB, Hojgaard L, Winkler K. Dynamic cholescintigraphy: induction and description of gallbladder emptying. J Nucl Med 1996;37:261-266PubMed\n\n17.\n\nKrishnamurthy S, Krishnamurthy GT. Gallbladder ejection fraction: a decade of progress and future promise (editorial). J Nucl Med 1992;33:542-543PubMed\n\n18.\n\nGad MA, Krishnamurthy GT, Glowniak JV. Identification and differentiation of congenital gallbladder abnormality by quantitative Tc-99m HIDA cholescintigraphy. J Nucl Med 1992;33:431-434PubMed\n\n19.\n\nKramer EL, Rumancik WM, Harkavy L, Tiu S, Banner HJ, Sanger JJ. Hepatobiliary scintigraphy of the compartmentalized gallbladder. Am J Roentgenol (AJR) 1985;145:1205-1206\n\n20.\n\nKrishnamurthy GT, Krishnamurthy S, Milleson T, Brown PH, Urstad DS. Segmentation of the gallbladder: effect on bile entry and exit and its clinical relevance in a patient with abdominal pain. Nucl Med Commun 2007;28:109-115PubMed\n\n21.\n\nPickelman J, Peiss RL, Henkin R, Salo B, Nagel P. The role of sincalide cholescintigraphy in the evaluation of patients with acalculous gallbladder disease. Arch Surg 1985;120:693-697\n\n22.\n\nFink-Bennett D, DeRidder P, Kolozsi WZ, Gordon R, Jaros R. Cholecystokinin cholescintigraphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease. J Nucl Med 1991;32:1695-1699PubMed\n\n23.\n\nZech ER, Simmons LB, Kendrick RR, Soballe PW, Olcese JA, Goff WB 2d, Lawrence DPl, DeWeese RA. Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder. Surg Gynecol Obstet 1991;172:21-24PubMed\n\n24.\n\nMisra DC Jr, Blossom GB, Fink-Bennett D, Glover JL. Results of surgical therapy for biliary dyskinesia. Arch Surg 1991;126:957-960PubMed\n\n25.\n\nHalverson JD, Garner BA, Siegel BA, Alexander R, Edmundowicz SA, Campbell W, Miller JE. The use of hepatobiliary scintigraphy in patients with acalculous biliary disease. Arch Intern Med 1992;152:1305-1307PubMed\n\n26.\n\nSorenson MK, Francher S, Lang NP, Eidt JF, Broadwater JR. Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia. Am J Surg 1993;166:672-675PubMed\n\n27.\n\nKlieger PS, O'Mara RE. The clinical utility of quantitative cholescintigraphy: the significance of gallbladder dysfunction. Clin Nucl Med 1998;23:278-282PubMed\n\n28.\n\nWestlake PJ, Hershfield NB, Kelly JK, Kloiber R, Liu R, Sutherland LR, Shaffer EA. Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy? Am J Gastroenterol 1990;85:986-990PubMed\n\n29.\n\nFox JG, Dewhirst FE, Shen Z, Feng Y, Taylor NS, Paster BJ, Ericson RL, Lau CN, Correa P, Araya JC, Roa I. Hepatic Helicobacter species identified in bile and gallbladder tissue from Chileans with chronic cholecystitis. Gastroenterology 1998;114:755-763PubMed\n\n30.\n\nBlaser MJ. Helicobacters and biliary tract disease. Gastroenterology 1998;114:840-841PubMed\n\n31.\n\nKrishnamurthy S, Krishnamurthy GT. Functional imaging in nuclear hepatology. Indian J Nucl Med 1997;12:216-232\n\nReferences\n\n1.\n\nIngelfinger FJ. Digestive diseases as a national problem. Gallstones. Gastroenterology 1968;55:102-104\n\n2.\n\nFriedman GD, Kannel WB, Dawber TR. The epidemiology of gallbladder disease: observations in the Framingham Study. J Chronic Dis 1966;19:273-292PubMed\n\n3.\n\nGracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone is not a myth. N Engl J Med 1982;307:798-800PubMed\n\n4.\n\nPelligrini CA, Way LW. Acute cholecystitis. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 251-264\n\n5.\n\nRyan ET, Pak PH, DeSanctis RW. Myocardial infarction mimicked by acute cholecystitis. Ann Intern Med 1992;116:218-220PubMed\n\n6.\n\nFreitas JE, Fink-Bennet DM, Thrall JH, Resinger WW, Calderon HC, Mirkes SH, Shah PK. Efficacy of hepatobiliary imaging of acute abdominal pain: concise communication. J Nucl Med 1980;21:919-924PubMed\n\n7.\n\nSchein CJ. Acute cholecystitis. Harper and Row, New York, 1972\n\n8.\n\nEikman EA, Cameron JL, Colman M, Natarajan TK, Dugal P, Wagner HN, Jr. A test for patency of the cystic duct in acute cholecystitis. Ann Intern Med 1975;82:318-322PubMed\n\n9.\n\nHandler SJ. Ultrasound of gallbladder wall thickening and its relation to cholecystitis. AJR Am J Roentgenol 1979;132:581-585PubMed\n\n10.\n\nBrachman MB, Tanasescu DE, Ramanna L, Waxman AD. Acute gangrenous cholecystitis: radionuclide diagnosis. Radiology 1984;151:209-211PubMed\n\n11.\n\nRanson JHC. Perforation of the gallbladder. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 265-273\n\n12.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23(Suppl):35S-45S\n\n13.\n\nWheeler HO. Concentrating function of the gallbladder. Am J Med 1971;51:588-595PubMed\n\n14.\n\nColletti PM, Ralls PW, Siegel ME, Halls JM. Acute cholecystitis: diagnosis with radionuclide angiography. Radiology 1987;163:615-618PubMed\n\n15.\n\nFonseca C, Greenberg D, Rosenthall L, Arzoumanian A. Assessment of the utility of gallbladder imaging with 99m-Tc-IDA. Clin Nucl Med 1978,3:437-441PubMed\n\n16.\n\nFreitas JE, Gulati MD. Rapid evaluation of acute abdominal pain by hepatobiliary scanning. JAMA 1980;244:1585-1587PubMed\n\n17.\n\nMatolo NM, Stadalnik RC, Dixon SM. Value and limitations of scanning of the biliary tract. Surg Gynecol Obstet 1980;150:521-524PubMed\n\n18.\n\nMauro MA, McCartney WH, Melmud JR. Hepatobiliary scanning with 99m-Tc-PIPIDA in acute cholecystitis. Radiology 1982;142:193-197PubMed\n\n19.\n\nSzlabick RE, Catto JA, Fink-Bennett D, Ventura V. Hepatobiliary scanning in the diagnosis of acute cholecystitis. Arch Surg 1980;115:540-544PubMed\n\n20.\n\nWeissmann HS, Badia J, Sugarman LA, Kluger L, Rosenblatt R, Freeman LM. Spectrum of 99m-Tc-IDA cholescintigraphic patterns in acute cholecystitis. Radiology 1981;138:167-175PubMed\n\n21.\n\nHelm JF, Venu RP, Geenen JE, Hogan WJ, Dodd WJ, Toouli J, Arndorfer RC. Effects of morphine on the human sphincter of Oddi. Gut 1988;29:1402-1407PubMed\n\n22.\n\nChoy D, Shi EC, McLean RG, Hoschl R, Murray IP, Ham JM. Cholescintigraphy in acute cholecystitis: use of intravenous morphine. Radiology 1984;151:203-207PubMed\n\n23.\n\nKim EE, Pjura G, Lowry P, Nguyen M, Pollack M. Morphine-augmented cholescintigraphy in the diagnosis of acute cholecystitis. AJR Am J Roentgenol 1986;147:1177-1179PubMed\n\n24.\n\nKeslar PJ, Turbiner EH. Hepatobiliary imaging and the use of intravenous morphine. Clin Nucl Med 1987;12:592-596PubMed\n\n25.\n\nMehta A, Alazraki N. The effectiveness of morphine in expediting the radionuclide diagnosis of acute cholecystitis. J Nucl Med 1987;28:596 (abstract)\n\n26.\n\nVasquez TE, Greenspan G, Evans DG, Halpern SE, Ashburn WL. Clinical efficacy of intravenous morphine administration in hepatobiliary imaging for acute cholecystitis. Clin Nucl Med 1988;13:4-6PubMed\n\n27.\n\nFig LM, Stewart RE, Wahl RL, Shapiro B. Potential pitfalls in the use of morphine hepatobiliary scintigraphy. J Nucl Med 1989;30:850 (abstract)\n\n28.\n\nFink-Bennett D, Balon H, Robbins T, Tsai D. Morphine-augmented cholescintigraphy: its efficacy in detecting acute cholecystitis. J Nucl Med 1989;30:850 (abstract)\n\n29.\n\nKistler AM, Ziessman HA, Gooch D, Bitterman P. Morphine-augmented cholescintigraphy in acute cholecystitis. A satisfactory alternative to delayed imaging. Clin Nucl Med 1991;16:404-406PubMed\n\n30.\n\nKim CK, Tse KK, Juweid M, Mozley PD, Woda A, Alavi A. Cholescintigraphy in the diagnosis of acute cholecystitis: morphine augmentation is superior to delayed imaging. J Nucl Med 1993;34:1866-1870PubMed\n\n31.\n\nKrishnamurthy GT. Acute cholecystitis: the diagnostic role for current imaging tests. West J Med 1982;137:87-94PubMed\n\n32.\n\nMoncada R, Cordoso M, Danley R, Rodriguez J, et al. Acute cholecystitis: 137 patients studied by infusion tomography of the gallbladder. AJR Am J Roentgenol 1977;129:583-585PubMed\n\n33.\n\nBushnell DL, Perlman SB, Wilson MA, Polcyn RE. The rim sign: association with acute cholecystitis. J Nucl Med 1986;27:353-356PubMed\n\n34.\n\nNetter FH. The CIBA collection of medical illustration, vol. 3. Digestive system, part 111. Liver, biliary tract and pancreas. CIBA Pharmaceutical Co., Summit, NJ, 1964, pp 1-31\n\n35.\n\nMeekin GK, Ziessman HA, Klappenbach RS. Prognostic value and pathophysiologic significance of the rim sign in cholescintigraphy. J Nucl Med 1987;28:1679-1682PubMed\n\n36.\n\nOates E, Selland DG, Chin CT, Achong DM. Gallbladder nonvisualization with pericholecystic rim sign: morphine-augmentation optimizes diagnosis of acute cholecystitis. J Nucl Med 1996;37:267-269PubMed\n\n37.\n\nSmith R, Rosen JM, Gallow LN, Anderson PO. Pericholecystic hepatic activity in cholescintigraphy. Radiology 1985;156:797-800PubMed\n\n38.\n\nSwayne LC, Ginsberg HN. Diagnosis of acute cholecystitis by cholescintigraphy: significance of pericholecystic hepatic uptake. AJR Am J Roentgenol 1989;152:1211-1213PubMed\n\n39.\n\nKrishnamurthy S, Krishnamurthy GT. Cholecystokinin and morphine pharmacological intervention during 99m-Tc-HIDA cholescintigraphy: a rational approach. Semin Nucl Med 1996;26:16-24PubMed\n\n40.\n\nChen CC, Holder LE, Maunoury C, Drachenberg CI. Morphine augmentation increases gallbladder visualization in patients pretreated with cholecystokinin. J Nucl Med 1997;38:644-647PubMed\n\n41.\n\nKim CK. Pharmacological intervention for the diagnosis of acute cholecystitis: cholecystokinin pretreatment or morphine, or both? J Nucl Med 1997;38:647-649PubMed\n\n42.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical speciality. J Nucl Med Technology 1995;24(Suppl):35S-45S\n\n43.\n\nSerafini AN, Al-Sheikh W, Barkin JS, Hourani M, Sfakiankis G, Clarke LP, Ashkar FS. Biliary scintigraphy in acute pancreatitis. Radiology 1982;144:591-595PubMed\n\n44.\n\nAli A, Turner DA, Fordham EW. Tc-99m-IDA cholescintigraphy in acute pancreatitis: concise communication. J Nucl Med 1982;23:867-869PubMed\n\n45.\n\nShea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, Tsai WW, Horangic N, Malet PF, Schwartz S, Williams SV. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994;154:2573-2581PubMed\n\n46.\n\nHamilton GW, Trobaugh GB, Ritchie JL, et al. Myocardial imaging with thallium-201: an analysis of clinical usefulness based on Bayes' theorem. Semin Nucl Med 1976;17:439-448\n\n47.\n\nMcNeil BJ, Adelstein SJ. Determining the value of diagnostic and screening tests. J Nucl Med 1976;17:439-448PubMed\n\n48.\n\nGoodman SN. Toward evidence-based medical statistics. 1: The p value fallacy. Ann Intern Med 1999;130:995-1004PubMed\n\n49.\n\nGoodman SN. Toward evidence-based medical statistics. 2: The Bayes factor. Ann Intern Med 1999;130:1005-1013PubMed\n\n50.\n\nFagan TJ. Nomogram for Bayes's theorem. N Engl J Med 1975;293:257PubMed\n\n51.\n\nGlossary. Terms used in therapeutics. ACP Journal Club 1998;129:A-21\n\n52.\n\nFreitas JE, Coleman RE, Nagle CE, Bree RL, Krewer KD. Gross MD. Influence of scan and pathologic criteria on the specificity of cholescintigraphy: concise communication. J Nucl Med 1983;24:876-879PubMed\n\n53.\n\nFrazee RC, Nagorney DM, Mucha P, Jr. Acute acalculous cholecystitis. Mayo Clinic Proc 1989;64:163-167\n\n54.\n\nSwayne LC. Acute acalculous cholecystitis: sensitivity in detection using technetium-99m iminodiacetic acid cholescintigraphy. Radiology 1986;160:33-38PubMed\n\n55.\n\nWeissmann HS, Burkowitz D, Fox MS, Gliedman ML, Rosenblatt R, Sugarman LA, Freeman LM. The role of technetium 99m iminodiacetic (IDA) cholescintigraphy in acute acalculous cholecystitis. Radiology 1983;146: 177-180PubMed\n\n56.\n\nJemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43-66PubMed\n\n57.\n\nGourgiotis S, Kocher HM, Solaini L, Yarollahi A, Tsiambas E, Salemis NS. Gallbladder cancer (review). Am J Surg 2008;196:252-264PubMed\n\nReferences\n\n1.\n\nLangenbuch CJA. Ein Fall von extirpation der Gallenblase wegen chronischer Cholelithiasis. Heilung Berl Klin Wochenscher 1882:19;725-727\n\n2.\n\nDeziel DJ. Complications of cholecystectomy. Incidence, clinical manifestations, and diagnosis. Surg Clin North Am 1994;74:809-823PubMed\n\n3.\n\nShea JA, Berlin JA, Bachwich DR, Staroscik RN, Malet PF, McGuckin M, Schwartz JS, Escarce JJ. Indications for and outcomes of cholecystectomy: a comparison of the pre- and postlaparoscopic eras. Ann Surg 1998;227:343-350PubMed\n\n4.\n\nEldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystectomy for the various types of gallbladder inflammation. A prospective trial. Surg Laparoscopy Endoscopy 1998;8:200-207\n\n5.\n\nLujan JA, Sanchez-Bueno F, Parrilla P, Robles R, Torralba JA, Gonzales-Costea R. Laparoscopic vs. open cholecystectomy in patients aged 65 and older. Surg Laparoscopy Endoscopy 1998;8:208-210\n\n6.\n\nHiggins A, London J, Charland S, Ratzer E, clark J, Haun W, Maher P. Prophylactic antibiotics for elective laparoscopic cholecystectomy. Arch Surg 1999;134:611-614PubMed\n\n7.\n\nDate RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 2008;196:599-608PubMed\n\n8.\n\nRanson JHC. Perforation of the gallbladder. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 265-273\n\n9.\n\nWay LW, Biliary stricture. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 419-429\n\n10.\n\nMurr MM, Gigot J, Nagorney DM, Harmsen WS, Ilstrup DM, Farnell MB. Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg 1999;134:604-610PubMed\n\n11.\n\nCheah WK, Goh P, Gagner M, So J. Needlescopic retrograde cholecystectomy. Surg Laparoscopy Endoscopy 1998;8:237-238\n\n12.\n\nMartin RF, Rossi RL. Bile duct injuries. Spectrum, mechanisms of injury, and their prevention. Surg Clin North Am 1994;74:781-803PubMed\n\n13.\n\nMacArthur P, Cuschieri A, Sell RA, Shields R. Controlled clinical trial comparing early with interval cholecystectomy for acute cholecystitis. Br J Surg 1975;62:850-852\n\n14.\n\nFowkes FG, Gunn AA. The management of acute cholecystitis and its hospital cost. Br J Surg 1980;67:613-617PubMed\n\n15.\n\nLo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998;227:461-467PubMed\n\n16.\n\nHunter JG. Acute cholecystitis revisited: get it while it's hot. Ann Surg 1998;227:468-469PubMed\n\n17.\n\nElboim CM, Goldman L, Hann L. Significance of post-cholecystectomy subhepatic fluid collection. Ann Surg 1983;198:137-141PubMed\n\n18.\n\nGilsdorf TR, Phillips M, McLeod MK, Gregg RO. Radionuclide evaluation of bile leakage and the use of subhepatic drains after cholecystectomy. Am J Surg 1986;156:259-262\n\n19.\n\nShreiner DP, Sarva RP, Van Thiel D, Yingvorapant N. Gallbladder function in diabetic patients. J Nucl Med 1986;27:357-360PubMed\n\n20.\n\nFisher RS, Stelzer F, Rock E, Malmud LS. Abnormal gallbladder emptying in patients with gallstones. Dig Dis Sci 1982;27:1019-1024PubMed\n\n21.\n\nRansohoff DF, Miller GL, Forsythe SB, Hermann RE. Outcome of acute cholecystitis in patients with diabetes mellitus. Ann Intern Med 1987;106:829-832PubMed\n\n22.\n\nMenegaux F, Dorent R, Tabbi D, Pavie A, Chigot J, Gandjbakhch I. Biliary surgery after heart transplantation. Am J Surg 1998;175:320-321PubMed\n\n23.\n\nMelvin WS, Meier DJ, Elkhammas EA, Bumgardner GL, Davies EA, Henry ML, Pelletier R, Ferguson RM. Prophylactic cholecystectomy is not indicated following renal transplantation. Am J Surg 1998;175:317-319PubMed\n\n24.\n\nJohnston DE, Kaplan MM. Pathogenesis and treatment of gallstones. N Engl J Med 1993;328:412-421PubMed\n\n25.\n\nLeitzmann MF, Giovannucci EL, Rimm EB, Stampfer MJ, Spiegelman D, Wing AL, Willett WC. The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med 1998;128:417-425PubMed\n\n26.\n\nLeitzmann MF, Rimm EB, Willet WC, Spiegelman D, Grodstein F, Stampfer MJ, Colditz GA, Giovannucci E. Recreational physical activity and the risk of cholecystectomy in women.N Engl J Med 1999;341:777-784PubMed\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_10(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 10. Biliary Dyskinesia\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nBiliary dyskinesia consists primarily of two disease entities, the sphincter of Oddi spasm (SOS) and cystic duct spasm (CDS). In the past when its pathophysiology was not clearly understood, cystic duct spasm was called cystic duct syndrome. These two entities are anatomically separate, but physiologically connected by an abnormal functional response to cholecystokinin. The sphincter of Oddi spasm is located within the sphincter at the distal end of the common bile duct, whereas the cystic duct spasm is confined mostly to the cystic duct of the gallbladder [1, 2]. In the literature, sphincter of Oddi spasm is also known by such names as papillary stenosis or bile duct dyskinesia, and cystic duct spasm as chronic acalculous cholecystitis. Both the sphincter of Oddi and gallbladder contain receptors for cholecystokinin, which is released endogenously into circulation from the intestinal mucosa upon entry of food into the duodenum [3, 4]. By binding to CCK-A type receptors, cholecystokinin normally stimulates the contraction of the gallbladder with simultaneous relaxation of the sphincter of Oddi. The cystic duct, which also contains CCK receptors, normally does not respond, because its serum threshold for contraction is set at a much higher level than the threshold for contraction of the fundus and body of the gallbladder [5].\n\nBiliary dyskinesia consists primarily of two disease entities, the sphincter of Oddi spasm (SOS) and cystic duct spasm (CDS). In the past when its pathophysiology was not clearly understood, cystic duct spasm was called cystic duct syndrome. These two entities are anatomically separate, but physiologically connected by an abnormal functional response to cholecystokinin. The sphincter of Oddi spasm is located within the sphincter at the distal end of the common bile duct, whereas the cystic duct spasm is confined mostly to the cystic duct of the gallbladder [1, 2]. In the literature, sphincter of Oddi spasm is also known by such names as papillary stenosis or bile duct dyskinesia, and cystic duct spasm as chronic acalculous cholecystitis. Both the sphincter of Oddi and gallbladder contain receptors for cholecystokinin, which is released endogenously into circulation from the intestinal mucosa upon entry of food into the duodenum [3, 4]. By binding to CCK-A type receptors, cholecystokinin normally stimulates the contraction of the gallbladder with simultaneous relaxation of the sphincter of Oddi. The cystic duct, which also contains CCK receptors, normally does not respond, because its serum threshold for contraction is set at a much higher level than the threshold for contraction of the fundus and body of the gallbladder [5]. Controversy over the real existence of the entity of biliary dyskinesia prevailed for many years [6]. Manometric studies, however, have helped to understand the basic sphincter mechanism and the action of cholecystokinin on it in both health (Chap. 6) and disease, especially in patients with SOS (Table 10.1.1). Both quantitative cholescintigraphy and biliary manometry have contributed to clear understanding of the bile secretion and flow mechanisms and the pathophysiological changes associated with biliary dyskinesia [7-9].\n\nTable 10.1.1\n\nBiliary pressure profile in asymptomatic control subjects and patients with sphincter of Oddi spasm [9]\n\nStructure | Control subjects (n = 9) | SOS patients (n = 10) | P value\n\n---|---|---|---\n\nCBD pressure (mmHg) | 8.6 + 1.02 (6-13) | 17.0 + 1.25 (12-22) | 0.001\n\nSp. Oddi pressure (mmHg) | 14.9 + 0.99 (11-21) | 36.9 + 5.44 (20-70) | 0.005\n\nPhasic contractions:\n\nAmplitude (mmHg) | 113.0 + 8.6 (95-125) | 109.5 + 9.3 (85-160) | 0.37\n\nFrequency (per min) | 6.89 + 0.20 | 7.56 + 0.41 | 0.46\n\nDirection of propagation:\n\nAntegrade | 54% + 6% | 29% + 7% | 0.04\n\nSimultaneous | 28% + 4% | 0% + 3% | 0.34\n\nRetrograde | 18% + 6% | 41% + 9% | 0.01\n\nValues are mean + SE. Ranges within parentheses. Adopted from Meshkinpour et al. [9]\n\n## 10.1 Pathophysiology\n\nA normal sphincter of Oddi exhibits an average of six to seven contractions per minute with a wave amplitude of 113 mmHg. The mean pressure in the sphincter of Oddi is about 15.0 mmHg, and 9.0 mmHg in the common bile duct. About 54% of the contraction waves progress antegrade, 18% retrograde, and 28% occur simultaneously in the proximal, middle, and caudal segment of the sphincter (Table 10.1.1). Administration of cholecystokinin abolishes the contraction waves and relaxes the sphincter of Oddi immediately, and promotes smooth passage of bile emptied from the gallbladder into the duodenum (Fig. 10.1.1). Sphincter of Oddi spasm is characterized manometrically by an increase in basal pressure of the sphincter to 37 mmHg, and the common bile duct to 17 mmHg. The total number of basal contractions increases to 17 min-1, and the number of retrograde contraction increases to 41% (Fig. 10.1.2A). In the case of SOS, usually dormant contractile receptors in the sphincter become activated. These activated receptors paradoxically induce contraction of the sphincter in response to cholecystokinin [10, 11]. Cholecystokinin administration increases both the number of waves and the number of retrograde waves per minute (Fig. 10.1.2B). Because of this paradoxical response (contraction) of the sphincter, the bile either fails to empty from the gallbladder or the emptied bile refluxes into the common hepatic duct and right and left hepatic ducts, and reenters the gallbladder soon after cessation of CCK-8 infusion [12].\n\nFig. 10.1.1\n\nAction of CCK-8 on normal sphincter of Oddi. Normal contraction waves are abolished immediately after CCK-8 administration, which facilitates dilatation of the sphincter for smooth passage of bile through it [11]\n\nFig. 10.1.2 a, b\n\nPropagation of contraction waves and effect of CCK-8 on the sphincter in SOS. Contraction begins first at the caudal end and travels retrograde towards the middle and cephalic end of the sphincter (top). Administration of CCK-8 paradoxically increases the number of retrograde contractions (bottom), resulting in closure of the sphincter [11]\n\nCystic duct spasm is often associated with kinking, fibrosis, and thickening of the wall with narrowing of the of the cystic duct lumen [13]. Hepatic bile enters the gallbladder slowly, but cannot get out readily in response to cholecystokinin (Chap. 9.2). Due to a decrease in the total number of CCK receptors, there is poor contraction and emptying of the gallbladder, post-meal [14, 15]. The threshold of the cystic duct contraction receptors is presumably lowered, which results in its contraction when cholecystokinin is released.\n\n## 10.2 Clinical Presentation\n\nBiliary dyskinesia patients are mostly women in their 3rd or 4th decades of life, and present with post-prandial right upper quadrant or epigastric pain. Pain usually begins 30 min after a meal and reaches its peak intensity 2-3 h later. Liver function tests and blood counts remain within normal range. The gallbladder and intrahepatic and extrahepatic bile ducts are morphologically normal, and gallstones are usually absent on the ultrasound examination. Because of these normal biochemical and morphologic findings, the diagnosis of biliary dyskinesia is frequently delayed for months or years, and patients often go from physician to physician seeking relief from post-prandial abdominal pain.\n\n## 10.3 Cholescintigraphic Diagnosis\n\nAlthough biliary manometry is considered the gold standard, it is invasive, expensive, and not readily availability in many community hospitals. Cholescintigraphy provides a non-invasive and less expensive alternative. Imaging and quantitative analysis are carried out by acquiring data in two separate phases: the hepatic phase and gallbladder phase. Patients are studied after 4-6 h of fasting. Detailed clinical and drug history is taken to exclude the intake of opioids, smooth muscle relaxants, calcium channel blockers, or other drugs that act either on the sphincter of Oddi or gallbladder. In hypertensive patients, calcium channel blockers are discontinued for 2-3 days prior to the test. With the patient in the supine position, a large field of view dual-head gamma camera fitted with a low-energy, all-purpose, parallel-hole collimator is positioned anteriorly and posteriorly, and 3-5 mCi Tc-99m HIDA is injected intravenously. The data are acquired on the computer at one frame\/minute for 60 min [16-19]. Hepatic phase images usually appear normal (Fig. 10.1.3, top) unless the disease is far advanced, in which case there may be bile stasis in the extrahepatic ducts and delay in entry of bile into the duodenum. If the gallbladder is not seen by 60 min, delayed images are obtained at 3-4 h after injection of a second dose of Tc-99m HIDA. Injection of opioids to induce contraction of the sphincter of Oddi to fill the gallbladder is avoided.\n\nFig. 10.1.3\n\nCholescintigraphy in SOS. The uptake and excretion of 99mTc-HIDA are normal with delineation of the gallbladder and entire biliary tree. Bile enters the small intestine normally (top). After CCK-8 infusion, the gallbladder contracts and empties bile, which refluxes into the common hepatic duct (KB). Refluxed bile reenters the gallbladder immediately after cessation of CCK-8 infusion with an increase in size of the gallbladder (bottom)\n\n## 10.4 Gallbladder Phase Imaging\n\nThe data are acquired with the gamma camera. Hepatic phase images are carefully scrutinized for superimposition of duodenal or common bile duct radioactivity over the gallbladder. If there is any superimposition, the gamma camera angle is altered to separate the gallbladder from other structures. Often this may require changing the gamma camera angle by 10-15\u00b0 to the left or right anterior oblique position (Fig. 10.1.3, bottom). Most of the time, no such angulation is required. The data are collected at one frame\/minute for 30 min, (between 61-90 min) after injection of Tc-99m HIDA. Cholecystokinin at a dose of 3 ng kg-1 min-1 is infused intravenously for 10 min beginning at 65 min after HIDA injection The patient's symptoms (nausea, abdominal cramps, and\/or pain) are monitored carefully, and their time of onset, severity, and time of relief are noted on the data sheet or gallbladder time\/activity curve. ROIs are drawn over the gallbladder, liver (background), common hepatic ducts including the right hepatic and left hepatic ducts, common bile duct, stomach, and intestine (Fig. 10.1.4), and gallbladder ejection fraction, ejection period, ejection rate, and duodenogastric bile reflux are obtained (Fig. 10.1.5). The gallbladder, common hepatic duct (including the right and left hepatic ducts), common bile duct, and stomach and their corresponding curves are scrutinized carefully. Sphincter of Oddi spasm is differentiated from cystic duct spasm (Fig. 10.1.6) by careful analysis of both the image pattern and quantitative functional parameters [12, 13]. In most cases, the gallbladder ejection fraction remains normal. In many patients, the post-CCK-8 paradoxical refilling volume exceeds the basal volume by showing much higher counts after refilling than basal counts before hormone injection (Fig. 10.1.7). A true paradoxical filling recurs with the second dose of CCK-8 (Fig. 10.1.8) and must be differentiated from pseudo-paradoxical filling that may occur due to superimposition of intestinal activity on the gallbladder region of interest (Fig. 10.1.9).\n\nFig. 10.1.4\n\nRegions of interest for gallbladder phase study. One ROI is drawn over each of the gallbladder, liver (background), common hepatic duct, including right hepatic and left hepatic ducts, common bile duct, stomach, and intestine. Raw curves on the right represent the region of the same color\n\nFig. 10.1.5\n\nGallbladder phase results. The length of horizontal bar at the top represents the duration of CCK-8 infusion. The software calculates the results automatically after the ROIs are drawn. Two vertical bars denote the beginning and end of gallbladder emptying. The operator makes adjustments if automatically calculated results do not agree with the expected results\n\nFig. 10.1.6\n\nBiliary dynamics in biliary dyskinesia. In the case of sphincter of Oddi spasm, the gallbladder contracts and empties bile, which refluxes into the common hepatic and intrahepatic ducts. Most of the refluxed bile reenters the gallbladder (top). In patients with cystic duct syndrome, the gallbladder empties poorly, and no refilling occurs (bottom). Pain or discomfort occurs mostly during the gallbladder ejection period [12]\n\nFig. 10.1.7\n\nTypes of post-CCK-8 paradoxical filling curve patterns seen in patients with sphincter of Oddi spasm. Most gallbladders show normal ejection fraction followed by different patterns of refilling. Many gallbladders show much larger bile volume after refilling than the basal volume as shown by overshooting of the refilling curve [18]\n\nFig. 10.1.8\n\nTrue paradoxical filling with CCK-8 given twice. In both cases, the gallbladder empties normally (EF 92% and 86%), followed by paradoxical filling\n\nFig. 10.1.9\n\nAn apparent paradoxical filling after normal emptying (EF75%) of the gallbladder (GB) due to superimposition of intestinal (INT) activity\n\n## 10.5 Sphincter of Oddi Spasm\n\nCholescintigraphic findings vary depending upon the presence or absence of the native gallbladder. There is usually no bile pooling within the intrahepatic ducts in SOS, a feature distinctly different from those with stricture of the common bile duct [17]. Several types of functional abnormalities have been shown by different authors, depending upon the method of data collection and analysis [20, 21]. Shaffer et al. measured the hepatobiliary peak uptake time and calculated the percent excretion at 45, 60, and 90 min. Cholecystokinin at a dose of 0.02 units kg-1 min-1 was infused slowly between 60 and 90 min. The region of interest included both the liver and bile ducts. In 22 subjects with previous cholecystectomy with no current symptoms (control), the hepatobiliary mean peak time was 9.8 \u00b1 0.7 min. Percent excretion at 45, 60, and 90 min was 50.6 + 3.6, 66.3 + 2.8, and 84.7 + 1.3, respectively. The emptying rate between 0 and 60 min, and 60-90 min (after CCK) was 1.46 + 0.07 min-1 and 0.73 + 0.6 min-1, respectively. In nine patients with post-cholecystectomy SOS, the mean peak time was increased to 23 min, and percent excretion at 45 and 60 min was decreased to 20 and 39, respectively. The emptying rate between 0 and 60 min was 1.05 + 0.13 min-1 and increased to 1.12 + 0.19 min-1 after CCK infusion between 60 and 90 min [21]. Others have shown prolongation of the hepatic hilum to duodenal transit time [22, 23]. Most of the functional parameters improved after papillotomy (Fig. 10.1.10).\n\nFig. 10.1.10\n\nHepatic bile clearance in SOS. Normally, peak uptake of 99mTc-HIDA occurs within 10 min and 66% is excreted within 60 min. CCK enhances excretion. In patients with SOS, the peak is delayed and 60-min excretion is decreased. CCK administration has only a partial effect before papillotomy. Both uptake and excretion improve after papillotomy [21]\n\nThe hepatic phase images appear normal in most patients with early SOS (Fig. 10.1.3), and the gallbladder shows a normal ejection fraction. Cholescintigraphy in SOS is characterized by reflux of gallbladder bile into the common hepatic and right and left hepatic ducts with re-entry of refluxed bile into the gallbladder immediately after cessation of CCK-8 infusion. The curve shows rapid refilling of the gallbladder almost to its original volume, often even exceeding the original volume because of stimulation and expulsion of hepatic bile by cholecystokinin. Intrahepatic and extrahepatic bile ducts can accommodate almost all of 40-50 ml of bile emptied from the gallbladder without being dilated. Common hepatic duct bile reflux also occurs in patients with stenosis of the common bile duct and is referred to as the Krishnamurthy-Bobba sign [24]. When patients complain of pain during the gallbladder dynamic phase, the pain duration usually corresponds to the gallbladder ejection period. Not every patient with biliary dyskinesia, however, complains of pain at the time of the study. The extrahepatic ducts may appear early and persist for a longer duration of time, resulting in a marked delay in peak hepatic uptake in advanced cases [22, 25].\n\nSphincter of Oddi spasm is differentiated from anatomic stricture of the common bile duct by assessing both the image pattern and quantitative curve analysis after a pharmacologic intervention. Amyl nitrite, nitric oxide, and nifedipine relieve the spasm and dilate the sphincter, promoting rapid bile flow through it in patients with SOS, but not in those with an anatomic stricture (Fig. 10.1.11) of the common bile duct [26-28]. Sensitivity of cholescintigraphy in SOS varies from 70 to 90% [29].\n\nFig. 10.1.11\n\nCholescintigraphic differentiation of SOS from CBD stricture. The normal common bile duct time\/activity curve shows an early peak with rapid decline before and after amyl nitrite (top). The peak is delayed in both stricture and SOS. Following amyl nitrite, there is a rapid decline in patients with SOS (bottom), but not with stricture (middle) [26]\n\n## 10.6 Cystic Duct Spasm\n\nThis spasm is often characterized by a slow filling of the gallbladder during the hepatic phase with poor emptying response to cholecystokinin in the gallbladder phase. Although most of the gallbladders appear within 60 min after injection of Tc-99m HIDA, some are delayed for 3-4 h. Reduction in the gallbladder ejection fraction with CCK-8 is the salient feature. Many patients, but not all, experience mild- to moderate-intensity abdominal pain during the gallbladder ejection period. The gallbladder curve appears flat in patients with ejection fractions below 15%, and it is often difficult to note the exact time of the onset and end of gallbladder emptying (Fig. 10.1.4B). There is usually no bile reflux into the intrahepatic or extrahepatic ducts, and the gallbladder curve does not show refilling after cessation of CCK-8 infusion [12, 18]. The direction of the latter half of the curve is assessed carefully to make sure that there is no refilling of the gallbladder, which would suggest SOS. A large, non-physiological CCK-8 dose when given as a rapid intravenous bolus often produces a low ejection fraction and abdominal pain in many of the normal subjects, mimicking cystic duct syndrome. This effect is attributed to exceeding the cystic duct threshold for contraction and should be avoided.\n\n## 10.7 Differentiation of SOS from CDS\n\nThe differentiation is critical for appropriate patient management because cholecystectomy is the preferred treatment for CDS and antispasmodics or sphincterotomy for SOS. Cholecystectomy for SOS is inappropriate and may make the patient's condition get worse by taking away its low pressure reservoir function [30]. Both conditions are relatively more common in women than men. Proper attention is given during patient preparation, data collection, and analysis. The hepatic phase imaging data appear similar in both conditions, and there is bile entry into the duodenum in early cases. Only during the gallbladder phase is a difference seen between SOS and CDS. Cholecystokinin-induced bile reflux into the common hepatic duct and paradoxical refilling of the gallbladder are typical for SOS. In the authors' experience, another condition that may cause such a paradoxical filling is hyperacute (within 48 h) complete obstruction of the common bile duct (Chap. 8). Cholecystokinin stimulates bile secretion by cholangiocytes lining the intrahepatic bile ducts and expels bile from the liver by inducing contraction of the bile ducts. The hepatic bile is forced to enter the gallbladder in the presence of complete obstruction of the common bile duct. Other features of hyperacute CBD obstruction include its acute clinical presentation, abnormal liver function tests, and no bile entry into the duodenum during the hepatic phase. On rare occasions, superimposition of jejunal or ileal loop activity over the gallbladder region may cause false elevation of the gallbladder curve, which is readily recognized with the cine display of the gallbladder phase data. Patients with CDS do not exhibit paradoxical filling of the gallbladder, and there is no bile reflux into the intrahepatic ducts (Fig. 10.1.12).\n\nFig. 10.1.12\n\nDifferentiation of CDS from SOS. Cholecystokin (CCK) receptors on the gallbladder smooth mucle remain free in the fasting state (left). In cystic duct syndrome (middle), the gallbladder empties poorly in response to CCK-8 infusion because of a decrease in the total number of CCK receptors in the gallbladder body and fundus and activation of contractile receptors in the cystic duct. In the case of the sphincter of Oddi spasm (right), the sphincter contracts because of activation of the contractile receptors, and the bile emptied from the gallbladder refluxes into the common hepatic and intrahepatic ducts, later reentering the gallbladder (CCK-induced paradoxical filling of the gallbladder) after cessation of CCK-8 infusion [12]\n\n## 10.8 Treatment\n\nTreatment for SOS is different from that of CDS. A normal sphincter of Oddi function is modulated by local generation of nitric oxide [27]. Medical treatment with nitrites, nitrates, calcium channel blockers (nifedipine), and other smooth muscle relaxants has been shown to relieve the spasm and dilate the sphincter in patients with SOS [28]. Endoscopic sphincterotomy is reserved for those patients who fail to respond to medical therapy. Sphinctero-tomy is invasive, expensive, and carries a high rate of procedural complications. The overall endoscopic sphincterotomy complication rate in 2,347 patients in a multicenter study from 17 institutions in the United States was 9.8%. The complication rate is much higher (21.7%) in patients with sphincter of Oddi dysfunction [31]. Acute pancreatitis (5.4%) and hemorrhage (2.0%) account for the great majority of complications from endoscopic sphincterotomy. Special training and frequent experience in doing large numbers of patient procedures reduce complication rates [32]. Sphincteroplasty through an endoscopic balloon dilatation is effective in patients with bile duct stones [33]. However, its role in sphincter of Oddi spasm has not been studied critically in a large number of patients. Cholecystectomy is a relative contraindication in SOS. An intact gallbladder acts as a reservoir and accommodates bile that fails to pass through the sphincter in patients with SOS. Cholecystectomy takes away this reservoir function, and the symptoms persist or may even get worse, manifesting a post-cholecystectomy syndrome [30, 34].\n\n## 10.9 Cholecystectomy\n\nThis is the treatment of choice for CDS. Due to its low morbidity and low mortality, laparoscopic cholecystectomy has become more popular and has replaced open cholecystectomy as the preferred therapy [35]. Of a total of 320 patients with CDS who underwent cholecystectomy solely on the basis of a gallbladder low ejection fraction, 90% had relief of abdominal pain [36-42]. Histopathological examinations showed microscopic changes of disease in the gallbladder wall or cystic duct in 90% of patients (Chap. 9.2). Abdominal pain is known to persist in about 20% of patients undergoing cholecystectomy for various reasons [43], and the majority of these patients may have SOS. Clinically, SOS is divided into three types. Only type I responds to endoscopic sphincterotomy, and types II and III have a varied response. Type III is considered as duodenal visceral hyperalgesia, and the pain may not originate from the biliary tree at all [44]. Sphincterotomy is more effective than placebo in patients with sphincter pressure greater than 40 mmHg than in those without pressure elevation [45].\n\n## 10.10 Post-cholecystectomy Syndrome\n\nThis can now be considered an iatrogenic disease exaggerated by an inappropriate therapy (cholecystectomy) for patients with SOS. Removal of the gallbladder, which serves as a low pressure reservoir by accommodating hepatic bile, exaggerates the symptoms in patients with SOS. This syndrome can now be studied non-invasively by combining magnetic resonance cholangiopancreatography (MRCP) with quantitative cholescintigraphy. Rubini and Dimonte reported five patients with post-cholecystectomy syndrome and showed dilatation of the common hepatic and common bile ducts in four and cystic duct remnant in three (two remnants with gallstones) on MRCP. Cholescintigraphy showed bile pooling in both intrahepatic and extrahepatic ducts, with no bile entry into the duodenum at 60 min in all five patients. Bile did not enter the duodenum for another 60 min after a high-fat meal. Both peak hepatic uptake time and excretion half time were increased. The hepatic extraction fraction stayed above 80%, suggesting primarily a biliary disease. All four patients who underwent endoscopic sphincterotomy responded well with relief of symptoms [46].\n\n## 10.11 Pitfalls\n\nCholescintigraphy plays an important role in the evaluation of patients with biliary dyskinesia. Clear understanding of the mechanism of bile secretion and flow and factors that alter bile flow is important in arriving at a proper diagnosis. Functional imaging and measurement of parameters quantitatively require appropriate patient preparation and attention to technical details during data acquisition and analysis. Unlike the left ventricle, whose ejection fraction remains constant, the gallbladder ejection fraction can be controlled to any desired level simply by controlling the dose, dose rate, and duration of infusion of cholecystokinin. Cholecystokinin is available in two different molecular forms: an intact molecule with 33 amino acids (CCK-33) and a fragment with 8 amino acids (CCK-8 or sincalide). The dose recommended in the package insert of Kinevac (Bracco Diagnostic Inc., Princeton, N.J.) is found to be too large and often elicits a non-physiologic response during cholescintigraphy [47-49]. The dose should be reduced for cholescintigraphy (Chap. 6). When cholecystokinin is not available, the test is standardized using a fatty-meal stimulation, where the total calorie, fat, carbohydrate, and protein contents are controlled strictly for the chosen meal. Use of opioids for pain control is quite common in both inpatients and outpatients, and their use reduces the gallbladder ejection fraction. The gallbladder ejection fraction returns to normal after the discontinuation of opioids (Fig. 10.1.13). A commitment to high technical quality control, test standardization, and direct interaction with the patient before, during, and after the procedure produces the best clinical outcome [50].\n\nFig. 10.1.13\n\nEffect of opioids on gallbladder ejection fraction. A patient on vicodin for pain during viral hepatitis A shows slow clearance of the radiotracer from the liver (T 1\/2 = 92 min) and an ejection fraction of only 3% (top). Both the clearance and ejection fraction return to normal after discontinuation of vicodin and recovery from hepatics (bottom)\n\nReferences\n\n1.\n\nOddi R. D'une disposition a sphincter specille del'ouverture du canal cholidoque. Arch Ital Biol 1887;8:317-322\n\n2.\n\nCozzolino HJ, Goldstein F, Greening RR. The cystic duct syndrome. JAMA 1963;185:920-924PubMedCrossRef\n\n3.\n\nIvy AC, Oldberg E. A hormone mechanism of gallbladder contraction and evacuation. Am J Physiology 1928;86:599-613\n\n4.\n\nSjolund K, Sanden G, Hakanson R, Sundler F. Endocrine cells in human intestine: an immunocytochemical study. Gastroenterology 1983;85:1120-1130PubMed\n\n5.\n\nCourtney DF, Clanachan AS, Scott GW. Cholecystokinin constricts the canine cystic duct. Gastroenterology 1983;85:1154-1159PubMed\n\n6.\n\nSteinberg WM. Sphincter of Oddi dysfunction: a clinical controversy. Gastroenterology 1988;95:1409-1415PubMed\n\n7.\n\nGeenen JE, Hogan WJ, Dodds WJ, Stewart ET, Arndorfer RC. Intraluminal pressure recording from the human sphincter of Oddi. Gastroenterology 1980;78:317-324PubMed\n\n8.\n\nThune A, Scicchitano J, Thompson IR, Toouli J. Reproducibility of endoscopic sphincter of Oddi manometry. Dig Dis Sci 1991;36:1401-1405PubMedCrossRef\n\n9.\n\nMeshkinpour H, Mollot M, Eckerling GB. Bookman. Bile duct dyskinesia. Clinical and manometric study. Gastroenterology 1984;87:759-762PubMed\n\n10.\n\nHogan WJ, Geenen JE. Biliary dyskinesia: Endoscopy 1988;20:179-183PubMed\n\n11.\n\nToouli J, Roberts-Thompson IC, Dent J, Lee J. Manometric disorders in patients with suspected sphincter of Oddi dysfunction. Gastroenterology 1985;88:1243-1250PubMed\n\n12.\n\nKrishnamurthy S, Krishnamuthy GT. Biliary dyskinesia: role of the sphincter of Oddi, gallbladder, and cholecystokinin. J Nucl Med 1997;38:1824-1830PubMed\n\n13.\n\nGoldstein F, Grunt R, Margulies M. Cholecystokinin cholescintigraphy in the differential diagnosis of acalculous gallbladder disease. Dig Dis 1974;19:835-849CrossRef\n\n14.\n\nUpp JR, Nealon WH, Singh P, Fagan CJ, Jonas AS, Greeley GH, Thompson JC. Correlation of cholecystokinin receptor with gallbladder contractility in patients with gallstones. Ann Surg 1987;205:641-648PubMedCrossRef\n\n15.\n\nSteigerwalt RW, Goldfine ID, Williams JA. Characterization of cholecystokinin receptors on bovine gallbladder membranes. Am J Physiol 1984;247:G709-G714PubMed\n\n16.\n\nKrishnamurthy GT, Bobba VR, McConnell D, et al. Quantitative biliary dynamics: introduction of a new noninvasive scintigraphic technique. J Nucl Med 1983;24:217-223PubMed\n\n17.\n\nKrishnamurthy S, Krishnamurthy GT. Evolution of nuclear hepatology as a clinical subspeciality. J Nucl Med Technol 1995;23:35S-45S\n\n18.\n\nKrishnamurthy GT, Krishnamurthy S, Watson RD. Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver, sphincter, and gallbladder in patients with sphincter of Oddi spasm. Eur J Nucl Med Mol Imaging 2004;31:85-93PubMedCrossRef\n\n19.\n\nKrishnamurthy GT, Krishnamurthy S. Diagnosis of sphincter of Oddi spasm with quantitative cholescintigraphy. Indian J Nucl Med 2004;19:75-80\n\n20.\n\nCicala M, Scopinaro F, Corzziari E, Viscardi A, Habib FI, Torsoli A. Quantitative cholescintigraphy in the assessment of choledochoduodenal bile flow. Gastroenterology 1991;100:1106-1113PubMed\n\n21.\n\nShaffer EA, Hershfield NB, Logan K, Kloiber R. Cholescintigraphic detection of functional obstruction of the sphincter of Oddi. Effect of papillotomy. Gastroenterology 1986;90:728-733PubMed\n\n22.\n\nFullarton GM, Hilditch T, Campbell A, Murray WR. Clinical and scintigraphic assessment of the role of endoscopic sphincterotomy in the treatment of sphincter of Oddi dysfunction. Gut 1990;31:231-235PubMedCrossRef\n\n23.\n\nDrane WE, Johnson DA. Sincalide-augmented quantitative hepatobiliary scintigraphy(QHBS): Definition of normal parameters and preliminary relation between QHBS and sphincter of Oddi(SO) manometry in patients suspected of having SO dysfunction. J Nucl Med 1990;31:1462-1468PubMed\n\n24.\n\nBrar HS. Scintigraphic cholecystokinin-induced bile reflux named as Krishnamurthy-Bobba sign. J Nucl Med 1990;31:248PubMed\n\n25.\n\nSostre S, Kalloo AN, Spiegler EJ, Camargo EE, Wagner HN Jr. A noninvasive test of sphincter of Oddi dysfunction in post-cholecystectomy patients: The scintigraphic score. J Nucl Med 1992;33:1216-1222PubMed\n\n26.\n\nMadacsy L, Velosy B, Lonovics J, Csernay L. Differentiation between organic and functional dyskinesia of the sphincter of Oddi with amyl nitrite-augmented quantitative hepatobiliary scintigraphy, Eur J Nucl Med 1994;21:203-208PubMedCrossRef\n\n27.\n\nMourelle M, Guarner F, Moncada S, Malagelada JR. The arginine\/nitric oxide pathway modulates sphincter of Oddi motor activity in guinea pigs and rabbits. Gastroenterology 1993;105:1299-1305PubMedCrossRef90132-V)\n\n28.\n\nBhatnagar A. Nifedifine interventional cholescintigraphy: a new method for assessing sphincter of Oddi? Indian J Nucl Med 1997;12:93-96\n\n29.\n\nDodds WJ, Thakur S, Collier RD. Quantitative hepatobiliary scintigraphy (editorial). J Nucl Med 1990;31:1468-1469PubMed\n\n30.\n\nTanaka M, Ikeda S, Nakayama F. Change in bile duct pressure response after cholecystectomy: loss of gallbladder as a pressure reservoir. Gastroenterology 1984;87:1154-1159PubMed\n\n31.\n\nFreeman ML, Nelson DB. Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty B, Ryan ME, Shaw MJ, Lande JD, Pheley AM. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-918PubMedCrossRef\n\n32.\n\nHuibregtse K. Complications of endoscopic sphincterotomy and their prevention. N Engl J Med 1996;335:961-962PubMedCrossRef\n\n33.\n\nMathuna PM, White P, Clarke E, Merriman R, Lennon JR, Crowe J. Endoscopic balloon sphincteroplasty (papillary dilatation) for bile duct stones: efficacy, safety, and follow-up in 100 patients. Gastrointest Endosc 1995;42:468-474PubMedCrossRef70052-8)\n\n34.\n\nGregg JA, Clark G, Barr C, McCartney A, Milano A, Volcjak C. Postcholecystectomy syndrome and its association with ampullary stenosis. Am J Surg 1980;139:374-378PubMedCrossRef90296-2)\n\n35.\n\nFrassinelli P, Werner M, Reed III JF, Scagliotti C. Surgical Laparoscopy & Endoscopy 1998;8:30-34CrossRef\n\n36.\n\nPickelman J, Peiss RL, Henkin R, Salo B, Nagel P. The role of sincalide cholescintigraphy in the evaluation of patients with acalculous gallbladder disease. Arch Surg 1985;120:693-697CrossRef\n\n37.\n\nFink-Bennet D, DeRidder P, Kolozsi WZ, Gordon R, Jaros R. Cholecystokinin cholescintigraphy: Detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease. J Nucl Med 1991;32:1695-1699\n\n38.\n\nZech ER, Simmons LB, Kendrick RR, et al Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder. Surg Gynecol Obstet 1991;172:21-24PubMed\n\n39.\n\nMisra DC, Blossom GB, Fink-Bennet D, et al Results of surgical therapy for biliary dyskinesia. Arch Surg 1991;126:957-960PubMedCrossRef\n\n40.\n\nHalverson JD, Garner BA, Siegel BA, et al The use of hepatobiliary scintigraphy in patients with acalculous biliary disease. Arch Intern Med 1992;152:1305-1309PubMedCrossRef\n\n41.\n\nSorenson MK, Francher S, Lang NP, Eidt JF, Broadwater JR. Abnormal gallbladder nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia. Am J Surg 1993;166:672-675PubMedCrossRef80677-4)\n\n42.\n\nKleiger PS, O'Mara RE. The clinical utility of quantitative cholescintigraphy: the significance of gallbladder dysfunction. Clin Nucl Med 1998;23:278-282CrossRef\n\n43.\n\nBlack NA, Thompson E, Sanderson CFB, ECHSS group. Symptoms and health status before and 6 weeks after open cholecystectomy: a European cohort study. Gut 1994;35:1301-1305PubMedCrossRef\n\n44.\n\nDesautels SG, Slivka A, hutson WR, chun A, Mitrani C, DiLorenzo C, Wald A. Postcholecy-stectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III. Gastroenterology 1999;116:900-905PubMedCrossRef70073-9)\n\n45.\n\nCraig AG, Toouli J. Sphincterotomy for biliary sphincter of Oddi dysfunction. Cochrane databse of systematic reviews 2001, issue 1, art. no.:CD001509. DOI:10.1002\/14651858.CD001509\n\n46.\n\nRubini G, Dmonte M. Postcholecystectomy syndrome. Evaluation by biliary cholescintigraphy and MR cholangiopancreatography. Clin Nucl Med 1999;24:784-789PubMedCrossRef\n\n47.\n\nKrishnamurthy GT, Bobba VR, Kingston E. Optimization of octapeptide of cholecystokinin (OP-CCK) dose for gallbladder emptying. In: Raynaud C, (ed) Proceedings of the third world congress of nuclear medicine and biology. Paris, France: Pergamon Press; 1982, pp 2224-2247\n\n48.\n\nToftdahl DB, Hojgaard L, Winkler K. Dynamic cholescintigraphy: Induction and description of gallbladder emptying. J Nucl Med 1996;37:261-266PubMed\n\n49.\n\nZiessman HA, Fahey FH, Hixon DJ. Calculation of a gallbladder ejection fraction: advantage of continuous Sincalide infusion over the 3-minute infusion method. J Nucl Med 1992;33:537-541PubMed\n\n50.\n\nKrishnamurthy S, Krishnamurthy GT. Gallbladder ejection fraction: a decade of progress and future promise (editorial). J Nucl Med 1992;32;542-544\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_11(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 11. Pediatric Nuclear Hepatology\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nThe liver and biliary system develops from a bi-lobed (cephalic and caudal) endodermal bud that sprouts along the ventral surface of the distal end of the foregut at its junction with the midgut. The cephalic bud divides into two branches, which later form the right and left lobes of the liver. The caudal bud gives rise to biliary tract and the gallbladder (Fig. 11.1.1, Chap. 1). The biliary tract starts first as a patent tubular structure, but turns into a solid core during early intrauterine life through the proliferation of epithelial cells. After recanalization of the solid core by 12-14 weeks, bile secretion begins and flows into the small intestine. Most of the congenital abnormalities of the biliary tract are due to either failure of recanalization of the ducts (biliary atresia) or faulty recanalization with cystic dilatation of intrahepatic (Caroli's disease) and extrahepatic ducts (choledochal cyst).\n\nThe liver and biliary system develops from a bi-lobed (cephalic and caudal) endodermal bud that sprouts along the ventral surface of the distal end of the foregut at its junction with the midgut. The cephalic bud divides into two branches, which later form the right and left lobes of the liver. The caudal bud gives rise to biliary tract and the gallbladder (Fig. 11.1.1, Chap. 1). The biliary tract starts first as a patent tubular structure, but turns into a solid core during early intrauterine life through the proliferation of epithelial cells. After recanalization of the solid core by 12-14 weeks, bile secretion begins and flows into the small intestine. Most of the congenital abnormalities of the biliary tract are due to either failure of recanalization of the ducts (biliary atresia) or faulty recanalization with cystic dilatation of intrahepatic (Caroli's disease) and extrahepatic ducts (choledochal cyst).\n\nPhysiologic jaundice occurs in 65% of near- or full-term infants, and usually clears within few weeks after birth. Persistent uncomplicated long-term hyperbilirubinemia is a concern, and past studies suggested some link with neurological sequelae, such as mental retardation, autism, and cerebral palsy. The effects of uncomplicated high serum bilirubin levels have been addressed well in more recent studies. In a Canadian study involving 56,019 near- or full-term infants with serum bilirubin levels greater than 20 mg%, no evidence of bilirubin toxicity (kernicterus, gaze palsy) was found, lessening the anxiety over uncomplicated hyperbilirubinemia [1]. There is also no increased risk of autism due to hyperbilirubinemia [2]. However, persistent hyperbilirubinemia beyond 2 weeks should raise concern for several other possibilities (Table 11.1.1), some requiring immediate intervention, while others may be managed by careful follow-up without a specific therapy. Neonatal hepatitis and congenital biliary atresia are two of the diseases that account for the great majority of persistent jaundice beyond 2 weeks in a neonate.\n\nTable 11.1.1\n\nCauses of persistent jaundice beyond 2 weeks after birth\n\n1. Neonatal hepatitis\n\n---\n\nViral\n\nCytomegalo virus\n\nHepatitis B\n\nRubella\n\nHerpes\n\nCoxsackie\n\nBacterial\n\nE. coli\n\nKlebsiella\n\nPseudomonas\n\nProteus\n\nBacteroids\n\nStreptococcus\n\nTreponema pallidum\n\nParasitic\n\nToxoplasma gondii\n\n2. Biliary atresia\n\nExtra-hepatic ducts (congenital biliary atresia)\n\nIntra-hepatic ducts.\n\nCongenital rubella\n\nTrisomy 17\n\nTrisomy 18\n\nAlagille's syndrome (arterio-hepatic dysplasia)\n\n3. Genetic or metabolic\n\nAlpha 1 anti-trypsin\n\nGalactosemia\n\nHereditary fructosemia\n\nHypothyroidism\n\n## 11.1 Congenital Biliary Atresia vs. Neonatal Hepatitis\n\nCongenital biliary atresia (CBA) is a progressive, sclerosing, inflammatory disease, primarily affecting the extrahepatic bile duct from the region of the portahepatis to its termination in the duodenum. It is estimated to affect 1 in 12,000 live births [3]. Untreated, the disease progresses relentlessly, leading to biliary cirrhosis and death. Hepatoportoenterostomy (Kasai procedure) is the definitive therapy in early stages. The rate of success of establishing an adequate bile flow by the Kasai procedure depends very much on the duct size at birth and the time interval between birth and hepatoportoenterostomy (HPE). Effective bile flow is established in 77-82% of the infants when HPE is performed within 60 days after birth. The success rate decreases to 45-59% when HPE is delayed for 60-90 days and decreases further to 10-28% when HPE is delayed for 3-4 months. The success rate increases to 92% when the duct lumen is greater than 150 \u03bcm in size [4]. Early diagnosis, therefore, plays a critical role in determining the outcome of therapy (Table 11.1.2).\n\nTable 11.1.2\n\nEffect of timing and duct size on rate of success of hepatoportoenterostomy (HPE) for congenital biliary atresia [4]\n\nAge at HPE | Success rate\n\n---|---\n\n<60 days | 77-82%\n\n61-90 days | 45-59%\n\n90-120 days | 10-28%\n\nDuct size\n\n>151 \u03bcm | 92%\n\n50-150 \u03bcm | 81%\n\nNo patent ducts | 18%\n\n### 11.1.1 Etiology\n\nThe exact etiology of CBA is unknown. Two theories have been proposed; one theory is that of metaplasia of the hepatocytes, and the other is that of faulty metaplasia combined with ingrowth from extrahepatic ducts [5, 6]. Ischemia, toxins, and duct injury are well recognized risk factors. Recent studies suggest that atresia may be due to a failure of remodeling at the hepatic hilum with a continuation of the fetal-type bile leak due to poor mesenchymal support. Bile leak through the ducts initiates an intense inflammatory reaction with a subsequent obliteration of the bile duct lumen. The characteristic findings on liver biopsy include ductal proliferation, canalicular and cellular bile stasis, periportal edema, and fibrosis. The title \"atresia\" is reserved for patients with complete obliteration of the duct lumen. Hypoplasia is a transition phase before complete obliteration of the duct lumen [7].\n\nCongenital biliary atresia is divided into two clinical forms, fetal and perinatal. The perinatal form is the most common and is characterized by late-onset neonatal jaundice, with a jaundice-free time interval after birth. There are no other accompanying congenital abnormalities. Remnants of the bile duct are found within the hepatoduodenal ligament [4]. The fetal form is less frequent and accounts for less than 25% of the cases. It is characterized by an early onset of neonatal jaundice, with no clearance of physiologic jaundice (no jaundice-free time interval). It is frequently associated with other congenital anomalies, including polysplenia, asplenia, cardiovascular defects, or abdominal situs inversus, etc. No bile duct remnants are found in the hepato-duodenal ligament.\n\n### 11.1.2 Clinical Presentation\n\nInfants with CBA are usually born at full term with a normal birth weight and show normal growth pattern in the immediate neonatal period. It is more common in girls than boys. Jaundice usually starts 2 weeks after birth with acholic stool. Serum shows nonspecific elevation of direct bilirubin, alanine aminotransferase (ALT), and gamma- glutamyl transferase (GGT). About 90% of infants show a serum conjugated bilirubin (direct bilirubin) level greater than 4 mg dl-1 [8, 9]. Aspiration of bile through a naso-duodenal tube (after instillation of 25% magnesium sulfate into the duodenum to stimulate gallbladder contraction and bile emptying) establishes patency of the bile ducts and thus excludes the diagnosis of congenital biliary atresia and confirms the diagnosis of neonatal hepatitis. Bile is aspirated from the duodenum in more than 80% of the infants with neonatal hepatitis, but not from infants with biliary atresia [10]. Intubation and duodenal bile aspiration are relatively invasive in a newborn, and a negative test (no bile aspiration) is not always specific for congenital biliary atresia.\n\nHepatomegaly is unusual at birth and begins to develop 6-8 weeks later. Cholestasis, fibrosis, and cirrhosis develop as the infant grows. The incidence of biliary atresia is higher among Chinese and Filipinos (2-3 per 10,000) than in Japanese and Caucasians [11]. Serial liver function tests provide an indication of the severity of the disease. Serum values of total bilirubin, direct bilirubin, GGT, and alkaline phosphatase, and the alkaline phosphatase\/GGT ratio do not reliably distinguish congenital biliary atresia from neonatal hepatitis [12]. Laparoscopy has no diagnostic role as it cannot assess the patency of the bile ducts. Cholangiography is invasive and technically difficult to do because of the small size of the ducts.\n\n### 11.1.3 Cholescintigraphy\n\nThe indication for cholescintigraphy in a neonate is persistent jaundice beyond the 2nd week of life or new jaundice that develops 3 weeks after birth. An ideal patient preparation includes treatment with 5 mg kg-1 per day of phenobarbital, in two equally divided doses, for 5-7 days prior to cholescintigraphy. Phenobarbital stimulates bile production [13] and increases the secretion of the radiotracer into bile, enabling better delineation of bile ducts and duodenum in infants with neonatal hepatitis, but not in those with CBA [14-16]. Cholestyramine or ursodeoxycholic acid also promotes bile secretion. The infant should not be fed for an hour before and an hour after injection of the radiotracer. The duration of fasting prior to cholescintigraphy should be increased in older children in proportion to their age.\n\n### 11.1.4 Data Collection\n\nThe agent of choice in neonatal cholestasis is Tc-99-m mebrofenin, because it competes with serum bilirubin for hepatocyte uptake much more effectively than Tc-99m disofenin or any other Tc-99m-HIDA agent [17]. A dose of 100 \u03bcCi kg-1 (1 mCi minimum) of Tc-99-m-mebrofenin is injected intravenously. A gamma camera, preferably with a small field of view, fitted with a low-energy, parallel-hole, all-purpose collimator, is positioned anteriorly over the upper abdomen. The computer data are collected on a 64 \u00d7 64 word mode matrix at one frame per minute for 60 min (Fig. 11.1.1). Delayed images are obtained between 2-4 h and 20-24 h when intestinal activity is not seen in early images.\n\nFig. 11.1.1\n\nCholescintigraphy in the neonate. There is normal extraction and rapid excretion of 99mTc-HIDA in a normal neonate (top left). Extraction is decreased (persistent heart activity), and there is delayed excretion in neonatal hepatitis (top right). In biliary atresia, extraction is good, but no excretion into small bowel is seen (bottom left). Kidneys form the alternate route of excretion [19]\n\n### 11.1.5 Data Analysis\n\nA normal neonate shows rapid liver uptake and excretion compared to the infant with CBA or hepatitis (Fig. 11.1.1). For quantification, three regions of interest are drawn, and time-activity curves are generated separately over the (1) heart, (2) right upper lobe of the liver, and (3) spleen. The spleen ROI is used for blood background. Because both the hepatic and splenic arteries arise from the same celiac artery, the spleen serves as an ideal organ to represent the liver blood background. The hepatic extraction fraction and excretion half times are obtained by subjecting data to deconvolutional analysis, very similar to the procedure for adults (Fig. 11.1.2) [18, 19]. Measurement of the hepatic extraction fraction by deconvolutional analysis is equivalent to measuring the first pass extraction by injecting the tracer directly into the hepatic artery or portal vein. The hepatic extraction fraction provides an objective criterion for separating biliary atresia from neonatal hepatitis in early cases of CBA. The liver extraction fraction and excretion half time provide a measure of the severity of hepatobiliary disease. For a comparable level of serum bilirubin, infants with congenital biliary atresia show a relatively higher hepatic extraction fraction than infants with neonatal hepatitis [19, 20]. Obstruction over a longer period of time ultimately compromises hepatocyte function, and the hepatic extraction fraction begins to decrease and loses its power to differentiate biliary from hepatocyte decrease. The diagnosis of congenital biliary atresia or neonatal hepatitis is also made by assessing both the images and the shape and direction of the curves (Fig. 11.1.3).\n\nFig. 11.1.2\n\nQuantitative biliary dynamic studies in pediatrics. Hepatic extraction fraction (HEF) and excretion half-time (HCT) in a normal neonate (left), congenital biliary atresia (middle), and neonatal hepatitis (right). HEF remains relatively normal in biliary atresia, whereas both HEF and HCT are abnormal in neonatal hepatitis (modified from [19])\n\nFig. 11.1.3\n\nHeart and liver simple time-activity curves in three children. In a normal child (a), both heart and liver curves show a rapid decline. In biliary atresia (b), the liver curve shows slow uptake and no excretion. In neonatal hepatitis (c), the liver curve shows slow excretion without an uptake peak, indicating mainly background reduction [12]\n\n### 11.1.6 Normal Neonate\n\nCholescintigraphy in a normal neonate is characterized by rapid hepatocyte uptake and secretion of Tc-99 m-HIDA. Peak hepatic uptake occurs within 5 min, the gallbladder appears within 10 min, and intestinal activity is seen between 20-30 min. Unlike in adults and older children, the common hepatic duct, common bile duct, and the cystic ducts are not seen in a neonate [15]. After reaching the peak within 5 min, the liver shows a rapid decline. Peak cardiac counts occur in the first frame (1 min) followed by a rapid decline, reaching a background activity level within 5 min. Both liver and heart curves converge towards the end [12]. A subjective analysis of the shape of the curves helps to separate normal infant from congenital biliary atresia or neonatal hepatitis (Fig. 11.1.3). Calculation of the hepatic extraction fraction and excretion half time provide better and more powerful objective functional parameters than a simple subjective analysis of the curves (Fig. 11.1.2). Two of the commercial vendors now are planning to provide hepatobiliary software for routine clinical use on their gamma camera and computer systems, but for others, the users have to develop their own software and database for clinical application.\n\nIn a normal neonate, the hepatic extraction fraction value ranges between 87 and 100% with an average of 99.0 \u00b1 3.6% (Table 11.1.3). A value below 92% (mean, 2 SD) is considered abnormal. Mean excretion half time with Tc-99 m disofenin is 23.6 \u00b1 7.7 min; a value above 40 min is considered abnormal. An artifact in the calculation of the hepatic extraction fraction due to an abrupt truncation of data collection is avoided by adding an appendage at the end of the curve [21].\n\nTable 11.1.3\n\nHepatic extraction fraction and excretion half time (mean \u00b1 SD) in normal subjects and children with congenital biliary atresia, hepatitis, and miscellaneous hepatobiliary diseases [18]\n\nParameter | Normal | CBA | Hepatitis | Miscellaneous\n\n---|---|---|---|---\n\nNumber | 12 | 9 | 16 | 8\n\nHepatic extraction fraction (%) | 99.0 \u00b1 3.6 | 79.3 \u00b1 25.5 | 51.5 \u00b1 20.6 | 87.8 \u00b1 13.3\n\nHepatic excretion halftime (min) | 23.6 \u00b1 7.7 | 183.1 \u00b1 201.1 | 101.9 \u00b1 77.0 | 44.8 + 35.7\n\n### 11.1.7 Congenital Biliary Atresia\n\nNeonates with congenital biliary atresia maintain a relatively high extraction Tc-99m-HIDA with clear delineation of the hepatic morphology with well-defined borders and contour. Major abnormalities are confined to bile secretion. Despite a good extraction by the hepatocytes, there is total lack of secretion of Tc-99m-HIDA into the bile, resulting in non-visualization of the entire biliary tree. The liver image appears much like a radiocolloid scan without the spleen. Delayed images at 24 h do not show any evidence of bile entry into the small intestine [15, 16]. The liver time-activity curve shows good uptake, but no excretion. Excretion half time values often indicate infinity (Fig. 11.1.2). The hepatic extraction fraction value is maintained at a high level despite high serum bilirubin, especially when cholescintigraphy is obtained within 45 days after birth. When the extraction fraction value begins to decline in patients with CBA, however, it indicates functional compromise because of persistent bile duct obstruction over a longer period of time [20]. A diagnosis of congenital biliary atresia is highly probable in a neonate with conjugated (direct) hyper-bilirubinemia, a relatively high hepatic extraction fraction in association with non-visualization of the entire biliary tree and the small intestine. Cholescintigraphy is unable to differentiate intrahepatic (Alagille's syndrome) from extrahepatic (congenital biliary atresia) ductal obstruction.\n\nThe incidence of persistent jaundice beyond 2 weeks after birth, in general, is estimated to be 1 in 5,000 live births; neonatal hepatitis occurs 1 in 8,000, and biliary atresia, 1 in 10,000-15,000 live births. Pure intrahepatic biliary atresia or hypoplasia is rare and occurs in 1 in 70,000 births [22]. The extrahepatic bile ducts are patent in most patients with intrahepatic biliary atresia. Intrahepatic biliary atresia is commonly associated with intrauterine infection and genetic abnormalities as listed in Table 10.1.1. Alagille's syndrome is a form of intrahepatic biliary hypoplasia or atresia in association with pulmonary stenosis, vertebral body abnormalities, sexual and mental underdevelopment, and a typical facial feature [23].\n\n### 11.1.8 Neonatal Hepatitis\n\nNeonatal hepatitis is usually caused by viral, fungal, or bacterial infection (Table 10.1.1). Jaundice persists beyond 2 weeks after birth, and the liver function tests show non-specific elevation of enzymes with conjugated hyper-bilirubinemia [11]. Cholescintigraphic features depend upon the severity of hepatocellular disease at the time of imaging. Uptake of Tc-99m-HIDA by the hepatocyte is delayed and decreased. Both the time-to-peak hepatic uptake and excretion half time are increased. Intestinal and gallbladder visualization time may be either normal or markedly delayed. Due to the marked reduction in hepatocyte extraction of Tc-99m HIDA, the liver morphology is poorly defined with indistinct borders and contour. Heart and liver time-activity curves run in parallel, indicating mostly background reduction (Fig. 11.1.3). The hepatic extraction fraction value shows an inverse relationship with the serum bilirubin level. Extraction fraction values as low as 30% are common [19]. Intestinal activity is seen by 24 h. An apparent appearance of good uptake by the liver is merely a reflection of hepatic blood pool radioactivity and is not due to true uptake by the hepatocytes, as reflected by low hepatic extraction fraction value.\n\nThe success of cholescintigraphy is variable, depending upon the time interval between birth and imaging (Table 11.1.4). A sensitivity of 100%, specificity of 80%, and accuracy of 93% have been reported from some centers with technetium-99m mebrofenin [24]. High accuracy is attributed partly to the agent's ability to compete effectively with serum bilirubin for uptake by the hepatocytes. One cannot always separate congenital biliary atresia from neonatal hepatitis solely on the basis of the HEF value, emphasizing the importance of combining quantification with the image pattern to increase diagnostic accuracy [20].\n\nTable 11.1.4\n\nEfficacy of cholescintigraphy, ultrasonography, and liver biopsy in the differential diagnosis of congenital biliary atresia from neonatal hepatitis [24]\n\nParameter | Cholescintigraphy | Ultrasonography | Liver biopsy\n\n---|---|---|---\n\nSensitivity (%) | 100 | 70 | 95\n\nSpecificity (%) | 80 | 70 | 100\n\nAccuracy (%) | 93 | 70 | 97\n\nPositive predictive value | 91 | 82 | 100\n\nNegative predictive value | 100 | 54 | 91\n\n### 11.1.9 Management of Neonatal Cholestasis\n\nNeonatal hepatitis is treated medically with good nutrition, anti-viral, anti-bacterial, or anti-parasitic agents, depending upon its etiology. Most patients recover uneventfully (Fig. 11.1.4A). The American Academy of Pediatrics recommends phototherapy for healthy term infants [24]. The Kasai procedure is the treatment of choice for congenital biliary atresia [26, 27]. The neonate is prepared for surgery with preoperative antibiotic prophylaxis, optimal hydration, and good nutrition. The abdomen is explored through a high transverse incision, and a fine catheter is inserted into the gallbladder by piercing the fundus. Fibrosis of the wall with no bile within the gallbladder or obliteration of the common bile duct lumen confirms biliary atresia. The presence of bile inside the gallbladder with patency of the common bile duct, on the other hand, indicates neonatal hepatitis. A cholangiogram is obtained by injecting the radiocontrast through the catheter.\n\nFig. 11.1.4\n\nResponse to therapy in neonatal cholestasis. An infant with giant cell neonatal hepatitis responds to medical therapy and shows bile secretion into intestine (left). An infant with congenital biliary atresia (right) shows bile secretion into the intestine after a Kasai procedure. (Courtesy of Dr. Vasundara Tolia, Detroit, MI [20])\n\nIn the original Kasai procedure, the jejunum is cut beyond the ligament of Trietz, and a portoenterostomy is established. The proximal part of the jejunum is anastomosed to the side wall of the Roux-en-Y limb, below the portoenterostomy. The most common complication of portoenterostomy is acute ascending cholangitis due to reflux of intestinal contents into bile ducts. Several modifications to the original portoenterostomy were made mainly with the hope of preventing acute ascending cholangitis (Fig. 11.1.5). The temporary jejunostomy stoma created for decompression is usually closed at 3 months after confirming adequacy of bile flow. Most pediatric surgeons now seem to prefer the original Kasai procedure (Kasai 1) and avoid creating an external fistula. Administration of appropriate antibiotics reduces the incidence of acute or recurrent cholangitis. A successful Kasai procedure establishes free bile flow into the small intestine (Fig. 11.1.4B)\n\nFig. 11.1.5\n\nPortoenterostomy for congenital biliary atresia. In Kasai I, an open end of a loop of the jejunum is attached directly to the undersurface of the liver to serve as a bile conduit. In Kasai II and Kasai III, a temporary external fistula is created. Other types of anastomoses include Segura I, Ueda I, and Lilly-Altman (modified from [11])\n\nThe rate of success of portoenterostomy for congenital biliary atresia depends primarily upon the time interval between birth and surgery and also upon the size of the duct lumen at birth (Table 11.1.2). Poor results are generally attributed to delayed portoenterostomy. A success rate of 89% and a 10-year survival rate of 33-74% are obtained when the neonate with congenital biliary atresia receives portoenterostomy within 60 days after birth (Table 11.1.5).\n\nTable 11.1.5\n\nClinical outcome after Kasai procedure for congenital biliary atresia [3]\n\nParameter | Success rate (%)\n\n---|---\n\nEffective bile excretion | 89\n\nClearance of jaundice | 62\n\nJaundice-free survival | 53-62\n\n10-year survival | 33-74\n\nOnset of esophageal varices | 29-73\n\nLiver transplantation is the ultimate therapy when HPE fails. The usual cause for HPE failure is continued fibrosis secondary to recurrent cholangitis. Approximately 65% of infants who receive HPE for biliary atresia ultimately require liver transplantation [28, 29]. Biliary atresia is the most common indication and accounts for 54% of all liver transplantation in children. Other indications include metabolic diseases (14%), acute hepatic necrosis (11%), autoimmune and other cirrhosis (7%), malignancy, and other miscellaneous conditions [30]. Split liver and living donor liver transplantations have helped to overcome, to some extent, the shortages of donor livers in the pediatric population [31, 32]. The high cost and limited availability of donors still remain two of major factors limiting liver transplantation in children (see Chap. 12). The Kasai operation remains the first choice of treatment, and its application early at experienced centers reduces the need for liver transplantation [33]. Non-invasive functional imaging with quantification is ideal for children, for evaluation of both native and transplant livers. Congenital biliary atresia, metabolic diseases, and acute hepatic necrosis all together account for nearly 80% of all transplants in children (Fig. 11.1.6). In the case of congenital biliary atresia, cholescintigraphy is suitable not only for diagnosis, but also for assessing function after the Kasai procedure or transplant liver function when the Kasai procedure fails [34].\n\nFig. 11.1.6\n\nIndications for liver transplantation in children. Congenital biliary atresia is the most common indication, followed by metabolic diseases, acute hepatic necrosis, and others [33]\n\n## 11.2 Cystic Diseases of the Hepatobiliary System\n\nCysts are abnormal spaces within the liver parenchyma or along the biliary tract (choledochal cysts). They vary in size and location and contain mostly clear liquid. Choledochal cysts are rare, occurring in 1 in 100,000-150,000 live births. About 80% of choledochal cysts become symptomatic early and are diagnosed before the age of 10. Cysts are classified in many ways, and the classification provided in Table 11.2.1 is primarily for diagnostic purposes using various imaging techniques, including ultrasound, CT, MRCP, and cholescintigraphy. Cystic diseases due to parasites (hydatid cyst) and bacteria (abscess) are covered separately under space-occupying lesions of the liver in Chap. 4. This section deals primarily with those congenital cysts that have direct communication with the bile ducts and hence fill in with radiolabeled bile. The diagnosis of a non-communicating cyst is inferred when radioactive bile does not enter the cyst.\n\nTable 11.2.1\n\nClassification of cystic diseases of the hepatobiliary system\n\n1. Parasitic (hydatid cyst)\n\n---\n\n2. Non-parasitic cystic disease\n\na) Intrahepatic\n\n1) Solitary or multiple intrahepatic cysts with no communication with the bile ducts (adult polycystic liver disease)\n\n2) Mixed variety where few cysts communicate with the bile ducts\n\n3) Diffuse or segmental cystic dilatation of the bile ducts (Caroli's disease)\n\nb) Extrahepatic.\n\n1) Choledochal cyst\n\na) Cystic\n\nb) Fusiform\n\nc) Cylindrical\n\nd) Rosary (multiple cysts)\n\ne) Diverticular\n\nf) Choledochocele\n\nCysts are either solitary or multiple. Solitary cysts are rare, found at all ages, and most remain asymptomatic [1]. The cysts occur mostly along the hepatobiliary tract, starting at the smallest intralobular duct to the termination of the common bile duct into the duodenum. Most of the cysts are congenital, but a few of the acquired cysts follow an infection, trauma, or obstruction of a duct. The cyst may be entirely extrahepatic or intrahepatic in location.\n\nThe occurrence of both intrahepatic and extrahepatic cysts in a patient is rare, but is well recognized [2].\n\n### 11.2.1 Etiology\n\nThe exact cause of cystic dilatation of the bile ducts is unknown. Various hypotheses have been proposed, including weakness of the duct wall, angulation of the duct, presence of a valve-like structure within the lumen, inflammation, or sphincter dysfunction, all of which increase in intraductal pressure with impedance to bile flow [3]. The dilatation is initiated by an irregular and unequal proliferation of duct cells during recanalization of the solid core during early intrauterine life. Cysts are relatively more common in the Japanese and other Asians than in people elsewhere in the western hemisphere. An incidence of 1 in 13,000 hospital admissions has been reported in Japanese children [4]. The cyst wall ranges in thickness from 1 to 10 mm and consists mostly of fibrous tissue lined with cuboidal cells, or often with no lining cells at all. The cyst wall lacks mucous glands and a muscle layer. The cyst volume varies from a few milliliters to several liters [3].\n\n### 11.2.2 Classification of Choledochal Cysts\n\nCysts are classified mainly into the intrahepatic and extrahepatic variety. Kami et al. and Todani et al. recommend classification based upon the shape, size, extent, and location of the cyst [5, 6]. The cystic type is the most common variety and accounts for 54% of all choledochal cysts (Fig. 11.2.1). Fusiform is the next most common (24%), followed by the cylindrical (15%) and rosary type (4%). Together, these four account for nearly 97% of all cystic lesions. The diverticular type arises from one side of the duct wall, consists of a narrow opening, and may compress the adjoining structures, manifesting clinical symptoms of obstruction. A cyst at the distal end of the common bile duct, situated within the duodenal wall close to the ampulla of Vater, is called a choledochocele and is the rarest type (0.5%). The gallbladder remains normal in size, and gallstones are relatively rare in patients with choledochal cysts [3].\n\nFig. 11.2.1\n\nClassification of extrahepatic bile duct cysts. Cystic type is the most common (54%), followed by fusiform (24%), cylindrical type (15%), rosary (4%), and diverticular form (2.5%). Choledochocele is cystic dilatation of the intraduodenal part of the common bile duct before its entrance into the duodenum\n\n### 11.2.3 Intrahepatic Cystic Dilatation (Caroli's Disease)\n\nCaroli et al. in 1958 first described an entity of pure intrahepatic cystic dilatation [2]. Numerous authors have since described frequent association of intrahepatic cysts with cysts of the extrahepatic ducts. Studies from Japan report as many as 28-42% of patients with extrahepatic cysts having simultaneous intrahepatic cysts [3, 5, 7]. The fusiform and cylindrical types are more common in patients with intrahepatic cysts (Fig. 11.2.2).\n\nFig. 11.2.2\n\nClassification of intrahepatic bile duct cysts. Fusiform and cylindrical types are typical examples of Caroli's disease. Cystic type may affect both the intrahepatic and extrahepatic ducts. Simultaneous involvement of both intrahepatic and extrahepatic ducts is found in 28-42% of patients\n\n### 11.2.4 Diagnosis\n\nCholedochal cysts are three times more common in women than men, and more common in Asia and the Orient than in the western hemisphere [3]. Cysts remain asymptomatic for many years. When symptoms occur, more than one half of the patients present with a triad of abdominal pain, abdominal mass, and jaundice. Pain is usually localized to the right upper quadrant. The onset of symptoms usually coincides with the enlargement of the cyst, and the symptoms subside when the cyst decreases in size or drains spontaneously into the duodenum. Liver function tests show mild non-specific elevation. Ultrasonography or CT is the initial diagnostic procedure of choice. Once a cyst is identified with one of the imaging modalities, cholescintigraphy confirms the diagnosis. A cyst by ultrasound or CT in the vicinity of the biliary tract that fills with radiolabeled bile is specific for a choledochal cyst (Fig. 11.2.3). Choledochal cysts must be differentiated from cysts in other nearby organs, including cystic lesions of the kidney (renal cyst, hydronephrosis, and Wilm's tumor), pancreas (pseudocyst), or duodenum (diverticulum), etc. The malignant potential of a choledochal cyst is about 2.4% [6].\n\nFig. 11.2.3\n\nCholescintigraphic features of a choledochal cyst. A choledochal cyst fills in with radiolabeled bile and appears as a round structure in the middle of the common duct. The gall\u00adbladder is not seen\n\n### 11.2.5 Cholescintigraphy\n\nThe imaging study is obtained 4-6 h after fasting. Usually there is no need for pretreatment with phenobarbital, unless the child is severely jaundiced. Any one of the Tc-99m-HIDA agents may be chosen when serum bilirubin is within normal range. Routinely 1 min per frame images are obtained for 60 min (Fig. 11.2.3). Delayed images are obtained at 4 and 24 h when necessary.\n\nThe most common cholescintigraphic feature of a choledochal cyst is that of an early defect (90%) in the vicinity of the common hepatic or common bile duct that fills with radioactive bile at 4 or 24 h (Table 11.2.2). Intrahepatic ductal prominence or bile pooling is seen in 22% [8]. The gallbladder usually appears late. Only about 25% of the gallbladders are seen within 60 min, and up to 25% remain nonvisualized, even at 24 h [8, 9, 10].\n\nTable 11.2.2\n\nCholescintigraphic features of choledochal cyst\n\nParameter | Frequency (%)\n\n---|---\n\n1. Prolonged intrahepatic ductal prominence | 22\n\n2. Visualization of the gallbladder within 1 h | 25\n\n3. Non-visualization of the gallbladder by 2-4 h | 71\n\n4. Non-visualization of the gallbladder by 24 h | 25\n\n5. Filling defect in the region of the cyst in early images | 90\n\n6. Filling of the defect with the radiolabel in late images | 89\n\nDelayed filling or non-filling of the native gallbladder in a patient with choledochal cyst suggests that the cyst may act as a low pressure reservoir for bile. Gallbladder histopathological changes indicative of acute cholecystitis are found in 7% and those of chronic cholecystitis in 59% of patients with choledochal cysts [8]. This raises the possibility that the presenting symptoms may be due to onset of cholecystitis and not the choledochal cyst itself. Large cysts (one measured 400 ml) may compress adjoining structures and present clinically as an acute emergency [11]. Combined application of ultrasound and Tc-99m-HIDA cholescintigraphy is the most cost-effective approach in the diagnosis of choledochal cysts [12].\n\n### 11.2.6 Management of Choledochal Cysts\n\nSurgical excision of the cyst is the treatment of choice [13]. The cyst is excised with the hepatic duct Roux-en-Y jejunal anastomosis. This approach results in the most favorable postsurgical outcome, with a low incidence of ascending cholangitis. Total excision of the cyst is recommended because of its high malignant potential, which is 20 times higher than in the general population [3]. Surgical management of pure intrahepatic cysts (Caroli's disease) remains controversial. Lobectomy is advocated when cysts involve only one lobe of the liver. In the severe form of Caroli's disease, recurrent ascending cholangitis often leads to fibrosis and portal hypertension. About 20% of the choledochal cysts diagnosed in adults are treated much like those in children with total surgical excision [14].\n\n### 11.2.7 Cystic Disease of the Liver Parenchyma\n\nLiver cysts can be either solitary or multiple. Solitary cysts are uncommon, non-hereditary, and not associated with cysts in other organs. The Mayo Clinic reported only 38 solitary asymptomatic liver cysts during a follow-up period of 47 years [15]. Frequent use of abdominal ultrasound examination now can detect many more asymptomatic liver cysts than before. Symptomatic solitary liver cysts are four times more common in women than men and are found more frequently in the anterior-inferior area of the right lobe [16]. The cyst surface is usually smooth with wall thickness less than a centimeter. The cyst size varies from a few milliliters to several liters. One reported cyst contained 17 l of fluid [17]. Most of the cysts contain clear fluid. Some cysts may contain blood, mucin, proteins, and cholesterol. Bile is rarely found in a solitary cyst, indicating its non-communication with the bile ducts. A solitary cyst on ultrasound or CT that does not fill with radiolabeled bile indicates a non-communicating simple liver cyst (Fig. 11.2.4A).\n\nFig. 11.2.4\n\nLiver cyst. A simple liver cyst appears as a round defect early and does not fill in with radiolabeled bile later (top). A polycystic liver shows multiple small and large liver cysts on CT (middle). Cholescintigraphy in polycystic liver disease shows functioning liver tissue along the margins of right and left lobes (bottom). No filling of the cysts occurs. The cyst fills in only when there is wall rupture\n\n### 11.2.8 Polycystic Liver Disease\n\nPolycystic liver disease is classified into two main categories, non-communicating, and communicating. Non-communicating cysts are usually multiple, common in adults (adult polycystic liver disease), and show an autosomal dominant pattern of inheritance. It is associated with cysts in other organs, especially of the kidneys [18]. Cysts become symptomatic when they rupture or get infected. Tc-99m-HIDA cholescintigraphy can establish reliably whether or not the abdominal pain is due to rupture of the liver cyst [19]. In patients with polycystic liver disease on CT or ultrasound, non-filling with radiolabeled bile indicates a non-rupture (Fig. 11.2.4B, C).\n\nReferences\n\n1.\n\nJangaard KA, Fell DB, Dodds L, Allen AC. Outcome in a population of healthy term and near-term infants with serum bilirubin levels of \u2265325 \u00b5mol\/l (>19 mg\/dl) who were born in Nova Scotia, Canada, between 1994 and 2000. Pediatrics 2008;122:119-124PubMedCrossRef\n\n2.\n\nCroen LA, Yoshida CK, Odouli R, Newman TB. Neonatal hyperbilirubinemia and risk of autism spectrum disorders. Pediatrics 2005;115(2):e135-e138PubMedCrossRef\n\n3.\n\nBalistreri WF. Neonatal cholestasis. J Pediatr 1985;106:171-184PubMedCrossRef80282-1)\n\n4.\n\nBalistreri WF, Grand R, Hoofnagle JH, Suchy FJ, Ryckman FC, Perlmutter DH, Sokol RJ. Biliary atresia: current concepts and research directions. Summary of a symposium. Hepato\u00adlogy 1996;23:1682-1692CrossRef\n\n5.\n\nCocjin J, Rosenthal P, Buslon V, Luk L Jr, Barajas L, Geller SA, Ruebner B, French S. Bile ductule formation in fetal, neonatal, and infant livers compared with extrahepatic biliary atresia. Hepatology 1996;24:568-574PubMedCrossRef\n\n6.\n\nDesmet VJ. Congenital diseases of intrahepatic bile ducts: variations on the theme \"ductal plate malformation\". Hepatology 1992;16:1069-1083PubMedCrossRef\n\n7.\n\nTan CEL, Davenport M, Driver M, Howard ER. Does the morphology of the extrahepatic biliary remnant in biliary atresia influence survival? A review of 205 cases. J Pediatr Surg 1994;29:1459-1464PubMedCrossRef90144-9)\n\n8.\n\nMieli-Vergani G, Howard ER, Portman B, Mowat AP. Late referral for biliary atresia-missed opportunities for effective surgery. Lancet 1989;1:421-423PubMedCrossRef90012-3)\n\n9.\n\nMowat AP, Davidson LL, Dick MC. Earlier identification of biliary atresia and hepatobiliary disease: selective screening in the third week. Arch Dis Child 1995;72:90-92PubMedCrossRef\n\n10.\n\nGreene HL, Helinek GL, Moran R, O'Neill J. A diagnostic approach to prolonged obstructive jaundice by 24-hour collection of duodenal fluid. J Pediatr 1979;95:412-414PubMedCrossRef80519-3)\n\n11.\n\nDe Lorimier AA, Harrison MR. Congenital biliary atresia. In: Way LW, Pelligrini CA (eds). Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 581-607\n\n12.\n\nLeonard JC, Hitch DC, Manion CV. The use of diethyl-IDA Tc-99m clearance curves in the differentiation of biliary atresia from other forms of neonatal jaundice. Radiology 1982;142:773-776PubMed\n\n13.\n\nJaffe SJ, Jachau MR. Perinatal pharmacology. Ann Rev Pharmacology 1974;14:219-238CrossRef\n\n14.\n\nThaler MM. Effect of phenobarbital on hepatic transport and excretion of 131 I-rose bengal in children with cholestasis. Pediatr Res 1972;6:100-110PubMedCrossRef\n\n15.\n\nMajd M, Reba RC, Altman RP. Effect of phenobarbital on 99mTc-IDA scintigraphy in the evaluation of neonatal jaundice. Semin Nucl Med 1981;11:194-204PubMedCrossRef80004-9)\n\n16.\n\nMajd M, Reba RC, Altman RP. Hepatobiliary scintigraphy with 99mTc-PIPIDA in the evaluation of neonatal jaundice. Pediatrics 1981;67:140-145PubMed\n\n17.\n\nKrishnamurthy S, Krishnamurthy GT. Technetium-99m-iminodiacetic acid organic anions: review of biokinetics and clinical application in hepatology. Hepatology 1989;9:139-153PubMedCrossRef\n\n18.\n\nBrown PH, Juni JE, Lieberman DA, Krishnamurthy GT. Hepatocyte versus biliary disease: a distinction by deconvolutional analysis of technetium-99m IDA time-activity curves. J Nucl Med 1988;29:623-630PubMed\n\n19.\n\nHowman-Giles R, Moase A, Gaskin K, Uren R. Hepatobiliary scintigraphy in a pediatric population: determination of hepatic extraction fraction by deconvolution analysis. J Nucl Med 1993;34:214-221PubMed\n\n20.\n\nTolia V, Kottamasu SR, Tabassum D, Simpson P. The use of hepatocyte extraction fraction to evaluate neonatal cholestasis. Clin Nucl Med 1999;24:655-659PubMedCrossRef\n\n21.\n\nJuni JE, Thrall JH, Froelich JW, Wiggins RC, Campbell DA Jr, Tuscan M. The appended curve for deconvolutional analysis-method and validation. Eur J Nucl Med 1988;14:403-407PubMedCrossRef\n\n22.\n\nShim WKT, Kasai M, Spence MA. Racial influence on the incidence of biliary atresia. In: Bill MA, Kasai M (eds) Progress in pediatric surgery, Urban, Scharzenberg, 1979\n\n23.\n\nAlagille D, Odievre M, Gautier M, Dommergues JP. Hepatic ductular hypoplasia associated with characteristic facies, vertebral malformation, retarded physical, mental, and sexual development, and cardiac murmur. J Pediatr 1975;56:63-71\n\n24.\n\nMaini A, Khanduri A, Gambhir S, Yacha SK, Das BK. Role of Tc-99 m-mebrofenin in evaluation of neonatal cholestasis syndrome. Indian J Nucl Med 1997;12:84-87\n\n25.\n\nAmerican Academy of Pediatrics, provisional committee for quality improvement and subcommittee on hyperbilirunemia. Practice parameter: management of hyperbilirunemia in the healthy term newborn. Pediatrics 1994;94(4):558-562\n\n26.\n\nKasai M, Kimura S, Asakura Y. Surgical treatment of biliary atresia. J Pediatr Surg 1968;3:665-668CrossRef90897-X)\n\n27.\n\nKasai M, Suzuki H, Ohashi F, Ohi R, Chiba T, Okamoto A. Technique and results of operative management of biliary atresia. World J Surg 1978;2:571-579PubMedCrossRef\n\n28.\n\nOtte JB, deVille de Goyet J, Reding R, Hausleithner V, Sokal E, Chardot C, Debande B. Sequential treatment of biliary atresia with Kasai portoenterostomy and liver transplantation: a review. Hepatology 1994;20:41S-48S (suppl)PubMed\n\n29.\n\nRyckman F, Fisher R, Pedersen S, Dittrich V, Heubi J, Farrell M, Balistreri W, Ziegler M. Improved survival in biliary atresia patients in the present era of liver transplantation. J Pediatr Surg 1993;28:382-385PubMedCrossRef90236-E)\n\n30.\n\nReyes J, Mazariegos GV. Pediatric transplantation. Surg Clin North Am 1999;79:163-189PubMedCrossRef70013-X)\n\n31.\n\nEgawa H, Uemoto S, Inomata Y, Shapiro J, Asonuma K, Kiuchi T, Okajima H, Itou K, Tanaka K. Biliary complications in pediatric living related liver transplantation. Surgery 1998;124:901-910PubMedCrossRef70015-7)\n\n32.\n\nReding R, Goyet J, Delbeke I, Sokal E, Jamart J, Janssen M, Otte J. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts. J Pediatr 1999;134:280-286PubMedCrossRef70450-6)\n\n33.\n\nChardot C, Carton M, Spire-Bendelac, Pommelet CL, Golmard J, Auvert B. Prognosis of biliary atresia in the era of liver transplantation: French national study from 1986 to 1996. Hepatology 1999;30:606-611PubMedCrossRef\n\n34.\n\nReyes J, Mazariegos GV. Pediatric transplantation. Surg Clin North Am 1999;79:163-189PubMedCrossRef70013-X)\n\nReferences\n\n1.\n\nWitzleben C. Cystic disease of the liver. In: Zakim D, Boyer TD (eds) Hepatology. A textbook of liver disease, vol 2. WB Saunders, Philadelphia, 1996, pp 1630-1649\n\n2.\n\nCaroli J, Soupault R, Kossakowski J et al. La dilatation polycystic congenitale des voies biliares intra-hepatiques. Sem Hop Paris 1958;34:488-491PubMed\n\n3.\n\nFonkalsrud E. Biliary cystic disease in children and adults. In: Way LW, Pelligrini CA (eds) Surgery of the gallbladder and bile ducts. WB Saunders, Philadelphia, 1987, pp 609-629\n\n4.\n\nKimura K, Tsugawa C, Ogawa K, Matsumoto Y, Yamamoto T, Kubo M, Asada S, Nishiyama S, Ito H. Choledochal cysts. Etiological considerations and surgical management in 22 cases. Arch Surg 1978;113:159PubMedCrossRef\n\n5.\n\nKomi N, Udaka H, Ikeda N, Kashiwagi Y. Congenital dilatation of the biliary tract; new classification and study with particular reference to anomalous arrangement of the pancreaticobiliary ducts. Gastroenterol JPN 1977;12:293-304PubMed\n\n6.\n\nTodani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: classification, operative procedure, and review of 37 cases including cancer arising from choledochal cyst. Am J Surg 1977;134:263-269PubMedCrossRef90359-2)\n\n7.\n\nSaito S. Surgical treatment and long-term follow-up results of congenital dilatation of the biliary duct. Presented at the International Symposium on Cholestasis in Infancy-Its pathogenesis, diagnosis, and treatment. Sendai, Japan, 1978, June 7-9\n\n8.\n\nKao PF, Huang MJ, Tzen KY, You DL, Liaw YF. The clinical significance of gall-bladder non-visualization in cholescintigraphy of patients with choledochal cysts. Eur J Nucl Med 1996;23:1468-1472PubMedCrossRef\n\n9.\n\nCamponovo E, Buck JL, Drane WE. Scintigraphic features of choledochal cyst. J Nucl Med 1989;30:622-628PubMed\n\n10.\n\nPadhy AK, Gopinath PG, Basu AK, Upadhyay P. Hepatobiliary scintigraphy in congenital cystic dilatation of biliary tract. Clin Nucl Med 1985;10:703-707PubMedCrossRef\n\n11.\n\nWilliams LE, Fisher JH, Courtney RA, Darling DB. Preoperative diagnosis of choledochal cyst by hepatoscintigraphy. N Engl J Med 1970;283:85-86PubMedCrossRef\n\n12.\n\nGates GF, Miller JH. Combined radionuclide and ultrasonic assessment of upper abdominal masses in children. AJR Am J Roentgenol 1977;128:773-780PubMed\n\n13.\n\nTsardakas E, Rdonett AH. Congenital cystic dilatation of the common bile duct. Arch Surg 1956;72:311-315CrossRef\n\n14.\n\nWeyant MJ, Maluccio MA, Bertagnolli MM, Daly JM. Choledochal cysts in adults. A report of two cases and review of the literature. Am J Gastroenterol 1998;93:2580-2583PubMed\n\n15.\n\nHenson SW Jr, Gray HK, Dockery MB. Benign tumors of the liver III. Solitary cysts. Surg Gynecol Obstet 1956;103:607-609PubMed\n\n16.\n\nCaplan LH, Simon M. Nonparasitic cysts of the liver. Am J Roentgenol Radium Ther Nucl Med 1966;96:421-428PubMed\n\n17.\n\nFlagg RS, Robinson DW. Solitary nonparasitic hepatic cysts. Report of oldest known case and review of the literature. Arch Surg 1967;95:964-973PubMedCrossRef\n\n18.\n\nGabow PA, Ikle DW, Holmes JH. Polycystic kidney disease: prospective analysis of nonazotemic patients and family members. Ann Intern Med 1984;101:238-247PubMed\n\n19.\n\nSalam M, Keeffe EB. Liver cysts associated with polycystic kidney disease: role of Tc-99m hepatobiliary imaging. Clin Nucl Med 1989;14:803-807PubMedCrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_12(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 12. Malignant Liver Lesions\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nThe liver is a common site for both primary and metastatic malignant lesions. Although the metastatic lesions are the most common, primary malignancies like hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) have become increasingly more common in recent years in the United States [1]. HCC arises from the hepatic parenchymal cells, the hepatocytes, and CC from the cells lining the major bile ducts and gallbladder, the cholangiocytes. In Asian countries like China, Taiwan, and Japan, HCC is one of the three most common causes of death due to malignancy. HCC has a serum marker in the form of \u03b1-fetoprotein, and no such marker exists for CC. Gallium-67 citrate, which has been an imaging agent for HCC over the years, still remains popular in places where F-18 fluorodeoxyglucose (F-18 FDG) is not readily available. A filling defect on a radiocolloid liver scan (Fig. 12.1.1) associated with intense Ga-67 uptake (Fig. 12.1.2) and increased serum \u03b1-fetoprotein in a patient is more likely to be HCC than any other type of malignancy. F-18 FDG shows avidity for CC, HCC, metastatic lesions, and abscesses. Being a common imaging agent for many different types of liver lesions, F-18 FDG imaging provides no specificity for any one particular type of malignancy.\n\nThe liver is a common site for both primary and metastatic malignant lesions. Although the metastatic lesions are the most common, primary malignancies like hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) have become increasingly more common in recent years in the United States [1]. HCC arises from the hepatic parenchymal cells, the hepatocytes, and CC from the cells lining the major bile ducts and gallbladder, the cholangiocytes. In Asian countries like China, Taiwan, and Japan, HCC is one of the three most common causes of death due to malignancy. HCC has a serum marker in the form of \u03b1-fetoprotein, and no such marker exists for CC. Gallium-67 citrate, which has been an imaging agent for HCC over the years, still remains popular in places where F-18 fluorodeoxyglucose (F-18 FDG) is not readily available. A filling defect on a radiocolloid liver scan (Fig. 12.1.1) associated with intense Ga-67 uptake (Fig. 12.1.2) and increased serum \u03b1-fetoprotein in a patient is more likely to be HCC than any other type of malignancy. F-18 FDG shows avidity for CC, HCC, metastatic lesions, and abscesses. Being a common imaging agent for many different types of liver lesions, F-18 FDG imaging provides no specificity for any one particular type of malignancy.\n\nFig. 12.1.1\n\nTc-99m radiocolloid scan (top) shows HCC as a filling defect in segment 4A and 4B of the left lobe. A CT (bottom left) shows it as a low density lesion and MRI with contrast (bottom right) shows the lesion as hypervascular\n\nFig. 12.1.2\n\nGallium-67 citrate scan of patient shown in Fig. 12.1.1 shows high intensity uptake in segment 4A and 4B of the left lobe. As the lesion is anterior in location, it is seen better in the anterior (left) than in the posterior view (right). Bone marrow and transverse colon activity below the liver is normal. Patient had increased serum alpha-fetoprotein, and surgical resection confirmed hepatocellular carcinoma\n\nDetection of primary and metastatic malignancy depends upon uptake and retention of F-18 FDG by the normal liver and tumor (Fig. 12.1.3). Uptake is dependent upon the enzyme glucokinase, which facilitates F-18 FDG uptake and immediate conversion into F-18 FDG-6 phosphate inside the cell. High levels of FDG-6 phosphatase enzyme in the hepatocyte promote conversion of F-18 FDG-6 phosphate back into F-18 FDG, which may exit the hepatocyte rapidly, especially in delayed images taken beyond an hour after injection. The balance between uptake and exit determines the sensitivity for tumor imaging. The serum level of \u03b1-fetoprotein and tumor stage greatly influence the sensitivity of F-18 FDG PET\/CT imaging (Fig. 12.1.4). Patients with a serum \u03b1-fetoprotein level of less than 20 ng ml-1 show a sensitivity of 44%, whereas those with levels greater than 400 ng gl-1 show a sensitivity of 86%. Stage II and III tumors show F-18 FDG PET\/CT sensitivity of 31-62%, whereas stage IVa and IVb show much higher sensitivity at 68-85%. Overall sensitivity of F-18 FDG PET\/CT for HCC is 61% and for metastatic lesions 86%. Higher sensitivity for metastatic lesions is related to the slow rate of conversion of F-18 FDG-6-phosphate back into F-18 FDG. Although colon cancer frequently metastasizes to the liver, other types of cancer, including breast and lung, also involve the liver (Fig. 12.1.5). Primary liver tumors less than 2 cm in size are rarely detected, and 78% of tumors \u22655 cm are readily identified with PET\/CT [2]. Risk factors for HCC include primary sclerosing cholangitis, hepatolithiasis, chronic infections, including typhoid and parasites, drug exposure, and genetic influence.\n\nFig. 12.1.3\n\nNormal PET\/CT. Brain and heart show the highest F-18 FDG uptake (middle panel). Liver, spleen, kidneys, and bone marrow show low uptake, and lungs show no uptake. Top (CT) and middle (PET) panel images are fused in the bottom panel\n\nFig. 12.1.4\n\nColon CA with liver metastases. Multiple metastatic lesions are found in both liver lobes\n\nFig. 12.1.5\n\nBreast CA with metastases to both lobes of the liver. Right lobe involves segments 5, 7, and 8. Segment 7 lesion shows central necrosis with no uptake in the center. Left lobe has lesions in segments 2 and 3\n\nCC is a malignant epithelial tumor of the biliary tree and is less common than HCC [3]. About 60% of CC tumors arise from the extrahepatic part of the biliary tree and spread upwards to invade the liver parenchyma (Klatskin tumor). Hilar lesions are classified into five different types, depending upon the extent of the tumor (see Chap. 8.2). Hilar tumors progress slowly, and the diagnosis is often delayed for weeks or months. Although the sensitivity for detection of the primary cholangiocarcinoma with F-18 FDG is slightly higher than for HCC, metastatic lesions show no difference between the two types (Table 12.1.1). CT remains the primary diagnostic procedure of choice, and PET\/CT adds valuable information with regard to the extent of the primary tumor and its resectability, especially in separating intrahepatic from common bile duct lesions [4, 5].\n\nTable 12.1.1\n\nSensitivity and accuracy (%) of F-18 FDG PET\/CT imaging in the detection of hepatocellular carcinoma and cholangicarcinoma | Hepatocellular carcinoma [1] | Cholangicarcinoma [3]\n\n---|---|---  \n|\n\nPrimary | Metastatic | Primary | Metastatic\n\nSensitivity | 61 | 86 | 84 | 83\n\nAccuracy\n\n|  |  |\n\n61 | 79\n\nEarly detection of metastatic liver lesions plays a crucial role in the proper management of the patient. A single lesion in either lobe is locally resected, whereas multiple lesions in one or both lobes call for more aggressive surgery and require clear delineation of involvement of each of eight segments of the liver. Couinaud's classification divides the liver into eight segments [6], and Bismuth divides the liver into nine segments by separating Couinaud's segment 4 into 4A and 4B [7]. Resection of four or more lesions followed by chemotherapy frequently results in 3-year survival [8].\n\n## 12.1 Management\n\nThe therapy for early uncomplicated primary tumor is surgical resection. Five-year survival for margin-negative resections ranges from 30 to 45 years. Margin-positive lesions show poor 5-year survival, ranging from 0 to 13 years [3].Only segments 6 and 7 (posterior half of the right lobe) are left behind in cases where other segments show metastatic involvement. Other forms of therapy include photodynamic therapy, intraductal high-intensity ultrasonography, radiofrequency ablation, and chemo-embolization. Liver transplantation, which was considered in the past as a contraindication for HCC and CC, is now accepted as a life-saving measure for both.\n\nReferences\n\n1.\n\nWood CB, Gillis CR, Blumgart LH. Retrospective study of the natural history of patients with liver metastases from locorectal cancer. Clin Oncol 1976;2:285-288PubMed\n\n2.\n\nPark JW, Kim JH, Kim SK, Kang KW, Park KW, Choi JI, Lee WJ, Kim CM, Nam BH. A prospective evaluation of 18F-FDG and 11C-Acetate PET\/CT for detection of primary and metastatic hepatocellular carcinoma. J Nucl Med 2008;49:1912-1921PubMedCrossRef\n\n3.\n\nUstundag Y, Bayraktar. Cholangicarcinoma: a compact review of the literature. World J Gastroenterol 2008;14(42):6458-6466PubMedCrossRef\n\n4.\n\nKim JY, Kim MH, Lee TY, Hwang CY, Kim JS, Yun SC, Lee SS, Seo DW, Lee SK. Clinical role of 18F-FDG PET\/CT in suspected and potentially operable cholangiocarcinoma: a prospective study compared with conventional imaging. Am J Gastroenterol 2008;103:1145-1151PubMedCrossRef\n\n5.\n\nMoon CM, Bang S, Chung JB, Park SW, Song SY, Yun M, Doo J. Usefulness of F18-fluodeoxyglucose positron emission tomography in the differential diagnosis and staging of cholangiocarcinomas. J Gastroenterol Hepatol 2007;23(5):759-765PubMedCrossRef\n\n6.\n\nCouinaud C. Le foie etudes anatomiques et chirurgicales. Masson, Paris, 1957\n\n7.\n\nBismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg 1982;6:3-9PubMedCrossRef\n\n8.\n\nTanaka K, Shimada H, Ueda M, Matsuo K, Endo I, Togo S. Role of hepatectomy in treating bilobar colorectal cancer metastases. Surgery 2008;143:259-270PubMedCrossRef\nGerbail T. Krishnamurthy and S. KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7_13(C) Springer-Verlag Berlin Heidelberg 2009\n\n# 13. Liver Transplantation\n\nGerbail T. Krishnamurthy1 and Shakuntala Krishnamurthy1\n\n(1)\n\nTuality Community Hospital, 97123 Hillsboro, OR, USA\n\nAbstract\n\nLiver transplantation is an optimal therapy for various types of end-stage liver disease [1]. The first liver transplantation was performed in a dog by Welch in 1955, and the first human liver transplantation was performed by Starzl et al. in 1963 [2, 3]. Although the early clinical results were disappointing, modern immunosuppressive agents have improved survival rates in both children and adults. The survival rates in children at 1, 3, 5, and 10 years are 82%, 80%, 78%, and 76%, respectively [4]. In the Model for End-Stage Liver Disease (MELD) survey, the 5-year survival rate after liver transplantation has now increased to 88% [5].\n\nLiver transplantation is an optimal therapy for various types of end-stage liver disease [1]. The first liver transplantation was performed in a dog by Welch in 1955, and the first human liver transplantation was performed by Starzl et al. in 1963 [2, 3]. Although the early clinical results were disappointing, modern immunosuppressive agents have improved survival rates in both children and adults. The survival rates in children at 1, 3, 5, and 10 years are 82%, 80%, 78%, and 76%, respectively [4]. In the Model for End-Stage Liver Disease (MELD) survey, the 5-year survival rate after liver transplantation has now increased to 88% [5]. The indications for liver transplantation for various end-stage liver diseases are shown in Table 13.1.1.\n\nTable 13.1.1\n\nIndications for liver transplantation\n\nParenchymal diseases\n\n---\n\nPost-necrotic cirrhosis\n\nPrimary biliary cirrhosis\n\nPrimary sclerosing cholangitis\n\nAlcoholic liver failure\n\nViral hepatitis\n\nInborn errors of metabolism\n\nFulminant hepatic failure\n\nAutoimmune hepatitis\n\nCystic fibrosis\n\nNeonatal hepatitis\n\nCholestatic diseases\n\nBiliary atresia\n\nCystic fibrosis\n\nBiliary cirrhosis\n\nSclerosing cholangitis\n\nFamilial cholestasis\n\nGraft vs. host disease\n\nChronic hepatic rejection\n\nTumors\n\nHepatoma\n\nHepatoblastoma\n\nApudomas\n\nMiscellaneous\n\nBudd-Chiari syndrome\n\nTrauma\n\n## 13.1 Types of Liver Transplantation\n\nThere are essentially three types of liver transplantation: (1) cadaver liver, (2) living-donor liver, and (3) auxiliary liver. In cadaver liver transplantation, the recipient's entire liver is removed and replaced (orthotopic) by a cadaver liver (Fig. 13.1.1). In the case of a living-donor liver transplantation, either the lateral segment (segments 2 and 3) or the entire left lobe (segments 4A, 4B, 2, and 3), anterior section (segments 5 and 8), or posterior section (segments 6 and 7) of the right lobe or the entire right lobe (segments 5, 6, 7, and 8) from the donor liver replaces the entire native liver of the recipient. In the case of an auxiliary liver transplantation for patients with fulminant hepatic failure, the donor liver acts as a transient bridge until the native liver recovers its function. The donor liver is placed either adjacent to the native liver or replaces the left lobe of the recipient liver [6-8]. The transplantation procedure usually involves four stages: (1) hepatectomy of the diseased native liver, (2) the anhepatic stage, which is the time interval between liver removal and interruption of blood flow through the vena cava, portal vein, and hepatic artery, (3) the reperfusion stage when the donor liver is being revascularized in the recipient, and (4) the biliary reconstruction stage in which a choledochocholedochostomy (adults) or a choledochojejunostomy (in children less than 35 lbs) is performed.\n\nFig.13.1.1\n\nLiver transplantation. Orthotopic liver transplant with end-to-end anastomosis is the most common type. In auxiliary transplantation, the donor liver is placed in either an orthotopic or heterotopic position\n\nNuclear medicine procedures are used for the evaluation of liver function both in the pre- and post-transplant period. In the case of a living-donor liver transplantation, both the donor and the recipient may undergo pre-transplant evaluation, which generally includes assessment of the functional reserve of the donor liver and determination of the ideal time for transplantation in the recipient [9]. It is essential to establish end-stage liver disease in the recipient prior to considering transplantation. Since no single test is adequate for either determining end-stage liver disease or indicating the ideal time for transplantation, serial imaging and non-imaging diagnostic procedures are performed over many months or years. Persistent poor function over many months or years despite appropriate therapy is an indication of end-stage liver disease. Just prior to liver transplantation, a multiple-gated acquisition (MUGA) study is obtained for evaluating the left ventricular ejection fraction and wall motion and a myocardial perfusion study for testing the adequacy of the coronary circulation in the recipient. After the transplantation, nuclear medicine studies are used to detect immediate and late postoperative complications (Table 13.1.2) and also for the assessment of functional recovery of the donor liver (Fig. 13.1.1). In the immediate postoperative period, cholescintigraphy is used to exclude bile leak or to assess transplant function. Blood pool studies are obtained to identify vascular complications, such as bleeding and thrombosis [10, 11]. Post-transplant chronic ischemia of the liver causes diffuse bile duct stenoses, manifesting as a vanishing bile duct syndrome in some patients [12].\n\nFig.13.1.2\n\nMagnetic resonance cholangiopancreatogram (left) shows the gallbladder, common bile duct, right hepatic duct (RHD), and left hepatic duct (LHD) and their segmental branches. RHD receives bile from anterior (A) and posterior (P) and LHD from medial (M) and lateral (L) segmental branches\n\nTable 13.1.2\n\nComplications of liver transplantation [10]\n\nComplication | Frequency (%)\n\n---|---\n\nInfections | 30.0-60.0\n\nBiliary obstruction | 15.0-25.0\n\nRejection | 10.0-15.0\n\nBile leak | 7.5-10.0\n\nBleeding | 5.5-6.5\n\nRenal failure (requiring dialysis) | 5.0\n\nArterial thrombosis | 3.0-5.0\n\nLymphoproliferative disorder | 2.0-2.5\n\nPortal vein thrombosis | 1.0-2.0\n\nIn the case of living-donor liver transplantation, the volume of the donor liver and its segmental morphology are measured with a single or multi-detector spiral CT. For a multi-detector spiral CT study, 750 ml of water is ingested as a negative contrast, and 120-150 ml of a non-ionic contrast is injected intravenously at 4-5 ml s-1 using scanning collimation of 1 mm, and 1-mm-thick images are reconstructed for interpretation [13]. The intraoperative volume in milliliters and weight in grams of the right lobe are estimated by using the preoperative volume [14]:\n\nIntraoperative volume = 0.656 \u00d7 preoperative volume + 87.629 ml\n\nIntraoperative weight = 0.678 g\/ml \u00d7 preoperative volume + 143.704\n\nSince one or two segments from an adult are adequate for a child, living-donor liver transplantation for post-Kasai biliary atresia has gained widespread acceptance with 5-year survival of nearly 90% [15]. Currently, hepatitis C infection is the most common cause of chronic liver disease in adults and accounts for 42% of cases, followed by hepatitis C and alcohol in 22%, alcohol alone in 8%, non-alcoholic fatty liver disease in 9%, hepatitis B in 3%, and other causes in 16% [16]. Hepatitis C in adults and congenital biliary atresia in children are the two most common indications for liver transplantation.\n\n## 13.2 Normal Functioning Liver Transplant\n\nTransplant liver maintains its normal shape and size in the right upper quadrant and functions much like a native normal liver. The gallbladder is usually absent as cholecystectomy is routinely performed as an integral part of transplantation to the prevent formation of as well as future complications from gallstones. The hepatic extraction fraction and excretion half time values of the transplant liver are maintained within the normal range established for the normal native liver. Common hepatic and common bile ducts show normal features. Duodeno-gastric bile reflux is rare (Figs. 13.1.3 and 13.1.4).\n\nFig. 13.1.3\n\nLiver segments derived from a planar Tc-99m-HIDA study. A line passing through the common bile duct (CBD) and common hepatic duct (CHD) when extended upwards to meet the superior margin divides the liver into right and left lobes. A line passing through the right hepatic duct and left hepatic duct divides each lobe into superior and inferior segments. In a planar image, segment 5 is superimposed on segment 6 and segment 7 on segment 8 of the right lobe. The segments are clearly separated in the left lobe. The caudate lobe (segment 1) is added to the right or left lobe depending upon user preference. Normal values for segments are shows within parentheses. Planar image depicts the biliary anatomy similar to MRCP shown in Fig. 13.1.2\n\nFig. 13.1.4\n\nNormal liver transplant. Early images beginning at 2 min show normal morphology and bile formation (top). Late images beginning at 38 min show free bile flow into intestine. Gallbladder is absent due to cholecystectomy (bottom). Hepatic extraction fraction and excretion half time are normal\n\n### 13.2.1 Complications\n\nLiver transplant complications occur both in the immediate and delayed postoperative period (Table. 13.1.2). Immediate complications include bile leak and arterial or venous thrombosis, and delayed complications (rejection) are immunological in nature.\n\n### 13.2.2 Bile Leak\n\nLeak is inferred when bile enters an unanticipated region or an anticipated region at an unanticipated time [17]. Bile leak at the anastomotic site is relatively common and accounts for 10% of all complications. The leak may occur into the liver parenchymam or into the subhepatic space forming a biloma, or the leak may enter the peritoneal space, causing bile peritonitis. Biloma produces a filling defect within the liver in early images and fills in with Tc-99m-HIDA-radiolabeled bile in late images. In contrast, a benign or malignant space-occupying lesion remains a \"cold\" defect throughout. Bile enters an abscess cavity when the abscess connects with a bile duct. Healing of the abscess cavity is demonstrated with serial imaging (Fig. 13.1.5). Bile leak at the anastomotic site (choledocho-choledochal) is usually small in size and closes spontaneously. Bile leak at the choledocho-duodenal junction, on the other hand, tends to be large in volume and carries a much higher morbidity and mortality due to simultaneous leakage of intestinal contents into the peritoneal space. In the supine position, leaked bile gravitates to the right or left paracolic gutter and later enters the pelvic cavity. Opioids prescribed for pain control often increase the volume of bile leak because of their constrictive effect on the sphincter of Oddi.\n\nFig. 13.1.5\n\nAbscess in a transplant liver. An abscess causes a large filling defect within liver parenchyma (a) and fills with bile at 4.5 h (b). A repeat study 3 months later shows shrinkage of the abscess, but fistula persists\n\n### 13.2.3 Bile Duct Stricture\n\nStricture is a late complication and accounts for 15 to 25% of the total complications of liver transplantation. Stricture is attributed to bile duct ischemia caused by arterial stenosis or thrombosis. Cholescintigraphy shows bile pooling in ducts proximal to the stricture. Segmental and area ducts are seen with unusual prominence [18]. Denervation during transplant surgery alters sympathetic-parasympathetic-hormonal control over the ducts and sphincter of Oddi. Nervous and hormonal imbalance may cause biliary dyskinesia. Distinction between anatomic stricture and biliary dyskinesia is made with the use of amyl nitrite or a calcium channel blocker (nefidapine), very similar to studies obtained in non-transplant patients [19, 20].\n\n### 13.2.4 Primary Non-Function Versus Rejection\n\nPrimary non-function is non-recovery of donor liver function in the recipient despite good surgical technique establishing adequate portal vein and hepatic artery blood flow. Clinically, it presents as liver failure in association with encephalopathy, persistent acidosis, and severe coagulopathy, and requires retransplantation. Acute rejection occurs within 3 months of transplantation, and chronic rejection follows later. Unlike the kidneys, the liver does not manifest a hyperacute rejection. Rejection is a microvascular phenomenon where fibrin, immune and inflammatory cells deposit within and around the capillaries, manifesting an obliterative angiopathy and chronic ischemia. Chronic ischemia leads to obliteration of the bile ducts (vanishing bile duct syndrome) and intrahepatic cholestasis. Both rejection and intrahepatic cholestasis resulting from other causes manifest similar cholescintigraphic findings, and hence one entity cannot be separated from the other [21]. Rejection is managed with immunosuppressive agents like cyclosporine and tacrolimus [22]. Serial studies enable evaluation of liver function and aid in the adjustment of the immunosuppressant dosage [23].\n\n### 13.2.5 Cholescintigraphy\n\nThe data are collected with a large field of view gamma camera fitted with a low-energy, all-purpose, parallel-hole collimator using 3-8 mCi of Tc-99m-HIDA. Technetium-99m mebrofenin is the best agent both in normal as well as jaundiced patients. Liver perfusion images are obtained at 2 s per frame during the first 1 min, followed by functional images at 1 min per frame for 59 min, for a total of 1 h, and recorded on a 128 \u00d7 128 word mode matrix. A short imaging interval is essential for location of the exact site of the bile leak. The first place of unexpected bile radioactivity usually indicates the site of origin of the leak. Once there is collection of a large volume of bile, it becomes difficult to identify the exact site of the bile leak.\n\n### 13.2.6 Auxiliary Liver Transplantation\n\nIn an auxiliary transplant, the donor liver is placed in a heterotopic position adjacent to the native liver or in the space created by partial hepatectomy of the native liver (Fig. 13.1.6). Auxiliary liver transplantation is restricted mostly to patients with fulminant hepatic failure where the native liver has the potential for full functional recovery if the patient survives the acute episode. Fulminant hepatic failure consists of liver failure and encephalopathy occurring within a 2-8 week period in a previously healthy person. Fulminant hepatic failure is relatively rare, and accounts for 6% of all adult liver transplants and 11% of all pediatric liver transplants each year in the United States [24]. Mortality is 100% in untreated patients. Full functional recovery is due to the generous regeneration capacity of the native liver in those patients who can withstand an acute insult [25].\n\nFig. 13.1.6a,b\n\nPattern of recovery of native liver function following auxiliary liver transplantation. Cholescintigram (a) and a corresponding schematic diagram (b) are shown in a 2-year-old child with auxiliary liver transplant for fulminant hepatic failure. At 10 days, the native liver shows poor uptake, and the auxiliary liver has good uptake of 99mTc-HIDA. Function appears equal by 7 months. Function of the auxiliary liver begins to decrease by 8.5 months and disappears completely at 11.5 months. The native liver recovers its function completely with 100% extraction fraction. (Courtesy of Dr. Muriel Buxton-Thomas, Kings College Hospital, London, UK)\n\nFulminant hepatic failure heals slowly over several months to attain full functional recovery (Table 13.1.3). When serum liver function tests show either an improvement or deterioration in a patient with auxiliary liver transplantation, it is not clear from the serum levels whether the changes reflect the function of the native or the donor liver. The immunosuppressive dose needs to be increased if there is rejection of the donor liver. An improvement of the native liver function, on the other hand, calls for either a reduction in dosage or total discontinuation of immunosuppressive agents. The donor liver undergoes spontaneous regression and atrophy when the native liver recovers its full function, and steroids are withdrawn safely at this time. The donor liver is surgically removed if it does not undergo spontaneous atrophy and interferes with the function of the native liver [26].\n\nTable 13.1.3\n\nDifferentiation of the native from donor liver function following auxiliary liver transplantation for fulminant hepatic failure\n\nStudy no. | Time post-transplant | Native liver function | Auxiliary liver function\n\n---|---|---|---\n\nHEF(%) | Ex. T\u00bd(min) | function(%) | HEF(%) | Ex. T\u00bd(min) | function(%)\n\n1 | 10 days | 37 | 27 | 15 | 73 | 21 | 85\n\n2 | 7 months | 51 | 18 | 44 | 54 | 17 | 56\n\n3 | 8.5 months | 78 | 16 | 64 | 50 | 53 | 36\n\n4 | 11.5 months | 100 | 8 | >99 | - | - | <1\n\n(Courtesy Dr. Muriel Buxton-Thomas, Kings College Hospital, London)\n\n### 13.2.7 Differentiation of Native vs. Donor Liver Function\n\nCholescintigraphy is able to measure the total as well as the function of the donor and native liver separately. The differential liver function information helps the clinician in adjusting the dose of immunosuppressive agents.\n\nCholescintigraphy is obtained in adults with a large field of view and in children with a standard or even small field of view gamma camera, fitted with a low-energy, general-purpose, parallel-hole collimator. With the patient in a supine position, the camera is positioned anteriorly to cover the entire native and the donor liver. A dynamic 60-frame image at minute intervals are obtained with 4 to 6 mCi of Tc-99m HIDA, and recorded on a 128 \u00d7 128 computer matrix. The preferred imaging agent in jaundiced patients is Tc-99m mebrofenin, which has superior biokinetic behavior in patients with hyperbilirubinemia [27]. One can obtain a liver scan with Tc-99m-S colloid to outline the liver borders, but it is not essential in most cases, as early Tc-99m-HIDA images, obtained within the first 5 to 6 min, provide similar morphologic information (Fig. 13.1.2).\n\n### 13.2.8 Quantification\n\nMany different methods have been used for quantification of transplant function. Deconvolutional analysis (Chap. 5) is applied to measure the extraction fraction of the native and auxiliary liver separately, by choosing heart for the input and liver for the output function. Excretion half time is measured with a monoexponential fit. Some express the function as uptake of the injected dose by the native versus donor liver. Four regions of interest are drawn; two ROIs over the liver (one over the entire native liver and the other over the entire donor liver) and two ROIs for background just lateral to each liver. Background counts (from Tc-99m-S colloid when a preliminary scan is obtained) are subtracted from the liver counts, and the net liver counts and curve are displayed. From the net liver curve, three functional parameters are generated [28].\n\n(1) T-max = time to maximum liver counts.\n\n(2) T 1\/2 = clearance half time using a mono-exponential fit to the data points from peak counts.\n\n(3) Relative uptake (RU) by the liver. RU is obtained by noting the area under the time-activity curves of the native and graft livers between 2 and 10 min.\n\n![$$\\\\begin{array}{l}\n{\\\\rm RU\\\\ by\\\\ native\\\\ liver = }\\\\frac{{{\\\\rm Native\\\\ liver\\\\ area\\\\ between\\\\ 2 - 10\\\\ min} \\\\times {\\\\rm 100}}}{{{\\\\rm Native\\\\ liver\\\\ area\\\\ between\\\\ 2 - 10\\\\ min  +  donor\\\\ liver\\\\ are\\\\ between\\\\ 2 - 10\\\\ min}{\\\\rm .}}}\\\\\\\\\n{\\\\rm RU\\\\ by\\\\ native\\\\ liver = }\\\\frac{{{\\\\rm Graft\\\\ liver\\\\ area\\\\ between\\\\ 2 - 10\\\\ min -- 100}}}{{{\\\\rm Graft\\\\ liver\\\\ area\\\\ between\\\\ 2}{\\\\rm .-- 10\\\\ min  +  native\\\\ liver\\\\ area\\\\ between\\\\ 2 -- 10\\\\ min}{\\\\rm .}}}\\\\\\\\\n\\\\end{array}$$](A978-3-642-00648-7_13_Chapter_TeX2GIF_Equ1_13.gif)\n\nIn one study, authors followed patient recovery for up to 30 months and calculated the percent uptake by the native liver by using the area under the curve between the 2nd and 10th min, and validated the scintigraphic method in the management of the patient with auxiliary liver transplantation [28].\n\nDeconvolutional analysis is applied when the software is available. In children, where the liver physiology is much faster than in adults, the data are collected at a much shorter interval, 30 s per frame for 30 min. Hepatic extraction fraction calculation uses only the first 30 frames (15 min), and the excretion T1\/2 is calculated using all 60 frames. Native and donor liver HEF and excretion half times are measured separately for both. The contribution of each liver towards total function is calculated and expressed as percent (Table 13.1.3).\n\n### 13.2.9 Recovery Pattern in Auxiliary Liver Transplantation\n\nImmediately after the transplantation, the function of the native liver remains depressed with a median uptake value of 27% (range 4%-36%) during the first 4 weeks. The median uptake value increases gradually to twice the baseline value 6-12 months after transplantation. When serum liver function tests show stable normal values, the uptake by the native liver raises to above 90%. The native liver T-max value may normalize within a month, but the excretion T1\/2 value usually remains elevated for a much longer period of time. The immunosuppressive drug dose may be decreased when the relative uptake value raises above 30%, and the drug may be withdrawn completely when the uptake value reaches above 90% [28]. The pattern of recovery of native liver function following an auxiliary liver transplantation in a 2-year-old child is shown in Table 13.1.3. The hepatic extraction fraction and excretion half time of the native liver and auxiliary liver are measured separately for each liver (Fig. 13.1.6). As the function of the native liver improves gradually and recovers fully, the auxiliary liver function deteriorates with regression of functional liver volume.\n\n### 13.2.10 Living-donor Liver Transplantation\n\nAlthough the liver is one solid organ, its distinct segmental and lobar anatomy and physiology allow resection into smaller portions for transplantation [29]. Resection of the donor liver is performed along the physiological planes (Fig. 1.1.3, Chap. 1). The lateral segment of the left lobe (areas 2 and 3) or the entire left lobe (areas 2, 3, 4A, and 4B) is resected from the donor for transplantation in the recipient (Fig. 13.1.1). The first living-donor liver transplantation was performed by Raia et al. in Brazil in 1989 [30]. The left lobe of the liver from a mother was transplanted successfully into her son in Australia in 1989 [31]. There are numerous centers around the world performing living-donor liver transplantations [32-34]. Major advantages of living-donor liver transplantation are: (1) reduction in waiting time, (2) high quality of the donor liver, and (3) immunological similarity in haplo-identical donors.\n\n### 13.2.11 Complications\n\nPostoperative complications are a major concern both in the donor and the recipient. Among the first 100 living-donor liver donor transplantations performed at the University of Chicago, 91 donors had resection of the lateral segment of the left lobe (areas 2 and 3), and the remaining 9 had resection of the entire left lobe (areas 2, 3, 4A, and 4B). Thirteen of the 100 donors had complications, including bile leaks, infection, injury to the bile ducts and spleen, etc., as listed in Table 13.1.4 [35]. Bile leak, bleeding, thrombosis, or infection may occur in either the recipient or the donor, or both. Rejection is an additional complication in the recipient. The living-donor liver transplantation procedure has been found to be safe both for the donor and the recipient. Donor survival is 100%, and the recipient survival ranges from 80 to 94% in centers that perform more than 15 living-donor transplantations in a year [22]. Common complications within 30 days after transplantation include bleeding, extrinsic obstruction, hemobilia, and bile leak around the T-tube or at the anastomotic site. Bile leaks around the T-tube usually close spontaneously, and those that continue to leak may require sphincterotomy or insertion of a biliary stent. Complications occurring after 30 days include stricture at or proximal to the site of anastomosis [36]. Viral, bacterial, and fungal infections are always a concern in an immunocompromised liver transplant patient [37].\n\nTable 13.1.4\n\nComplications in living-liver donors [31]\n\nBile leak from cut end\n\n---\n\nInjury to bile ducts\n\nInjury to spleen\n\nStricture of the common bile duct\n\nIleus\n\nWound infection\n\nUrinary tract infection\n\nHepatic artery thrombosis\n\nAbscess\n\n### 13.2.12 Future Directions\n\nThe major advantage of hepatobiliary imaging is the opportunity to detect functional abnormality early before irreversible morphological changes take place. Simultaneous quantification of function provides a measure of the severity of disease and enables the clinician to determine the appropriate time to intervene with therapy, and also to test later whether or not the chosen therapy has achieved the intended goals. Following a thorough clinical evaluation and analysis of liver function tests, Tc-99m-HIDA cholescintigraphy is an appropriate initial imaging procedure for detection of most pathophysiologic changes associated with bile formation and flow [38]. Cholescintigraphic results can guide the clinician in developing a management strategy and also aid in determining the need for other imaging (CT or MR) or non-imaging procedures that will lead to the ultimate diagnosis. Liver biopsy is the most appropriate next step for patients with intrahepatic cholestasis. For extrahepatic cholestasis, the clinician may choose percutaneous transhepatic cholagiography for obstruction at or proximal to the union of the right hepatic and left hepatic ducts. ERCP is preferred for obstructions in the common hepatic or common bile duct. Magnetic resonance cholangiopancreatography (MRCP) is being used more often as a non-invasive alternative to invasive ERCP [39]. Receptor-based imaging may enable the selection of a receptor-specific therapy. Quantitative asialoglycoprotein receptor imaging with Tc-99m DTPA galactosyl human serum albumin enables to predict residual liver function after resection of hepatocellular cancer and cholangiocarcinoma and to forecast prognosis of liver cirrhosis [40-42]. A somatostatin receptor-positive metastatic gastrinoma may respond to therapy with octreotide.\n\nReferences\n\n1.\n\nNational Institute of Health Consensus Development Conference statement: Liver transplantation. June 20-23, 1983, Hepatology 1983;3:(Suppl) 107S-110S\n\n2.\n\nWelch CS. A note on transplantation of whole liver in dogs. Transplant Bull 1955;2:54\n\n3.\n\nStarzl TE, Marchioro TL, Von Kaulla KN, Hermann G, Brittain RS, Waddell UR. Homo\u00adtransplantation of the liver in humans. Surg Gynecol Obstet 1963;117:659-676PubMed\n\n4.\n\nGoss JA, Shackleton CR, McDiarmid SV, Maggard M, Swenson K, Seu P, Vargas J, Martin M, Ament M, Brill J, Harrison R, Busuttil RW. Long-term results of pediatric liver transplantation. An analysis of 569 transplants. Ann Surg 1998;228:411-420PubMedCrossRef\n\n5.\n\nPfitzmann R, Schwenger J, Rayes N, et al. Long-term survival and predictors of relapse after orthoptic liver transplantation for alcoholic liver disease. Liver Transpl 2007;13:197-205PubMedCrossRef\n\n6.\n\nStarzl TE, Demetris AJ, Van Thiel D. Liver transplantation (1). N Engl J Med 1989;321:1014-1022PubMedCrossRef\n\n7.\n\nKawasaki S, Makuuchi M, Matsunami H, Hashihura Y, Ikegami T, Nakazawa Y, Chisuwa H, Terada M, Miyagawa S. Living related liver transplantation in adults. Ann Surg 1998;227:269-274PubMedCrossRef\n\n8.\n\nSudan DL, Shaw BW Jr, Fox IJ, Langnas AN. Long-term follow-up of auxiliary orthotopic liver transplantation for the treatment of fulminant hepatic failure. Surgery 1997;122:771-778PubMedCrossRef90086-6)\n\n9.\n\nShah AN, Dodson F, Fung J. Role of nuclear medicine in liver transplantation. Semin Nucl Med 1995;25:36-48PubMedCrossRef80005-4)\n\n10.\n\nStieber AC, Gordon RD, Galloway JR. Orthotopic liver transplantation. In: Zakim D, Boyer TD (eds). Hepatology. A text book of liver disease. WB Saunders, Philadelphia, 1996, pp 1759-1780\n\n11.\n\nBrown RK, Memsic LD, Busuttil RW, Pusey E, Ray RA, Kangarloo H, Hawkins RA. Accurate demonstration of hepatic infarction in liver transplant recipients. J Nucl Med 1986;27:1428-1431PubMed\n\n12.\n\nSanchez-Urdazpal L, Gores GJ, Ward EM, Maus TP, Wahlstrom HE, Moore SB, Wiesner RH, Krom RA. Ischemic-type biliary complication after orthotopic liver transplantation. Hepatology 1992;16:49-53PubMedCrossRef\n\n13.\n\nPannu HK, Warren WR, Fishman EK. Liver transplantation: preoperative CT evaluation. RadioGraphics 2001;21:S133-S146PubMed\n\n14.\n\nLamke AJ, Brinkman MJ, Schott T, Niehaus P, Felix R. Living donor right liver lobes: Preoperative CT volumetric measurement for calculation of intraoperative weight and volume. Radiology 2006;240:736-742CrossRef\n\n15.\n\nKyoden Y, Tamura S, Sugawara Y, Yamashiki N, Matsui Y, Togashi J, Kaneko J, Kokudo N, Makuuchi M. Outcome of living donor liver transplantation for post-Kasai biliary atresia in adults. Liver Transpl 2008;14:186-192PubMedCrossRef\n\n16.\n\nBell BP, Manos M, Zaman A, Terrault N, Thomas A, Navarro VJ, Dhotre KB, et al. The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: Results from population-based surveillance. Am J Gastroenterol 2008;103:2727-2736PubMedCrossRef\n\n17.\n\nVon Moll LK, Juni JE, Merion RM. Scintigraphic demonstration of accessory hepatic duct leak following liver transplantation. J Nucl Med 1988;29:259-262PubMed\n\n18.\n\nLantsberg S, Lanchbury EE, Drolc ZA. Evaluation of bile duct complications after orthotopic liver transplantation by hepatobiliary scanning. Nucl Med Commun 1990;11:761-769PubMedCrossRef\n\n19.\n\nMadacsy L, Velosy B, Lonovics J, Csernay L. Differentiation between organic stenosis and functional dyskinesia of the sphincter of Oddi with amyl nitrite-augmented quantitative hepatobiliary scintigraphy. Eur J Nucl Med 1994;21:203-208PubMedCrossRef\n\n20.\n\nBhatnagar A. Nifedipine interventional cholescintigraphy. A new method for assessing sphincter of Oddi? Indian J Nucl Med 1997;12:93-96\n\n21.\n\nJain A, Khanna A, Molmenti EP, Rishi N, Fung JJ. Immunosuppressive therapy. Surg Clin North Am 1999;79:59-76PubMedCrossRef70007-4)\n\n22.\n\nParker BM, Cywinski JB, Alster JM, Irefin SA, Popovich M, Beven M, Fung JJ. Predicting immunosuppressant dosing in the early postoperative period with noninvasive indicyanine green elimination following orthoptopic liver transplantation. Liver Transpl 2008;14:46-52PubMedCrossRef\n\n23.\n\nHawkins RA, Hall T, Gambhir SS, Busuttil RW, Huang SC, Glickman S, Marciano D, Brown RK, Phelps ME. Radionuclide evaluation of liver transplant. Semin Nucl Med 1988;18:199-212PubMedCrossRef80028-X)\n\n24.\n\nShakil AO, Mazariegos GV, Kramer DJ. Fulminant hepatic failure. Surg Clin North Am 1999;79:77-108PubMedCrossRef70008-6)\n\n25.\n\nBoudjema K, Cherqui D, Jaeck D, Chenard-Neu MP, Steib A, Freis G, Becmeur F, Brunot B, Simeoni U, Bellocq JP, et al. Auxiliary liver transplantation for fulminant and subfulminant hepatic failure. Transplantation 1995;59:218-223PubMed\n\n26.\n\nMetselaar HJ, Hesselink EJ, de Rave S, ten Kate FJ, Lameris JS, Groenland TH, Reuvers CB, Weimar W, Terpstra OT, Schalm SW. Recovery of failing liver after auxiliary heterotopic transplantation. Lancet 1990;335:1156-1157PubMedCrossRef91158-7)\n\n27.\n\nKrishnamurthy S, Krishnamurthy GT. Technetium-99m-iminodiacetic acid organic anions: review of biokinetics and clinical application in hepatology. Hepatology 1989;9:139-153PubMedCrossRef\n\n28.\n\nBuyck D, Bonnin F, Bernuau J, Belghiti J, Bok B. Auxiliary liver transplantation in patients with fulminant hepatic failure: hepatobiliary scintigraphy follow-up. Eur J Nucl Med 1997;24:138-142PubMedCrossRef\n\n29.\n\nBismuth H, Houssin D. Reduced-size orthotopic liver graft in hepatic transplantation in children. Surgery 1984;95:367-372PubMed\n\n30.\n\nRaia S, Nery JR, Mies S. Liver transplantation from live donors. Lancet 1989;2:497PubMedCrossRef92101-6)\n\n31.\n\nStrong RW, Lynch SV, Ong TH, et al. Successful liver transplantation from a living donor to her son. N Eng J Med 1990;322:1505-1507CrossRef\n\n32.\n\nEmond JC. Clinical application of living-related liver transplantation. Gastroenterol Clin North Am 1993;22:301-315PubMed\n\n33.\n\nDonovan J. Nonsurgical management of biliary tract disease after liver transplantation. Gastroenterol Clin North Am 1993;22:317-336PubMed\n\n34.\n\nReding R, Goyet JV, Delbeke I, Sokal E, Jamart J, Janssen M, Otte J. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts. J Pediatr 1999;134:280-286PubMedCrossRef70450-6)\n\n35.\n\nGrewal HP, Thistlethhwaite JR Jr, Loss GE, Fisher JS, Cronin DC, Siegel CT, Newell KA, Bruce DS, Woodle ES, Brady L, Kelly S, Boone P, Oswald K, Millis JM. Complications in 100 living-liver donors. Ann Surg 1998;228:214-219PubMedCrossRef\n\n36.\n\nStratta RJ, Wood RP, Langnas AN, Hollins RR, Bruder KJ, Donovan JP, Burnett DA, Lieberman RP, Lund GB, Pillen TJ, et al. Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation. Surgery 1989;106:675-684PubMed\n\n37.\n\nMazariegos GV, Molmenti EP, Kramer DJ. Early complications after orthotopic liver transplantation. Surg Clin North Am 1999;79:109-129PubMedCrossRef70009-8)\n\n38.\n\nKrishnamurthy S, Krishnamurthy GT. Nuclear hepatology: where is it heading now? J Nucl Med 1988;29:1144-1149PubMed\n\n39.\n\nFulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM. Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects. Radiology 1998;207:21-32PubMed\n\n40.\n\nSasaki N, Shiomi S, Iwata Y, Nishiguchi S, Kuroki T, Kawabw J, Ochi H. Clinical usefulness of scintigraphy with Tc-99m Galactosyl-human serum albumin for prognosis of cirrhosis of the liver. J Nucl Med 1999;40:1652-1656PubMed\n\n41.\n\nHwang E, Taki J, Shuke N, Nakajima K, Kinuya S, Konoshi S, Michigishi T, Aburano T, Tonami N. Preoperative assessment of residual hepatic functional reserve using Tc-99m-DTPA-galactosyl-human serum albumin dynamic SPECT. J Nucl Med 1999;40:1644-1651PubMed\n\n42.\n\nUetake M, Koizumi K, Yagawa A, Nogata H, Tezuka T, Kono H, Ozawa T, Kusano T, Miyabukuro M, Hosaka M. Use of Tc-99m DTPA galactosyl human serum albumin to predict postoperative residual liver function. Clin Nucl Med 1999;24:428-434PubMedCrossRef\nGerbail T. Krishnamurthy and Shakuntala KrishnamurthyNuclear HepatologyA Textbook of Hepatobiliary Diseases10.1007\/978-3-642-00648-7(C) Springer-Verlag Berlin Heidelberg 2009\n\nIndex\n\nA\n\nAbscess\n\nAquaporins\n\nApopstosis\n\nAbsorption of water\n\nAbsorbed doses\n\nAdenoma\n\nAction of somatostatin\n\nArea method\n\nAlcoholic hepatitis\n\nAcute cholecystitis\n\nAcute cholangitis\n\nAcute acalculous cholecystitis\n\nAuxiliary liver transplantation\n\nAmpula of Vater\n\nB\n\nBismuth\n\nBile canaliculous\n\nBile concentration\n\nBile ducts\n\nBudd-Chiar syndrome\n\nBiliary apparatus\n\nBasolateral border (domain)\n\nBile secretion\n\nBile entry\n\nBasolateral transport\n\nBone marrow uptake\n\nBlood pool\n\nBile duct obstruction\n\nBenign recurrent intrahepatic cholestasis (BRIC)\n\nBenign stricture\n\nBiliary pain pathway\n\nBile aspiration\n\nBaye's analysis\n\nBile leak\n\nBiliary dyskinesia\n\nBiliary atresia\n\nC\n\nCanalicular membrane\n\nCystic duct\n\nCholecystectomy\n\nCaudate lobe\n\nCouinaud\n\nCaudate process\n\nCommon bile duct\n\nCholangiocytes\n\nChild's classification\n\nCholecystokinin\n\nCerulein\n\nCisterna chili\n\nCholangiocarcinoma\n\nComposition of gallstones\n\nChronic acalculous cholecystitis\n\nCholelithiasis\n\nCongenital abnormalities\n\nCystic duct spasm\n\nCongenital biliary atresia\n\nCholedochal cyst\n\nCystic diseases of the gallbladder\n\nCaroli's disease\n\nD\n\nDucts\n\nDifferential bile flow\n\nDuodeno-Gastric bile reflux\n\nDuodenum\n\nE\n\nEmbryology of liver and gallbladder\n\nExtrahepatic obstruction\n\nEndothelial cell\n\nEndocytosis\n\nExcretion\n\nExtraction fraction\n\nExcretion halftime\n\nEjection fraction\n\nExtrensic compression\n\nF\n\nFalciform ligament\n\nFocal lesions\n\nFocal nodular hyperplasis\n\nFatty meal\n\nFluorine-18 FDG\n\nFilling of the gallbladder\n\nG\n\nGallbladder\n\nGallbladder emptying\n\nGallium-67 citrate\n\nGallbladder segmentation\n\nGalactosyl human serum albumin (GSA)\n\nGallbladder cancer\n\nGallstones\n\nGold-198\n\nGastrinoma\n\nH\n\nHepatobiliary imaging\n\nHepatopulmonary syndrome\n\nHemobilia\n\nHepatocellular carcinoma\n\nHepatic artery\n\nHepatic veins\n\nHepatocyte\n\nHemangioma\n\nHepatic extraction fraction\n\nHartmann pouch\n\nI\n\nImaging agents\n\nIntrahepatic cholestasis\n\nIrritable bowel\n\nIndium-111 pentetreotide (OctreoScan)\n\nJ\n\nJaundice\n\nK\n\nKlatskin's tumor\n\nKupffer cell\n\nKHBS\n\nKasai procedure\n\nL\n\nLiver function\n\nLiver lobes\n\nLymphatics\n\nLiver function\n\nLeukocytes\n\nLilli-Altnman\n\nLiver transplantation\n\nLiving-donor liver transplant\n\nLigand\n\nLiver cysts\n\nLiver abscess\n\nM\n\nMicrostructure\n\nMultidrug resistance glycoprotein (MDR)\n\nMorphine\n\nMalignant liver diseases\n\nMorphology of liver\n\nMagnetic resonance cholangiopancreatography (MRCP)\n\nN\n\nNerve supply\n\nNuclear receptors\n\nNecrosis\n\nNeonatal hepatitis\n\nNeonatal cholestasis\n\nO\n\nOrganic anions\n\nOrganic cations\n\nOctreotide\n\nOctreoScan\n\nOpioids\n\nP\n\nParasites\n\nPitt cell\n\nPortal vein\n\nProtein secretion\n\nPlasma proteins\n\nPseudopod\n\nPhagosome\n\nPrimary biliary cirrhosis\n\nPrimary sclerosing cholangitis\n\nPerforation of the gallbladder\n\nPost-cholecystectomy syndrome\n\nQ\n\nQuadrate lobe\n\nQuantification of function\n\nR\n\nRadiocolloid\n\nReticuloendothelial cell\n\nRelative merits of tests\n\nRed blood cell\n\nRadiation dose\n\nRim sign\n\nS\n\nSerege-Cantlie line\n\nSclerosing cholangitis\n\nSegments of the liver\n\nSincalide dose\n\nSlope method\n\nSegmental biliary obstruction\n\nSpiegel's lobe\n\nStellate cell\n\nSphincter of Oddi\n\nSpleen function\n\nStructure-function relation\n\nS-I units\n\nSomatostatin receptors\n\nSolitary focal lesion\n\nStricture\n\nStent patency\n\nSurface receptors\n\nSomatostatin scintigraphy\n\nSugura procedure\n\nT\n\nTransport proteins\n\nTechnetium-99m-sulfurcolloid\n\nTechnetium-99m HIDA agents\n\nTechnetium-99m mebrofenin\n\nTechnetium-99m-disofenin\n\nTechnetium-99m-HMPAO\n\nTechnetium-99m --depreotide\n\nTechnetium-99m-GSA\n\nTotal parenteral nutrition\n\nTransplantation\n\nU\n\nUptake\n\nUeda I\n\nUltrasound\n\nV\n\nViral hepatitis\n\nVascular compartment\n\nW\n\nWall thickening\n\nWirsung duct\n","meta":{"redpajama_set_name":"RedPajamaBook"}}
+{"text":"\n\nFirst published by Zero Books, 2013   \nZero Books is an imprint of John Hunt Publishing Ltd., Laurel House, Station Approach,   \nAlresford, Hants, SO24 9JH, UK  \noffice1@jhpbooks.net  \nwww.johnhuntpublishing.com  \nwww.zero-books.net\n\nFor distributor details and how to order please visit the 'Ordering' section on our website.\n\nText copyright: Paul Gordon 2012\n\nISBN: 978 1 78099 327 0\n\nAll rights reserved. Except for brief quotations in critical articles or reviews, no part of this book may be reproduced in any manner without prior written permission from the publishers.\n\nThe rights of Paul Gordon as author have been asserted in accordance with the Copyright,   \nDesigns and Patents Act 1988.\n\nA CIP catalogue record for this book is available from the British Library.\n\nDesign: Stuart Davies\n\nPrinted and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY\n\nWe operate a distinctive and ethical publishing philosophy in all areas of our business, from our global network of authors to production and worldwide distribution.\n\n# CONTENTS\n\nAcknowledgements\n\nVictor Serge - a life line\n\nIntroduction: the art of not dying away\n\n1. In the shadow of madness: the experience of prison\n\n2. Yesterday we were nothing: the revolutionary experience\n\n3. Building on corpses: the repressive state\n\n4. A stranger to no land: the experience of exile\n\n5. Magicians of word and thought: the Russian cultural revolution\n\n6. A certain sort of courage: the writer as witness\n\n7. Shared veins: hope and the soul\n\nWritings by Victor Serge\n\nFurther reading\n\nEndnotes\nFor John Berger  \nwith love and gratitude\n'What does not change \/ is the will to change'  \nCharles Olson, 'The Kingfishers'\n\n# Acknowledgements\n\nThis book simply would not have come into being without Gareth Evans. Love and thanks to him and to Melissa Benn and Graham Music for their encouragement and critical engagement; also to Hannah and Sarah, for being who they are. If I may borrow some words from Serge, I am grateful to them all for existing.\n\nThe music of Dino Saluzzi and Mal Waldron, brooding, tender, searching, endlessly evocative, provided the perfect soundtrack.\n\nPaul Gordon\n\nJuly 2012\n\n_Permissions_\n\nThe quotations from Serge's novels are used by kind permission of the translator, Richard Greeman. The lines from Serge's poems are reprinted by kind permission of City Lights Books, translation (c) 1989 by James Brook. The lines from 'The Kingfishers' are from Charles Olson, _The Collected Poems of Charles Olson_ , _Excluding the Maximus Poems_. (c) 1987 by the Regents of the University of California, reprinted by kind permission of the University of California Press.\n\n# Victor Serge - a life line\n\n1890 - Born 30 December, Victor Lvovich Kibalchich, into Russian revolutionary \u00e9migr\u00e9 family in Brussels\n\n1912 - Sentenced to five years in French prison for association with armed anarchist gang\n\n1915 - Marries Rirette Maitrejean\n\n1917 - Released from prison, takes part in syndicalist uprising in Barcelona  \nRussian Revolution\n\n1918 - Interned in concentration camp in France trying to get to Russia\n\n1919 - Arrives in Petrograd to join the revolution, marries Liuba Russakova\n\n1920 - Son, Vlady, born\n\n1923 - Comintern agent in Berlin and Vienna\n\n1924 - Death of Lenin, succession of Stalin\n\n1928 - Expelled from Communist Party, begins writing fiction, _Men in Prison_ (1930), _Birth of our Power_ (1930) and _Conquered City_ (1932), all published in France\n\n1933 - Exiled to Orenburg, near Kazakhstan, writes _Midnight in the Century_ (1939) and much of his poetry\n\n1935 - Daughter, Jeannine, born\n\n1936 - International solidarity campaign secures his exit from Soviet Union, lives in Brussels and Paris\n\n1937 - Publishes _Destiny of a Revolution_ and _From Lenin to Stalin_\n\n1940 - Fall of France; assassination of Trotsky in Coyocoan, Mexico\n\n1941 - Begins exile in Mexico where he writes three more novels, _The Long Dusk, The Case of Comrade Tulayev_ and _Unforgiving_ _Years_ , and _Memoirs of a Revolutionary_ , marries Laurette Sejourne\n\n1947 - Dies of heart attack, 17 November, stateless, he is buried as a Spaniard in the French cemetery\n\n# Introduction:  \nthe art of not dying away\n\n_Dazzling_. That was the last word Victor Serge ever wrote. In his poem, 'Hands', a meditation on a sixteenth century terra cotta, which he had finished and typed up in the early hours of the day that would be his last. That evening, Tuesday 17 November 1947, he had gone out to see his artist son, Vlady, but he wasn't at home. He met Julian Gorkin, his old comrade, who had traveled from revolutionary Barcelona to greet him in Brussels when he was finally allowed to leave Russia. They talked for a bit before shaking hands and parting. Probably feeling unwell, he decided to take a cab home. His heart gave way before he even had time to tell the driver where he wanted to go.\n\nGorkin went to the police station to identify him just after midnight:\n\nIn a bare shabby room with grey walls, he was laid out on an old operating table, wearing a threadbare suit and a worker's shirt, with holes in his shoes. A cloth bandage covered the mouth that all the tyrannies of the century had not been able to shut. One might have thought him a vagabond who had been taken in out of charity. In fact, had he not been an eternal vagabond of life in search of the ideal? His face still bore the stamp of bitter irony, an expression of protest...\n\nHe had arrived here six years before with Vlady - his companion, Laurette, and his daughter, Jeannine, would come later - fleeing from Nazi-occupied Europe, leaving behind a lifetime of political activity - an anarchist in France, a syndicalist in Spain, a critical Bolshevik in Russia, an agent of the Comintern in Germany and Austria, years of internal exile in Russia, a supporter of the revolutionary POUM in Spain, of which Gorkin had been one of the leaders. The journey had taken six months on a cargo ship he described as 'an ersatz concentration camp of the sea'. There were more than 300 of them on it, including the surrealist Andre Breton, with whom Serge had campaigned in Paris against the Stalinist show-trials, and Breton's wife, Jacqueline. Oddly, the passengers included the anthropologist Claude Levi-Strauss, on his way to a new post in New York. Levi-Strauss was clearly in awe of Serge: he was a man, after all, who had known Lenin, but he found his physical presence at odds with his preconceptions. 'more like an elderly and spinster aunt...with an asexual quality...very far removed from the virile and superabundant vitality commonly associated...with subversive activities.' This, surely, says more about Levi-Strauss than it does about Serge. (Although he complained, Levi-Strauss traveled in comparative comfort compared to most of the passengers, as he was one of the few to have the use of the ship's two cabins.)\n\nBy stark contrast, the young man who would become Mexico's greatest writer and who would eventually win the Nobel Prize, Octavio Paz, had met Serge in Paris not long before and was 'immediately and powerfully' drawn to him. 'I spent hours talking with him, 'he recalled. 'Serge's human warmth, his directness and generosity, could not have been further from the pedantry of the dialecticians. A moist intelligence. In spite of his sufferings, setbacks. and long years of arid political arguments, he had managed to preserve his humanity....I was not moved by his ideas, but by his person...an example of the fusion of two opposing qualities: moral and intellectual intransigence with tolerance and compassion.' (It was Serge who introduced Paz to the work of the French painter\/writer, Henri Michaux, 'a discovery of capital importance for me'.)\n\nTheir journey involved yet another period in prison (this time in French-run Martinique) and, then bizarrely, his first ever flight in a plane. Mexico was not his choice but there was nowhere else, and it had become a home of sorts to thousands of political refugees, thanks to Lazaro Cardenas, the former president whose government was one of the few to have supported the Republican side in Spain, and opened the country to many Spanish and other exiles.\n\nBut the exiles brought their disputes with them, and these were often violent. Only a few months before Serge got there, Trotsky had finally fallen to the assassins who had pursued him for so long. (A previous attempt had involved an armed raid on his compound led by the Communist artist David Siqueiros, who would eventually find refuge in Chile, thanks to the intervention of the Chilean consul-general in Mexico, a poet who would come in time to speak for thousands in his hatred of oppression, one Pablo Neruda. Strange days indeed.)\n\nSerge's and Gorkin's own lives were threatened and on more than one occasion they had to go into hiding. The country's president received appeals from US and British politicians and intellectuals calling on him to protect them. At the same time, the editor of a magazine to which they had contributed was being told by the Interior Minister, Miguel Aleman, later to be President, that the governments of Britain and the USSR were demanding that all platform be withdrawn from these 'agents of Hitler'. Meetings were broken up and, on one occasion, Gorkin and another comrade were stabbed.\n\nAlways poor, and often indescribably lonely, (as he wrote to a friend), he explored the country. And he wrote and wrote and wrote - for _Partisan Review, Politics, Horizon, New Leader_ (as their Mexican correspondent), _The New International, Mundo, Libertad y Socialismo_. And three more novels: his best, his most ambitious yet, against all the odds to add to the four he'd already published, _The Long Dusk, The Case of Comrade Tulayev_ and _Unforgiving Years_. And a life of Trotsky with his widow, Natalia Zedova, a real act of generosity given Trotsky's abuse of Serge when he had dared to disagree. Only one of these would be published while he was still alive. Writing for the desk drawer, he called it.\n\nWith characteristic lack of self-pity, Serge wrote in his notebook: 'It is terribly difficult to create in a void without the slightest support, without the least ambience...at the age of 50...facing an unknown future which does not exclude the possibility that the dictatorships will last longer than the rest of my life.' And he was living at an altitude, over 7,000 ft above sea-level, that could do him no good whatsoever because of his heart, and learning to live with endless _temblores_ (earthquakes), 2000 recorded each year.\n\nAnd he read and read, making sense of the world as the ever worse news reached him from Europe. And he developed his interest in psychology. He'd always believed in the soul, what Vlady called his 'materialist spirituality'. This interest was encouraged by his friendship with the revolutionary German psychiatrists, Fritz Fraenckel and Hubert Lennhof. He was grief struck by Fraenckel's early death - he was only 52 - in June 1943, and it was a year before he was able to write about him, forcing himself to do so, knowing 'only too well the frailty of memory and the iniquitous and impoverishing omission which entombs the dead'. 'I owe a great deal,' Serge wrote, to his 'intelligent equilibrium in a time of instability and to his intellectual richness, which the malicious and the foolish weren't able to appreciate on account of his ways as an amused, sad and irresolute Bohemian...'How light he was on the earth!' At his funeral Serge said, 'Nobody who came close to him escaped his influence, everyone has been made at least a little better.' (Lennhof whispered, 'You don't know how much hostility there was towards him.')\n\nAnd it was here in exile that Serge wrote his single, greatest work, the incomparable _Memoirs of a Revolutionary_ , a work of political witness and engagement and solidarity, unparalleled since. The very first lines speak of a deep feeling he had known from childhood, of 'living in a world without any possible escape, in which there was nothing for it but to fight for an impossible escape'. (The very same existentialist dilemma was being articulated thousands of miles away by Sartre, Camus and de Beauvoir...)\n\nLooking back on his life, Serge said:\n\nI give myself credit for having seen clearly in a number of important situations. In itself, this is not so difficult to achieve, and yet it is rather unusual. To my mind, it is less a question of an exalted or shrewd intelligence, than of good sense, goodwill and a certain sort of courage to enable one to rise above the pressures of one's environment and the natural inclination to close one's eyes to facts, a temptation that arises from our immediate interests and from the fear which problems inspire in us.\n\nAmong the countless things he had seen clearly: that the creation of the Cheka (the secret police) in 1917 was one of the Bolsheviks' 'gravest and most impermissible errors'; that the Bolshevik leadership had lied about the nature of the Kronstadt rebellion in 1921; that the Communists would turn on the independent revolutionary left in Spain; that Stalin would eliminate the entire 1917 revolutionary generation in order to safeguard his power; that Russia had become a vast prison camp. (It was Serge who first described the state as totalitarian.)\n\nAnd yet he never lost hope, that ordinary people would act for themselves and take control of their own lives. On the ship taking him away from Europe he recalled, 'The Russians and Spaniards among us know what it is to take the world into their hands, to set the railways running and the factories working...no kind of predestination impels us to become the offal of the concentration camps.' He wasn't one of those former communists, whose 'god had failed', for he had never had one. For him there was no inevitability in how the revolution had turned out, any more than there was inevitability in anything. History was made by men and women who made choices.\n\nHoping to return to Europe, Serge envisaged a democratic renewal, 'of traditional democratic freedoms made revolutionary once again', in order 'simply to practice the art of not dying away'.\n\n* * *\n\nIt would be wrong to suggest that Serge was completely unrecognized during his life. Far from it; it was precisely his standing internationally that protected him from Stalin and brought about his and his immediate family's release from the Soviet Union, although it could not save his remaining relatives, most of whom would die in camps. And, because he wrote in French, several of his novels and his poetry were published in France, although obviously not in Russia. (One, _Midnight in the Century_ , was even nominated for the Prix Goncourt, the prestigious French literary prize, in 1939, although it didn't win.)\n\nAnd he had his influential admirers and supporters who included the radical US critic and editor, Dwight Macdonald, and George Orwell, who tried to find a publisher for his _Memoirs_. (Serge was so poor he had only one copy of the manuscript which he was, understandably, reluctant to trust to the transatlantic mail.) And he is even a character in a poem 'Aesthetique du mal', by Wallace Stevens. The first of his books to be translated into English, _The Long Dusk_ , was translated by Ralph Manheim, who would go on to become the foremost translator of contemporary German writers, including Brecht and Gunter Grass. And, in Britain, some of his books were published in mass-market editions by Penguin in the 1960s.\n\nBut since his death his work has had a precarious existence, going in and out of print, and waiting a long time to be translated into English. While _The Long Dusk_ was translated by Ralph Manheim the year before Serge died, all his other novels waited a long time. It was 20 years before Roger Trask's translation of _The Case of Comrade Tulayev_ appeared. Richard Greeman's translations of _Men in Prison, Birth of Our Power_ and _Conquered City_ all appeared in the early 1970s. But it was a further ten years before _Midnight in the Century_ appeared in translation, with _Unforgiving Years_ doing so only in 2008, nearly sixty years after it was written. And while the _Memoirs_ were published in 1963 by Oxford University Press in Peter Sedgwick's pellucid translation, they insisted he cut the manuscript by one-eighth before they would do so. It is only now, nearly 50 years later in 2012, that we have a complete English version. (Richard Greeman tells the story of Sedgwick's labors, an act of love and of solidarity, in the new edition.)\n\nAnd since his death he has, of course, had his prominent partisans. His 'unrepentant humanism' was celebrated by Christopher Hampton in his quietly thoughtful book, _Socialism in a Crippled World_ (1981), while Christopher Hitchens acknowledged him as 'the first person to recognize and comprehend the roots of the emerging Stalinist regime'. For John Berger, there is 'no other writer with whom Serge can very usefully be compared'. This singularity, for Berger, the 'essence of the man and his books', is to be found in his attitude to the truth; 'for Serge the value of the truth extended far beyond the simple (or complex) telling of it...The truth for Serge was something to be undergone.' In her introduction to a new edition of _The Case of Comrade Tulayev_ , Susan Sontag was moved to a generous celebration of the man:\n\nThere was nothing, ever, triumphant about his life...except[s] the triumph of being immensely gifted and industrious as a writer...of being principled and also astute and...incapable of keeping company with the faithful and cravenly gullible... of being incorruptible as well as brave and therefore on a lonely, different path from the liars and toadies and careerists, the triumph of being, after the 1920s, right.\n\nBut Serge has also been the subject of almost casual misrepresentation: the maverick British Trotskyite, David Widgery, dedicated his impressive account of the left in Britain to his memory, describing him as a 'Syndicalist, Bolshevik, Trotskyist', conveniently forgetting the anarchist he had been for many years, which got him several years in prison and which was _always_ part of who he was, while the epithet 'Trotskyist' is just misleading. A biography of the 'American Pimpernel', Varian Fry, who helped Serge and very many other intellectuals and artists to escape from France in 1940, describes him as a man 'who had travelled the revolutionary road from violence to tolerance', a gross oversimplification, that is also a misrepresentation. And it's a surprise to see the radical, and usually inspired, critic, John Leonard, say of him, that he 'had helped the Russian Revolution but then run away from it'. Really? Serge didn't run from anything, other than the Nazis in 1940 when his life and the lives of his family were in danger and he had done everything he could to put the revolution right, or at least stop it going wrong. And even Sontag, in what is otherwise a marvelous appreciation of the man, somehow manages to depoliticize him, which is quite a feat, given that he was born, lived and died a political being. It is this, more than anything else, that has stopped him getting the recognition that is his due. And while we must be grateful to the individuals and groups on the far left who have done so much to keep Serge's words and spirit alive, he is much too important to be a figure of the margins.\n\n* * *\n\nFor myself, I first read Victor Serge as a disaffected teenager in the late 1960s\/early 1970s, when I was trying to make sense of this thing called communism which seemed to be doing such terrible things in the world, despite its claim to be acting for the benefit of humankind, an idea to which I was strongly drawn. One of the books on our shelves at home was a volume called _The God That Failed_ , a collection of essays by former Communists, about why they had become disillusioned. The book, edited by the Labour MP Richard Crossman, with contributions by Richard Wright, Ignazio Silone and Arthur Koestler and others, was a popular volume with a catchy title, that seemed to damn the communist cause pretty conclusively. Equally damning were books like Alexander Solzhenitsyn's _One Day in the Life of Ivan Denisovich_ , Koestler's _Darkness at Noon_ , and George Orwell's _Animal Farm_ and _Nineteen Eighty Four_ , which I read around the same time. It was at the same time that I came across Serge's, _The Case of Comrade Tulayev_ , then published in its iconic Modern Classics series by Penguin. But this was telling a much more subtle and complex story that I was only able to appreciate with time.\n\nSerge's _Memoirs_ is the book I've read more often, and given to more people, than any other. Many people will recognize themselves in Serge biographer Susan Weissman's account of her total absorption. She first read them on a long train journey but had not finished them when she reached her destination. She sat on a bench in the station and read right to the end. Even after many readings, I still have to tear myself away once I pick them up, they are so engrossing. It was also one of the books I took traveling with me after I left university, including to Portugal, then in the throes of its own revolution, along with the wonderful Penguin volume of John Berger's _Selected Essays_ , and John Dos Passos' massive _USA_ , an astonishing counter-story of that country's development. (I learned much later that Serge admired Dos Passos and was clearly influenced by him.)\n\nI have never had a need for heroes, but Serge is a man I have admired greatly for most of my life and my admiration has deepened with my reading and re-reading of him over the years. That he wrote at all given the circumstances of his life, the persecution and the poverty, is remarkable; that he wrote so creatively, tellingly, movingly, is little short of astonishing, as is the fact that he never lost hope that people could take their destiny in their own hands and make a better world. And I've always loved the fact that this man - novelist, poet, historian, witness, revolutionary activist, humanist - who spoke several languages, never set foot inside an institution of formal learning; his father thought it 'stupid bourgeois instruction for the poor'. He was truly educated in museums, libraries and churches and in 'ransacking encyclopedias' and in, what he calls somewhere, 'the university of the streets'.\n\n* * *\n\nSo what follows is an introduction to a man who really shouldn't need it and who, in many ways, does not; all we have to do, ultimately, is to read him. But he does need to be contextualized and that is what I've done, as well as provide a critical appreciation of his main writings, following, roughly, the chronology of his novels. If I've quoted him at length in places that's because he says things so much better than any paraphrase or summary and also because he often achieves what he does by an accumulation of images. (That's why I quote rarely from the _Memoirs;_ as someone said, the problem in writing about Serge's life is that he says it all so much better than we can.) And, yes, this is also a celebration of a unique and inspiring man and repayment of a debt of gratitude that is long overdue.\n\n# 1  \nIn the shadow of madness: the experience of prison\n\n'I was no longer a man', Serge wrote of the moment of sentence, but 'a man in prison. An inmate'. The process of dehumanization started then, 'I had crossed the invisible boundary'. Admission to the prison itself began with the inmates losing their few personal effects, 'We start out by being robbed.' And whatever individuality they have is also taken away when their heads are shaved and they are 'sufficiently depersonalized' to appear before the administrative authorities. Nothing distinguishes one man from another, 'the same stubbly chins, the same shaved skulls - and doubtless the same look of the hunted man'. The mass photographing, 'a gallery of lost souls', further reduces every one to two or three varieties of expression: 'animal passivity, confusion, humiliation - each modified by anger, despair, defiance, or taciturn sullenness...'\n\nWhen he was in his early twenties, Victor Serge was implicated by the French police in the activities of the notorious 'Bonnot Gang', a group of illegalist anarchists who had been causing havoc in parts of the country. Believers in the 'propa-ganda of the deed', they carried out armed robberies and made their getaway by car, which was then something of a novelty. Serge had expressed his support for them and when police raided the offices of the newspaper he edited, they found a couple of revolvers. He refused to give evidence against the robbers, was convicted and given what could only be seen as a vindictive sentence of five years imprisonment. Writing nearly 30 years later, Serge wrote, with an honesty and self-evident pain, of the emotional legacy this had left him:\n\nIt burdened me with an experience so heavy, so intolerable to endure, that long afterwards, when I resumed writing, my first book (a novel) amounted to an effort to free myself from this inward nightmare, as well as performing a duty towards all those who will never so free themselves...\n\nAlthough written in the first person, narrated by a man who is never named, _Men in Prison_ is, Serge makes clear at the outset, a work of fiction, but it is also true. 'Everything in this book is fictional and everything is true.' Serge said that what he was trying to do, was through literary creation, to bring out the general meaning and human contents of a personal experience. In other words, Serge is saying, don't make the mistake of thinking that this book, is about me. The book is called, after all, _men_ in prison, not _a man_ in prison. It's about all men 'crushed in that dark corner of society'. And the only way open to Serge to do it at that time, with the creative resources available to him, was as a first person narrative. He was being true to his own experience, but also that of the many people whose lives he had shared or observed.\n\nThe rules of the prison can be summarized, Serge wrote, in three peremptory words: _'Living is forbidden!'_ Everything in prison came down to this. Above all, life was extinguished through time. Prisoners often speak of 'doing time'. They are punished through the theft of time; it is not theirs and what time there is, is either structured, as in meaningless work, or dead, empty time that destroys the soul. Serge was able to articulate this with an emotional depth which is truly frightening. Faced with 'the mystery of time's passage', the experience of time becomes like a torture. There are minutes and hours which have no end, 'the eternity of the instant'. But there are also empty hours, endless days, and weeks which pass without 'leaving the least memory behind them, as if they had never been. I cannot distinguish the years that are behind me'.\n\nWhen they are repeated indefinitely, the same feelings grow dull. One loses count of the hours and the days. Even something that moved or terrified during the first days no longer has any effect: 'Suffocation? Drowning? A torpor sneaks into your veins, between your temples: All of life takes on the faded ocher-hue of the cell. You can no more escape this torpor than you can escape these four walls. The rhythm of your inner life slows down.'\n\nNight brings no respite:\n\nEven the city's rumble seems to have stopped. Nothing. Sleep is impossible...I am already in a sort of tomb. I can do nothing. I see, hear, and feel nothing. I only know the next hour will be exactly like this one. The contrast between this vacant, empty prison time and the intense rhythms of normal life is so violent that it will take a long and painful adaptation to slow down the pulse of life, to deaden the will, to stifle, blot out, obliterate every unsettling image from my mind.\n\nThis experience comes to feel like being buried, a terrifying sensation that occurs again and again in the book: 'Burial. Each hour is like a shovelful of earth falling noiselessly, softly, on this grave...I am alone in a numbered sepulchre...Stretched out on my cot, like a dead man in his shroud (I even like to cross my hands over my chest like a dead man)...'\n\nLife is also extinguished through hard work, forced labor, 'poured onto the limit of your strength', twelve hours a day, from seven in the morning to seven in the evening. Not only that, but this work was supposed to be done in absolute, perpetual silence. The absurdity of that rule was, Serge commented, equaled only by its cruelty. 'If it were actually enforced and respected, it would be the simplest way to drive the prisoners quietly mad'. In practice, it was not rigidly applied, but its very existence gave the guards huge power as they could resort to it as and when they wanted, at any moment.\n\nThe prison also did all it could to kill any living relationship between prisoners. Communication between the inmates, as in the use of the 'telephone', using the wastepipes of the building, was especially severely punished. But even something as banal as whistling, humming, talking to yourself out loud were prohibited, as these too were signs of life, however pathetic. Of course, prisoners disobeyed, but they did so in a situation of considerable fear that they would be caught.\n\nSerge was an acute observer of how the modern prison _as a building_ served its function beautifully. The only 'perfect and irreproachable work of architecture in the modern city', he said, its perfection lay in the total subordination of its design to its function: 'Its perfection is revealed at first glance: it is impossible to mistake it for any other kind of edifice. It is proudly, insularly, itself.' It was able to do the seemingly impossible task of housing a vast crowd, while achieving the total isolation of each individual in that crowd: 'Busier than a beehive, it is able to accomplish, silently and systematically, as many different tasks as there are lives tossed into its grinding cogs'.\n\nThe hold of the modern, urban prison was total. No one ever escaped from them. While people even used to escape from the Bastille, that symbol of pre-revolutionary despotism, and even from the French overseas territories of New Caledonia and Guiana, where people were transported, 'no one escapes from the model jail'.\n\nSerge resisted completely any tendency to romanticize his fellow prisoners. One encountered, he remarked, just the same proportion of 'weak spirits, human scum, average types, and exceptional men, gifted with some spark of divinity', as anywhere else. As for the warders, they too, he said, were criminal, but respectably so, and with a guaranteed immunity from punishment for anything they might do. These people, who included 'sadists, inflexible hypocrites, morons, racketeers', could look forward to a pension at the end of their unspeakable lives. Serge drew a devastating picture of this person:\n\nThe hybrid of bureaucratic scribbler and turnkey...a singularly monotonous breed...their bodies grown fat from sitting...faces...stamped by the murky grayness of the prison bureau...eyes...grown dim with the horrid dullness that emanates from the forms, receipts, registers and filing cabinets, where the same inanely bureaucratic descriptions of hopeless victims and miserable wretches pile up _ad infinitum_...\n\nAnd yet, 'incredible as it may seem', there were also warders who were good and 'almost intelligent', men who were capable of acts of kindness, when, for instance, they would respond to the pleadings of a man in isolation who is 'too weary of solitude', and allow him a yard companion during exercise. On one such occasion, the narrator himself met a man who, when hearing he was an anarchist, shook his hand effusively. This man had known Peter Kropotkin and Pierre Martin, prominent Russian and French anarchists respectively, who had signed the 1883 Manifesto of the Anarchists and been imprisoned for their politics.\n\nThe warders and inmates ended up in a bizarre, shared existence, 'the same life on both sides of the same bolted door'. (The use of the familiar _tu_ , as a form of address, was evidence of an instinctive recognition of a common existence and a common mentality.) And yet, of course, warders had power and prisoners were powerless; few men in modern society, Serge observed, wielded 'such absolute power' over their fellow men as did prison wardens. They had, in effect the power of life and death over the prisoner:\n\nAll it takes from him is a suggestion to the chief Guard...and the prisoner...is constantly harassed with petty discipline and loaded down with penalties. The Warden can inflict penalties up to ninety days in the hole; more than enough to send the man...to the infirmary, eyes ruined, lungs ravaged by tuberculosis, throat swollen, and ears dripping pus...in effect, several sentences of slow death...\n\nThose disciplined were subjected to an extremely harsh regime, with their rations reduced to dry bread and morning soup; they have to march for twenty minutes with their arms folded across their chests, then for twenty minutes with their arms folded behind their backs. Even when they are allowed to rest, they have to sit with their legs together, their elbows pressed to their sides. They marched 30 miles a day.\n\nEvery man who is thrown into a cell, Serge said, immediately begins to live 'in the shadow of madness'. Serge was an acute observer of the many ways in which people fended off this ever-present threat. Something as unremarkable as walking was something everyone discovered within a few hours of being inside, 'He begins to walk', he says simply. Some, like him, even write poems as they do so. Others, like the narrator too, turned to books, but the bulk of the prison library consisted of bad adventure novels, probably bought because not even the public would buy them, but then there was also a collection of Balzac, 'heaven-sent'. At breaks in work everyone would read, but some books had to be disguised so as to appear as if they came from the library. A strange type of contraband came into existence, for which the prisoners even invented a word, _camelote_ , such as a volume of Casanova's Memoirs, while the narrator reads the philosopher, Taine, on intelligence. Each, in its own way, provides 'rich spiritual nourishment'.\n\nSerge would also say later that it was the possibility of writing about his experience that helped keep him sane. As he wrote to his friend, the Romanian writer Panait Istrati, 'I already saw a kind of justification of that infernal voyage in the possibility of describing it'.\n\nVisits from families, too, helped men survive, but these, also, could be a source of torment, loaded with a weight of expectation they could not possibly bear, accompanied by shame and embarrassment. People were unable to touch each other, but there were times too when, because of the darkness, people could not even see each other clearly. _'The other person is there:_ corporeal, yet ghostly; present, yet inaccessible'. Letters were 'tiny wings in the hands of the men'. Each one had its soul, its character, its voice, 'a woman's love on the page' can lift someone out of his misery.\n\nSo too can a glimpse of life outside: 'The silent _quai_ under the tall, green poplars, the shimmering water where trees trembled in reflection among patches of sky, the path along the bank where a child was running: This peaceful vision of life, glimpsed suddenly through the window calmed him.'\n\nEven the coming of spring, 'bittersweet season' that it is, is impossible not to feel:\n\nIn April, with the first buds on our stunted trees, the first clear skies, the first warm days, such a powerful call seemed to come from the very heart of life that we all felt we were emerging, our nerves raw, from some great lethargy. April quickened our failing energies. Three hundred wooden shoes beat more smartly against the pavement in our round; broken marionettes began to straighten up again; grey faces were uplifted...\n\nIn the same way, a thought or memory coming unbidden might bring some comfort, but it could never last:\n\nSome times, especially in the evening, a noise from the street may reach the prisoner in his cell. An automobile sounds its horn. The bell of a trolley car rings out in the distance. Instantaneously, the image of the illuminated streets and of that trolley car appears in your mind's eye. You see the conductor taking the steering bar into his wool-gloved hands. You see everything. You breathe in the smell of asphalt and gasoline. And then everything vanishes...the calm grayness of time sooner or later resumes its usual hue.\n\nSooner or later, everyone went to see the doctor. If he was lucky, a man might get some extra bread or even medicine, but what made a difference to so many people, Serge said with some insight, was that this involved moments of contact with _other men_. It was _this_ that made their ailments subside. Serge was not being judgmental here; he's not saying people are pretending to be ill, but showing a subtle appreciation of the true nature of the psychosomatic. If the only way we can get care is by being ill, we become ill.\n\nThe prison hospital, too, provided considerable respite; one was allowed to walk in the infirmary 'garden'. The term garden is used here, Serge says, in its 'most perfunctory sense'; the barren pond, the stunted trees, the cropped bushes - this could be the square, he said evocatively, in some mining village in the north, the men survivors of a gas explosion, 'After all, one form of suffocation is much like another.' But even there, one could walk up and down these paths at will, 'Divine freedom of the body! We meet, we talk; divine freedom of the soul!' Here, too, even the barest of the natural world provides comfort; here are the white quartz pebbles that the men look for in the gravel, 'so velvet, so soft to the touch, so white that they bring to mind many forgotten things'. And the trees are not abstract, but 'real, accessible trees, whose bark we love to touch and on which we love to watch the ants climbing'.\n\nSerge was clear about what was involved in the struggle of those who chose to resist, as opposed to going under. In a chapter called, 'Drunken boat', taking its title from the poem by the young Rimbaud, Serge said, in almost unbearable prose, that it was:\n\n...a voyage toward the unknown. The march will be long, so long that there is nothing by which to measure its duration, through a relentless night strewn with pitfalls. Falling along the way would be like sinking into a dark lake on a moonless night under a leaden sky in solitude: No cry would ever be heard. So be silent, then, whatever happens. The fleeting circles would barely break the surface of the still water, which would soon close without a ripple over the drowned man.\n\nThis silence is not the silence of submission, but neither is it a silence of pointless resistance, however understandable. Something else is called for, an acceptance that is, at the same time, a refusal, of the status of prisoner - 'I will be Number 6731...a robot programmed to obey', because one has no choice, but not to be confined by this - 'I will be myself - a free man'. The stakes in this struggle were high:\n\nA victory over jail is a great victory. At certain moments you feel astonishingly _free_. You sense that if this torture has not broken you, nothing will ever be able to break you...And when a broad ray of sunlight inundates the barred window, when good news comes in from the outside, when you have succeeded in filling the dismal day with useful work, an inexpressible joy may ascend within you, like a hymn.\n\nBut he is stunned, when he had served his sentence in full, not to feel the great joy he had anticipated, 'at this dark threshold to life', a brilliant formulation, capturing all the contradictory feelings of the moment. He felt, instead, a sort of oppressive anxiety and, at the same time, a certain joy in a negative sense, 'like a fleeting light at the bottom of a well', that if he were not, after all, going to be freed, he would kill himself. At the same time, Serge had the insight that nothing could be more disappointing than the long-awaited fulfillment of a wish, because the reality itself was too concrete. One came to the realization that one had been living on exaltation which, once gone, left in its place 'a great void in which things appear only as they are, nothing more'.\n\nFor a time, a brief time, he experiences what we know now as institutionalization, that state of mind in which individuals have become so used to their confinement, whatever its nature, that they find it very difficult, or even impossible, to leave. And if they do succeed, it is what takes them, sooner or later, back inside, to what is familiar:\n\nI will be free in a few hours. Free. The enormous word is written in flaming letters before me...I am about to enter the unreal...I can no longer imagine what life is...I begin to love this darkness...where every stone is familiar to me...a world that has become a deep unforgettable part of me...My heart aches as a corner of the workshop and certain faces appear before me. I am leaving, they are staying. The Mill is eternal. That must be it; I feel the mark of jail too deeply within. They no longer brand your shoulder with a hot iron; it is an inner wound that will start to ache tomorrow.\n\nBut he struggles, resolving to overcome this, not to carry away with him any defeat. The Mill has not worn him down. He will leave it with his mind intact, stronger for having survived, tempered by thought. He has not lost the years taken from him.\n\nThe narrator has, like Serge, been in prison while a long, destructive and bitter war has been fought outside; the prison has been 'an unbelievable island, cut off from the movement of history'. Once outside, the first human figure he comes across is like a specter, shockingly evoked, a ghost in uniform who transforms into reality the unreal landscape, 'this landscape of the world between', which he will never see again: 'Our ringing footsteps fall in together. The first man I meet on the threshold of the world is a man of the trenches.'\n\n* * *\n\nWithin a year or so, Serge was in prison once again. This time, after the failure of the syndicalist uprising in Barcelona when he was in France trying to get to Russia in the early throes of revolution, he found himself interned in a concentration camp, in a disused convent, in the west of the country. He would make use of this experience in his second novel, _Birth of our Power_ , which was published in France in 1931. This prison was nothing like the one in _Men in Prison;_ it was, relatively speaking, lightly guarded, barbed wire, a row of sentries, a low wall covered by fragments of broken bottles. Even so, no one had yet managed to get out of it. The prisoners were free to associate with one another, to read, to discuss things, to walk about within the camp confines, and no one had to work. And yet they were still prisoners.\n\nThis little world within the world is powerfully depicted by Serge. The camp, he said, might have been the main square of 'a bizarre village where there aren't any women'.\n\nIn this 'little piece of Europe', there were Greeks, Macedonians, Bulgarians, Chetniks, Serbs, Russians, Alsatians, Spaniards, Belgians and Romanians - 'thieves, marauders, phony foreign noblemen, probable spies, certain victims, unlucky people, vagabonds, second offenders, undesirables, Germanophiles, simple-minded people, rebels, revolutionaries'. And, as the powerful in Europe started to fear more and more the threat to their power posed by the communists, there are 'Jewish tailors and restaurant owners' who were 'guilty of having, elbows on the counter, maintained the integrity of the Bolsheviks'. (Serge himself was interned as a Bolshevik sympathizer.)\n\nThe camp was a reflection of the society in which it sat. It was even possible to get rich there, as one of the men, Maerts, 'the buccaneer', does. There were the decent and the corrupt, the highly intellectual and those who have lost their minds; some eat well while others, like Antoine, a traveler, driven from his roads by the war, lived on potato peelings, carrot leaves and even-gnawed bones found in the garbage every night. At night, one of the barracks becomes like 'an inn of olden times, in an old port haunted by pirates'.\n\nWhat makes life tolerable is the existence of a community of like-minded people and the continued existence of the life of the mind: 'We formed a world apart within this city. It sufficed for one of us to call the others together with that magic word 'Comrades', and we would feel united, brothers without even needing to say it, sure of understanding each other even in our misunderstanding.'\n\nIn their dormitory, there were always people pouring over their 'endlessly annotated, commented, summarized texts'. There, revolutionary figures from the past like Saint-Just, Robespierre, Babeuf, Blanqui, Bakunin, were spoken of 'as if they had just come down to take a stroll under the trees.' Even those with 'no great sense of history', still had some great stories to tell, like Dmitri, the Russian sailor, who almost got his whole crew of an English steamer to mutiny, after throwing inedible soup in the face of the first mate, but ended up in chains instead. And in the late afternoon, a few people from each room would assemble to hear someone read from the newspapers. This is how they hear what is happening in Russia, in fragments, which are often inaccurate, as when they hear that Lenin has been assassinated. In fact, he survived. But this also serves to emphasize their isolation from everything that is going on in the world, and their impotence, and to instill a sense of futility, of time running out, while great things were being achieved elsewhere. And these feelings turn into rage. They think about an uprising, but know it would be futile. With some insight Serge remarked on how one of their fears was precisely that of being cowardly and they were therefore afraid of 'throwing ourselves into an adventure...out of our own impotence'.\n\nAnd there was the ever-present threat of death, which came 'without fanfare, simply, faceless, without terror'. The camp is decimated by an epidemic of typhus, but the political Russians do better than others. Even in this regard, their solidarity makes them stronger. The emergency fund they had set up, though meager, provides just about enough for the least fortunate 'to keep the flame of life glowing, if only as an ember'. And, they do not allow anyone to be moved to the infirmary, which has been nicknamed the Morgue, because that is where people go to die.\n\nOnce again, it was time which was taken from the inmates and time which they had to contend with. And unlike criminal prisoners who know when they will be released however far in the future, they had no idea at all when they might be freed, and, if so, what will then happen to them:\n\nLong walks in the yard, to kill the time. Rare were those, in this forced leisure, who still knew the value of time, who read, who sketched, who studied, Equally rare the obstinate ones who refused to let themselves go...We stayed alive. The days passed by. The weeks, the months, the seasons, the battles, the revolution, the war passed by. Life passed by.\n\nWhen the armistice comes, 'it exploded above us, like a dazzling rocket, tracing a meteoric curve through the sky of our gray life'. Suddenly there is joy at the prospect of freedom, 'the end of the nightmare'. But this is only the beginning of the end of their captivity as they must wait for negotiations about an exchange of prisoners over which they have no control whatsoever. But, in the end, they leave.\n\n* * *\n\nIt is a century since Victor Serge began his years in prison. It may seem incredible now, but there was a time, not so long ago, when many of us on the left believed in the abolition of prison, that prison might be done away with, for all but the most dangerous people. _(The Politics of Abolition_ (1974) was the title of radical criminologist, Thomas Mathiesen's fine book about the prisoners' movement in Norway and his involvement in it.) We argued that sending people to prison was unjust and unfair, that it was counterproductive, and that it was a mark of a disciplinary state. Serge's writings were among those that inspired us.\n\nThings could not have turned out more differently. Our societies have become more, not less, punitive; almost everywhere, prison populations are higher than they ever have been. The provision of prison and associated services has become very big business indeed, one of the few growth industries. Prisoners are no longer transported around the country in the prominent and threatening 'black marias' of old, but in anonymous vehicles, which might easily be delivering groceries. The concentration camp, which Serge must have been one of the first to describe, has become a central feature of life in many authoritarian regimes.\n\nThe physical conditions of prison may well have improved in some countries, the specific details may be different from Serge's time, but _Men in Prison_ today is completely relevant to our modern understanding of the central nature of imprisonment. It is a genuine classic of prison writing that transcends its time. Rarely has the brutality, the pointlessness, the tedium, the dehumanization of prison, been so memorably depicted, but without bitterness or self-indulgence.\n\nModern jails, Serge concluded, 'are imperfectible, since they are perfect. There is nothing left but to destroy them.'\n\n# 2  \nYesterday we were nothing:  \nthe experience of revolution\n\nOn his release from prison in 1917, Victor Serge went to Barcelona to take part in the planned syndicalist uprising there. This failed, bloodily, and Serge lost many friends and comrades. He then traveled to Russia to join the revolution there, eventually reaching Petrograd in 1919. Despite his anarchist past and libertarian convictions, he had decided that he would join the Bolsheviks, but do so 'independently, without renouncing thought or critical sense'. Serge believed that the Bolsheviks were profoundly mistaken in many ways, in their centralizing leanings and bureaucratic tendencies, their intolerance of difference and their unquestioning belief in the state. But, for Serge, they still represented the best hope for the revolution. One had to be with them and among them if one were to counter them 'with freedom of the spirit and the spirit of freedom'. Serge was widely respected outside the Party and enjoyed good, if sometimes strained relations with the non-Bolshevik revolutionaries, such as the anarchists and the Mensheviks, and with the cultural intelligentsia. From the outset he was actively involved in the revolution, both as an organizer and as a soldier. (Serge took part in the battle of Pulkovo Heights in October 1919, which would prove decisive in the defense of the city and of the revolution itself.) It was these experiences of revolution that would be the subject of his next two novels, _Birth of our Power_ , published in France in 1931, and _Conquered City_ , published the following year.\n\nWith no strong narrative to engage the reader, _Birth of our Power_ is, to my mind, the least successful of Serge's novels. Sometimes one feels his struggle to find a new form for what he is saying. Serge was trying to take the novel away from a central subject, to capture a process, and he isn't always successful. There are times, too, when it feels as though he has been swept up in his creative processes, but forgets about his readers. And that is a pity because there are always passages of great lyricism, and Serge's descriptions - of people, of environments - are often arresting. And no one described the values of solidarity and courage, or changes in political consciousness, as he did.\n\nHere, for example, is Serge's description of the group his narrator found himself in:\n\nThere were at least forty or fifty of us, coming from every corner of the world - comrades, that is to say, more than brothers by blood or law, brothers by a common bond of thought, habit, language, and mutual help. No profession was foreign to us. We came from every conceivable background. Among us, we knew practically every country in the world, beginning with the capitals of hard work and hunger, and with the prisons. There were among us those who no longer believed in anything but themselves. The majority were moved by ardent faith; some were rotten - but intelligent enough not to break the law of solidarity too openly. We could recognize each other by the way we pronounced certain words, and by the way we had of tossing the ringing coin of ideas into any conversation. Without any written law, we comrades owed each other (even the most recent newcomer) a meal, a place to sleep, a hide-out, the peseta that will save you in a dark hour, the _douro_ (a hundred sous) when you're broke (but after that it's your own look out!). No organization held us together, but none has ever had as much real and authentic solidarity as our fraternity of fighters without leaders, without rules, and without ties.\n\nAnd there is the portrait of Dario, the agitator; up at 6am, he has time for a coffee only while standing in the street, and then a day of leafleting, meetings, speaking, standing on a chair, at factories. But the most tiring hour is when he has to meet Portez the cement worker and argue his positions once again. When the narrator thinks of expressing his doubts, he knows Dario would laugh, 'You distrust intellectuals, especially those who have tasted the poison of Paris'.\n\nSerge was also trying to capture the change in political consciousness of those who wish to make their own future. The shoe-shine stand operator, Sanche _el Tuerto_ ('One-eye'), who 'usually sees men only from the knees down', is barely literate, struggles to read, but when he picks up the revolutionary paper _Soli_. 'A sort of smile twists his mouth. He wouldn't be able to repeat or to explain what he is reading, but a great contentment flows into the marrow of his bones.' And when he says, simply, 'No time' to 'a rich French shoe', he is doing something momentous and the customer goes away with the understanding that 'something is happening in the world'. Sanche's 'No time', both 'worries and enlightens him immeasurably', much more even than the day's news of a German sinking of a Brazilian boat and the bombing of London by Zeppelins. He knows, or at the very least senses, that something is afoot, something that he does not yet understand.\n\nBut the changing consciousness is not confined to individuals. It is something that affects the collective which is transformed by an increasing awareness of its own power, which surges through the city like 'new blood injected into the arteries of an old organism', unseen but vividly experienced by those in the know:\n\nWorkers stream out through the dazzling city toward their houses in the poor quarters, their steps lightened, shoulders thrown back with a new feeling of power. Their hands never tire of caressing the weapons' black steel. And waves of pride flow from that steel into their muscular arms...to those precincts of the brain where, by a mysterious chemistry, that essential life force we call the Will is distilled...\n\nAs elsewhere, Serge is particularly attuned here to people's subjective experience, what it _feels_ like to be poor, to _feel_ degraded, as the workers do, by 'the contrast between their sloppy old suits or overalls and bourgeois dress', when they pass expensive restaurants and luxurious cafes they never enter, or shop windows with astonishing displays of objects, 'so beyond their means as to be not even tempting'. It is here they 'encounter the women of that other race, sheathed in precious fabrics, their complexions colored by good health and luxury as if by a soft inner light...the well-fed men with relaxed faces, haughty, superior looks, under broad felt hats'.\n\nAnd he evokes powerfully the sheer physicality of being in a mass of people: 'Heads, bodies, hands are growing all around us like tropical vegetation; a powerful odor of warm and vibrant flesh - the smell of masses of men and of sunlight - makes our nostrils throb. I also breathe in the avid smell of the oranges being eaten greedily by a young girl...'\n\nSerge was also a keen observer of the places he found himself in and powerfully evoked these topographies, these physical contexts, as he does in this book, which opens with the words, 'This city and us'. And later on he remarks, 'Every city contains many cities. This was ours. We did not penetrate into the others.' Serge beautifully describes the landscape, the 'craggy mass of sheer rock - shattering the most beautiful of horizons', that towers over this city. It is 'crowned by an eccentric star' of jagged masonry cut centuries ago into the brown stone which now conceals secret constructions under the innocent grassy knolls. The secret citadel underneath lends 'an evil aspect' to the rock, which, between' the limpid blue of the sky, the deeper blue of the sea, the green meadows of Llobregat and the city, resembles a strange primordial gem'. We would have loved this rock, Serge says, had it not been for the way in which it had become an instrument of oppression, for the mountain was 'a prison - subjugating the city, blocking off its horizon with its dark mass under the most beautiful of suns'. The landscape, in other words, which might seem natural to most people, is itself political and saturated with history. It is a continual reminder of oppression, and even death:\n\nOur voices would suddenly drop off, when, at a bend in the path, the stark, grass-covered corner of the citadel's ramparts loomed up before us. The name of a man who had been shot was on all our lips. [Francisco Ferrer, libertarian educator, executed in 1909] We used to stop at certain places from which we could see the narrow confines of the dungeons. Somewhere within these fortifications, men like us, with whom each of us at one time or another identified ourselves, men whose names we no longer remembered, had undergone torture not long ago...\n\nPeople's names and faces may have been forgotten with the passing of time, but what remains is 'a searing, confused feeling for the indignities suffered in the cause of justice'. The pain these men suffered comes to be remembered 'as one remembers something one has suffered oneself...And, from that, I had an even greater sense of the communion between their lives and ours'.\n\nAnd there is the constant awareness of the danger faced by those at the forefront of the struggle:\n\nAnd the idea I am trying to get rid of pierces me, like an electric needle, from one temple to the other: Dario will be killed, for that city, for us, for me, for the future. Every morning when he leaves the house where he has slept, every evening when he enters the back rooms of little cafes where fifteen men - including one traitor - are waiting for him, at every moment of his patient agitator's labor, he moves toward that end marked out for him.\n\nAnd even in the maelstrom of political upheaval there is room for love:\n\nHe pressed herself close to him without speaking a word. He sought her face and found only her ardent lips. \"Let me look at you,\" he said. He struck a phosphorous match against the wall. A sputtering blue star, hissing and spidery, burst into flame at his fingertips, her delicate, soft-toned face - with its huge dark eyes, each now lighted by a spark, shining from out of their deep-set, dusky orbits - was nestled in the hollow of his arm, with a poor, gentle, worried smile. Dario gazed at it until the ephemeral light singeing his fingers went out. They made love in total darkness - in silence, for he was hurried and tired, and she always felt on the verge of losing him.\n\n* * *\n\nThe uprising having failed, the narrator is on the run in Paris whose beauty 'smiles on implacably like summer'. It is a bad day, he says, and he runs all over Paris in search of refuge but his 'addresses are running out, and time is moving on'. He worries that the papers he has will not stop him being arrested if he is forced to register at a hotel. 'Where to find a roof tonight? A few hours under shelter, time to recharge my nervous equipment, and the future is saved.' He eventually ends up at a sixth-floor door in 'this enemy city' where he is told he is in luck, that the man's girlfriend walked out on him recently, leaving him more room. He reassures him wonderfully saying, 'You'll be all right here. I have an excellent reputation; you can sleep with both eyes shut.'\n\nThe man with the 'excellent reputation' is Broux, who despite 'his worn-out lungs, his obstinate self-effacement, his bookish timidity', is a strong man, strong by means of his 'awareness of how impossible it is to live, he raises himself precisely to a higher possibility of living, to an endurance which is more sure of itself because it believes it has nothing more to lose. From his weakness he was able to create a strength, from his despair, an acquiescence, from his acquiescence, a hope...'\n\nOutside, and almost as a backdrop, there is a war going on. Somewhere, up there above these clouds, 'men dressed in leather are trying to fix this city in their bombsights'. The anti-aircraft guns produce in response, 'explosive blossoms'. Serge remarks, without any irony, that civilization reaches its high point in this 'senseless combat' above the Louvre, as 'Masterpieces of ingenuity, summing up the work of all races in all times - millions of men suffering, striving, daring - seek each other out, with the greatest human lucidity, in order to destroy each other...'\n\nWhen they eventually reach the Russian border, there is no great welcome, only the 'indifferent expressions, undernourished looks' of the guards:\n\nNever could the idea come to anyone to rush toward them with outstretched hand saying _Brothers!_ for they belonged entirely to a world where words, feelings, fine sentiments shed their prestige immediately on contact with primordial realities. One could only have talked to them about a fire in front of which you could warm up, about shoes to be mended, about flannels to keep your empty stomach warm, about hot soup with which to fill it. I stared intently at these silent men, standing there in such great distress. I thanked them for teaching me about true fraternity, which is neither in sentiments or words, but in shared pain and shared bread. If I had no bread to share with them I must keep silent.\n\nThe novel ends with the narrator remembering a letter he had received from Spain just before the final journey, that he has not yet read. As old books burn in the fire, he recalls 'the city we had not been able to take, our hope, our will, our power, our real power since I was about to go to sleep in a conquered city where...this moment, this shelter, this warmth which allow me to think of you [his former comrades].' He imagines Dario walking in at that moment, to 'shrug his invisible burden off his shoulders', when his eyes alight on one line, 'no different from all the others in the forest of symbols...\"they killed our Dario\".'\n\n* * *\n\nIf _Birth of Our Power_ doesn't always work well as a novel, _Conquered City_ which followed, must be _the_ novel of the revolutionary experience. Again, there is no central story but a series of narratives, different perspectives. Serge's use of montage or jump-cuts can be disorienting, but he makes us _feel_ we are in the unnamed city, Petrograd, at a crucial point for the city, and the revolution for which it stands. The novel takes place in 1919\/20 at a time when revolutionary Russia was threatened by its enemies within, who were backed by the major powers from outside, Britain, the United States, France who were appalled, and profoundly threatened, by this radical challenge to the established order, their order. 1919 saw the creation of socialist republics in Hungary and Bavaria, a workers' uprising in Germany, a general strike in Barcelona, and a general strike in Glasgow which brought tanks on to the streets of the city: 'How they long for our death back there, for the death of this Republic...which is still the greatest hope...the work of those who have always been vanquished, always duped first and then massacred...'. Only yesterday, someone says, 'we were nothing...we counted only as statistics: labor force, emigration, death rate, crime rate, suicide rate.' This is what the revolution challenges.\n\nThe title, of course, is ironic, but sadly so. The city, as the novel shows clearly, is far from conquered: it reflects the growing awareness of one of the narrators who has arrived in the country with great expectations only to see a very different reality at almost every turn:\n\nWe have conquered everything and everything has slipped out of our grasp. We have conquered bread, and there is famine. We have declared peace in a war-weary world, and war has moved into every house. We have proclaimed the liberation of men, and we need prisons...and we are the bringers of dictatorship. We have proclaimed fraternity, but it is the 'fraternity and death' in reality.\n\nEven the snow is not bright, but grey. Everywhere there is a prehistoric gloom because there is no power. Everywhere people are hungry, everywhere the people are cold. They keep their old fur coats on and they rip up floorboards in old houses to keep their fires going. The factory chimneys no longer smoke unless there is some emergency work to be done. People work in semidarkness because there is no power. There is typhus and the threat of cholera. And the spring thaw will, within a few days, make cesspools of the frozen piles of excrement in the courtyards. We feel the cold along with Professor Lytaev, who still teaches a class at the university in the evening as if 'in a city of another time, in the middle of an abandoned monastery'. He has to keep his fur cloak and hat on while his audience listen 'frozen, in their coats'. 'Hard rectangles of night pressed in through the white frost-ferns on the windows.' We experience the constant plotting and threats to the revolution from within: 'Everywhere the enemies of the revolution are active: The Counterrevolutionary Centre Right organization could count on 146 confederates in the city, organized in groups of five, and a thousand sure sympathizers. These forces could be mobilized in a single night.' Chapter 11 starts, 'The 1st Estonian Regiment went over to the enemy on May 24. The 3rd Infantry of the Second Brigade turned traitor on May 28...'\n\nThe revolution is already over-reacting massively, 'spider webs knocked down with ax blows'. An anarchist bomb attack is used as a pretext to execute no fewer than sixty-seven people, 'spies, counterrevolutionaries, foreign agents' but also, 'ex-financiers, ex-high officers, monarchistic professors, vice-den operators, and unlucky adventurers'. The report of their deaths fills two tiny columns in the barely legible newspapers plastered on the walls. At a time when the southern front in the civil war was going badly, 'Sixty-seven? The price in blood of a skirmish...'\n\nAnd all the time, people's hearts and minds are being hardened. When a vote is taken at a Special Commission (Cheka) hearing, only one person, Kirk, dares to vote against the death sentence. The chair, Osipov, dismisses him saying they must be pitiless and share the responsibility. 'You're a Don Quixote', he tells Kirk, 'with your lone horsemen's ways...this affair no longer has any importance. No more than your death or mine would have this week.' So too, Danil, who has nothing but contempt for intellectuals, who haven't 'the least idea of the stench of a sacked town or the look of an open belly full of fat green flies over which poppies droop their heads', dismisses historian Platon Nikolaevich's resort to Dostoyevsky. The Karamazovs, he says, 'split hairs with their beautiful souls; we are carving flesh itself and the beautiful soul doesn't mean a damn thing to us. What is serious is to eat, to sleep, to avoid being killed, and to kill well. There's the truth.'\n\nA 'monstrous state' is arising, devouring its enemies, real and imagined, as happens to many of the people we encounter here. And at the same time, the new administration must also address the ordinary problems of everyday life in a city and Serge vividly conveys the enormity of the tasks facing those who want to build a new order:\n\nOther oases of electricity burning from dusk to dawn: the Committees, Committees of Three, of Five, of Seven, of Nine, the Permanent, Temporary, Special Subaltern, Superior, Supreme Committees deliberating on the problem of nails, on the manufacture of coffins, on the education of preschool children, on the slaughter of starving horses, on the struggle against scurvy, on the intrigues of the anarchists...on road transport...So much thought straining and working every-where in these messy rooms under the same portraits, in that same atmosphere of neglect characteristic of conquered places where people are always rushing in and out.\n\nSerge is also alert to the new bureaucracy that is taking shape and which is wonderfully captured in this passage, with its echoes of the depictions of city life by other modernist writers, notably TS Eliot and Virginia Woolf:\n\nAround ten o'clock the street took on a feeble animation. People suddenly rushed by on urgent, necessary, imperious, deadly tasks. They moved quickly, similar in their diversity - uniforms and black leather - men and women alike, young or ageless, carrying overstuffed briefcases under their arms: dossiers, decrees, transcripts, theses, orders, mandates, absurd plans, grandiose plans, senseless paperwork and the quintessence of will, intelligence, and passion, the precious first drafts of the future, all this traced in little Remington or Underwood characters, all this for the task, for the universe; plus two potato pancakes and a square of black bread for the man carrying these burdens. This was also the hour when those who had accomplished the tasks of the previous night returned homeward, chilly and agitated with oddly wrinkled yellowed faces, yet feeling a final rush of energy mixed with their fatigue.\n\nAnd all the time there is the stunning contrast between the grandeur of the city, built by the modernizing Peter the Great in the early years of the eighteenth century as his new capital, and the misery which now prevails. Grimy red flags hang from the eighteenth century Italianate palaces, 'Nobility and grandeur still showed through the rags and tatters'.\n\nLaundry hangs from dirty windows on the main boulevard, while the chimney pipes of little iron stoves, spitting out their puffs of dirty black smoke, poke through broken windows:\n\nMud-spattered shop fronts, crumbling facades, shopwindows full of bullet-holes and held together with tape, splintered shutters, watchmakers' shopwindows displaying three watches, an old alarm clock, and one fancy pendulum; unspeakable grocery stores; herb teas packaged to look like real tea, as if there were still fools so stupid as to be taken in by these labels, tubes of saccharine, dubious vinegar, tooth powder - brush your teeth carefully, citizens, since you have nothing to use them on...\n\nIn the countryside, source of the grain which the city needs if it is not to starve, murderous divisions are emerging all the time and families are divided against one another:\n\nThe harvest had been brought in the countryside. It was being hidden. Tillers who fought under the red flags with their old scythes buried the wheat and sounded the tocsin at the approach of the Anti-Christ. Others, their sons, with red stars sewn into their old Imperial Army caps, arrived to search their barns. Workers, fearful of being stoned, harangued village elders. They were men caught between hunger, hatred, discipline, faith, war, fraternity, typhus, and ignorance.\n\nAnd in the chaos that prevails, the most ordinary, unexceptional individuals acquire an appalling power, 'a non-com transformed into an ataman had railroad workers thrown into locomotive boilers alive. But, a son of the people, he gave the daughters of his old generals to his exasperated soldiers...'\n\nAt the same time, Serge is alert, as he always is, to the beauty and joy that are present despite the cold, the hunger, the fear: 'Scattered bursts of laughter hung in the woods among the slim white trunks of birches. Specks of dull silver seemed to hang in the air.' (This has echoes of those amazingly condensed poems of the imagists, such as Pound's poem about the Paris Metro.) And after Xenia, the young Party member, has carried out the searches assigned to her one night, she decides to go for a walk. She stops to look at a single white cloud, reflected in the water of the canal, floating 'in the sky of that water' as if above the city:\n\nWhen we are dead, thought Xenia, when everything is finished, perhaps a similar cloud will pass through a similar sky at this very spot. What eyes will see it reflected in this water, eyes that will have known neither war, nor famine, nor fear, nor anguish, nor night patrols, that will not have seen man strike down man? I can't even imagine it.\n\nAnd people still are in love, as are Olga and Arkadi:\n\nShe was happily aware of the red glow of his cigarette in the semidarkness. She loved to move about in the invisible light of eyes following her from the far end of a dimly-lighted room. Nowhere in the world could anyone give this man a greater feeling of calm, a more secure rest, a surer joy. She knew this. And the warmth of his eyes resting on her, soft at first, then imperious like a magnet, enveloped her wholly, imparted new suppleness to her movements. Somewhere deep inside, her whole being cried out that this was an immense happiness...she laughed silently.\n\nAlthough even this most private realm is not totally removed from the political context, as when Xenia worries if she should wear French perfume when she goes to meet Rhyzik, 'Was the use of these luxuries invented by the depravity of the rich not unworthy?...Wouldn't he be angry at this bit of refinement in her?'\n\n* * *\n\nIf _Birth of our Power_ is a novel about the unsuccessful bid for power, and _Conquered City_ the struggle to hold onto power, part of Serge's last novel, _Unforgiving Years_ , is about the revolution gone wrong. D, a long-time Communist, has decided while in Paris that he must, finally, break with the Party. Using the skills he learned as a Comintern agent, he is on the run from his former masters but he is taking so many precautions that he starts to wonder if by the very act of doing so, for example by changing taxis, he is drawing attention to himself. And, in any case, how easily he might have been seen, just by chance, by one of his numerous faceless pursuers. When he is hiding out in a small hotel, everything he hears or sees may be significant and dangerous - a time given for a taxi, or the time of arrival of a telegram may be codes. 'I'm going crazy', he thinks.\n\nHere, Serge was using his own experience as an agent of the Communist International (Comintern), set up by the Bolsheviks in 1919 to promote revolution abroad. He worked with revolutionary organizations in Germany and Austria and reported to the International on the developing situation. (His published reports are collected in the volume, _Witness to the German Revolution.)_. This was, at times, incredibly dangerous, and some pages of the _Memoirs_ dealing with this period read like a thriller.\n\nFoolishly, D has announced his resignation before escaping. This is not formally a capital offense but only because it is simply unthinkable. An unwritten law, Serge writes, dictated the elimination of agents who disobeyed, and disapproval of the regime was the worst form of disobedience since it implied the use of the individual conscience whose existence could not even be brooked, for what it might do to the ruling edifice of iron discipline. The idea that anyone might bow out without betraying, or withdraw into a state of simple insignificance, any superior believing this would be thought a lunatic or an accomplice to be himself eliminated.\n\nEven as he looks forward to his rendezvous with Nadine, he worries that she too is being caught up in an invisible net, precisely because she is to be trusted and because she is bound to him by 'a friendship more definitive than love'. The bare fact of her connection to him puts her in extreme danger.\n\nAnd yet the ordinary life of the city goes on and is beautifully evoked: 'Morning purity of cobbles and asphalt...a dappled light under which one would wish to live for a long time, meditating'. At the same time, there is the appalling complacency of the city in the face of its future, with its 'windows of clockmakers, cobblers, and booksellers, the elaborate food stuffs, the color postcards full of gross jokes and sexual innuendo...in which human beings have attained the maximum possible degree of self-indulgence, and thus the height of freedom, of relaxation'. This city in which people are being hunted cannot see its own future which is so evident, 'A dangerous thing, relaxation...'\n\n# 3  \nBuilding on corpses: the repressive state\n\nNo one grasped the awful reality of repression in the Soviet Union more than Victor Serge did, and no one was better able to show the truth of what was happening than he did. Twenty years before Soviet leader Nikita Khrushchev would admit _some_ of the truth of the Stalinist terror on 25 February 1956, in his speech to the 20th Party Congress, Serge was describing _in detail_ what was going on in this country, a country he was the first to describe as totalitarian. (Although obviously of huge significance, equally important was the fact that Khrushchev's speech was itself given _in secret_. It was only published in full in Russia in 1989.) Serge's writings, such as _Destiny of a Revolution_ and _From Lenin to Stalin_ , also predate by more than 30 years Alexander Solzhenitsyn's monumental _The Gulag Archipelago_ , a book that shocked the west with its horrendous account of the camps. (Solzhenitsyn says in his preface that, when he started to write the book in 1958, 'I knew of no memoirs or works of literature dealing with the camps'.)\n\nSerge was the first person to describe in any detail the vast prison camp system in Russia. It was in 1937 that he wrote that the country had the largest concentration camp system in the world. There were forced-labor camps, dungeons, lumber camps, mines, even secret camps, camps notorious for their brutality or for their hunger, 'filthy corners from which there is no return'. There were camps, such as the SLON, the Solovietsky Special Camp, so vast they occupied 'an entire, vast northern country'. There were even model camps, 'attractive reform colonies for the edification of foreign investigators and movie-goers'. (Serge is here referring to a propaganda film made for foreign consumption.) The location of these, in the most remote and inhospitable areas, was not just to keep them away from the mass of the population. More important, the environment itself was a crucial feature of the punishment, killing many, but demoralizing and dividing those who managed to survive. Serge summed it up well:\n\nWhat cannot happen in a detachment of condemned men lost in the Siberian brush, including bandits, desperate or exasperated peasants, stool-pigeons ready for anything, intellectuals and technicians, harshly treated politicals, all of them bound to a hard task, badly fed, and submitted to the absolute power of a policeman who is himself a condemned man?\n\nSerge also quoted from a brief newspaper report, the message of thanks sent to Stalin by miners in Karaganda to Stalin. Nowhere is it said that this mine is at the centre of a vast concentration camp, that the work is done by prisoners, that perhaps some of the signatories themselves are condemned men, that the Karaganda is 'one of the most dreaded camps for the hunger that reigns there, for its remoteness from all civilization, for the harshness of its inner rule'.\n\nSerge also saw the crucial importance to the Soviet state of internal passports, probably unique in modern times, which served to control, not just the movement of ordinary people as the name suggests, but their everyday lives. Passports were always refused to families of people who were executed or sent to prison for long periods. So anyone without a passport was automatically suspect when looking for housing or work or, simply trying to buy anything, let alone in the eyes of the police. And the passport could always be marked at work to the serious detriment of the holder. Serge cites examples of workers who didn't turn up for days of 'voluntary labor', that is unpaid work to help meet targets, and who were sacked for 'sabotage of the production plan'. There was never any secret about the internal passport, yet it still came as a shock to many in the West to know these existed and what their effect was.\n\nAnd, of course, Serge understood the complete power wielded by Stalin, a power that extended far beyond the borders of the country he ruled. Trotsky was, of course, killed by his agents thousands of miles away in Mexico, but he was only the most famous to be murdered on Stalin's orders. Andres Nin, Serge's friend and comrade from the POUM, was abducted on the streets of Barcelona and never seen again. In September 1937, Serge himself had been due to meet the NKVD agent, Ignace Reiss, who wanted to defect. He failed to keep the rendezvous arranged in Rheims and his bullet-ridden body was later found, with a ticket to Rheims in his pocket.\n\n* * *\n\nAfter the 1917 revolution, the new government found itself in possession of the files of the Tsarist secret police, the Okhrana, and one of the many tasks Serge was entrusted with was to make a study of these. What he and his colleagues found provided an astonishing insight into the workings of a repressive regime. In a secret room in the Okhrana building in Petrograd, accessible only to the chief of police and the officer in charge of the files, they found dossiers on more than 35,000 provocateurs. These Tsarist agents included a man who had been the exiled Lenin's spokesman in the Russian parliament, Malinowsky, and also the head of the Social Revolutionary party's terrorist organization, at a time when it was engaged in carrying out assassinations. (When a Commission was established after the revolution to question former police officials, it turned out that two members were themselves former Tsarist agents.)\n\nSerge also discovered a series of files on himself, even though he had returned to Russia only in 1919, after the fall of the Tsar. The Okhrana clearly had paid great attention to the activities of revolutionaries abroad; when the Russian embassy in Paris was handed over to the Provisional Government, files there showed that 15 Tsarist agents had been working in that city alone and, what's more, that a prominent French journalist, head of the foreign desk at the leading paper, _Le Figaro_ , was also on the Okhrana payroll.\n\nThe files made Serge think about the psychology of the provocateur or informer, what it was that made people betray their supposed comrades and friends. Serge used as an example a woman, Serova, who had informed on revolutionary groups, betraying the location of literature and weapons, as well as individuals, who were then arrested. She was, Serge said, 'a weak character, living in poverty, who works courageously as a party member'. She is arrested. 'Abruptly torn out of her normal existence, she feels lost.' Fearing forced labor or even death, she realizes that she can avoid this fate if she says 'a word, just one word', about someone who actually had done her some wrong. She hesitates. But 'an instant of cowardice is enough; and there is plenty of cowardice in the depths of a human being. The most terrible thing is that from now on, she will no longer be able to turn back...They have her now.'\n\nFar more dangerous for Serge, however, were those who were not cowards, but who believed in nothing and who cared nothing for the cause they served, taken by the idea of danger, intrigue, conspiracy, 'a complicated game in which they can make fools of everyone'.\n\nIn the files, Serge also found what he described as among 'the saddest of human documents'. - receipts for payments involved in the execution of political opponents; the cost of setting up a gallows, the travel, return, of a priest. and, of course, the hangman's traveling expenses.\n\n* * *\n\n_Midnight in the Century_ , written by Serge while himself in exile, is the story of a group of oppositionists, in internal exile in the fictional place, Chernoe. A central part of the story is how they are ensnared in the murderous machinations of the leader. The novel begins with the lecturer, Mikhail Kostrov, having an uneasy feeling that something is about to happen to him. He is arrested in the street and thrown for several weeks into, what Serge calls, 'Chaos', in a hideously over-crowded prison, cut off from the world with no information about the charges against him. ('If the houses of detention are overcrowded', a judge tells him, 'it is not the fault of the proletarian dictatorship but that of the counter-revolution which assails us on every side'.) One day, he gets a parcel from his wife of boiled eggs and, even though it has been broken open by the guards with a dirty knife, he is relieved because he understands the messages implicit in the package; he knows this would not be allowed in serious cases. It also means his wife is still working.\n\nAfter several months detention he is finally questioned and it quickly becomes clear that he has been watched closely. He is confronted with statements he has made in lectures and articles he has written which are taken to be critical of the regime. When he refers to disorders in Uzbekistan he is warned of 'domestic espionage', and even the 'scornful way' he pronounced certain names in private is evidence of his oppositional tendencies. Kostrov is also confronted with a joke against the leader that he has told. About the actress to whom he shared this joke, he is told, 'You sent her far, to a very cold climate'. (Elsewhere, Serge relates the true story of how a seemingly private joke can have the most appalling consequences. Two couples who are out for a drive and are slightly drunk. They get a puncture and one of them makes a joke about an explosion under Stalin's behind. Several months later, the two women fall out and the remark is reported; the man who made the joke gets ten years in prison for terroristic agitation, and the two women five years for failing to report it.)\n\nThe next day, Kostrov decides to give in, 'and wrote out one more surrender' with 'all the right words...the edification of socialism, the great wisdom of the CC [Central committee], the correctness of its tactics, the repudiation of errors due to lack of understanding, to the petty bourgeois spirit, to the counter-revolutionary influence of comrades now denounced and capitulated'. When he finishes he hears himself say, 'Go on, you rotten fraud.'\n\nThe fourth part of the book, 'Directive', is a chilling account of a meeting of the Politburo. Stalin is thinking about how to use the forthcoming party conference to his best advantage. He needs to install 30 new regional secretaries, involving 30 dismissals in disgrace, which threaten 300 influential local secretaries, 3000 less influential local secretaries, 30,000 even less influential local secretaries - none of which will be discussed. The dismissals are necessary to get rid of people who implemented a plan that resulted in two failed harvests. That the plan was his is fatally beside the point.\n\nSerge shows how the directive will have to be carefully worded for maximum political effect, to take account of all the convolutions of the leader's mind; it must be both very obscure and very precise at the same time; it must foresee eventualities, even if these are contradictory; it must command definite actions, while suggesting various others so as to permit effective repudiation of anyone who might carry them out. Those around Stalin understand that the greatest danger was not the visible one, it is the one 'which cannot be unmasked because it does not yet exist in the facts: analysis reveals it lying latent among the masses'. One man's paranoia had become a whole system of thought.\n\nIn charge of the Chernoe exiles is GPU officer Fedossenko. When he receives the directive, it is immediately clear to him what he must do, prepare a case against several of them and, even as he reads the order, 'faces appeared clearly before his eyes, faded, re-appeared...Ryzhik, Elkin, Varvara...Tabidze, Avelii...Kostrov'. Fedossenko 'was satisfied with himself'. In fact, his unfailing intuition had already in effect anticipated the directive. He already has a hold over Varvara, who was sacked over a stolen loaf (it was stolen by the delivery man; Kostrov is implicated in the alleged sabotage of a consignment of school notebooks, (they have a simple misprint in a table), and is suspected of 'duplicity toward the central committee' (Fedossenko has a copy of his statement of repentance). Moreover, a woman with whom Kostrov has become friendly, Maria Ismailova, is an informer.\n\nAt first, Fedossenko tries a friendly approach to Kostrov, 'I'm talking to you as a comrade', telling him he is sure the Party will re-admit him soon. But Fedossenko is up against time, he needs to get his report done in time for it to be useful in the preparations for the party conference. He is also ambitious and wants very much to see his report published in the monthly bulletin of the Security Department. But even Kostrov is resisting, despite the lack of news from his wife and child, the filthy cell he is kept in, and the fact that every day he looks older. Meanwhile, Rodion says he will confess, 'For everything. I'm the one who did everything. Alone, I confess!' This, of course, is completely useless as there has to be a conspiracy.\n\nIn the end, Fedossenko himself is accused of incompetence, of chasing after minor crimes, while a 'secret Committee of Five' was carrying out its activities. A loose association of comrades has become the 'counter-revolutionary Trotskyite centre of Chernoe'. He is also accused of allowing the most dangerous Trotskyist to escape; in truth, Rodion, who managed to get away, is the least political of the group. He has also failed to inform Moscow of the 'active and organized counter-revolutionary Right opportunists in the distribution service of the Public Education Department right in Moscow'. He is relieved of his command, his physical being shrinks before his colleagues and, like a 'puppet or ghost', the 'demolished Fedossenko' is locked in a cell. (Serge was good at showing the rivalries among state officials, in this case how visibly relieved everyone is at the meeting when the blame is being pinned on Fedossenko, 'Six pairs of lungs exhaled the same _ouf'_ and the same thoughts of 'pig-face', big-shot'.)\n\nSerge was also acute about the character types that inhabit the state machine, like the head of security, 'a middling-minded man', who sits slightly back from the table as a sort of self-effacement and whose cropped moustache reminded one that 'he shaved every morning, like an ordinary man, that he probably desired a woman, that he too lived an ordinary life'. And, at the same time, he is all too aware of his great importance, 'the eye and hand of the Party - The hand that searches. The hand that holds the handcuffs. The hand that holds the poison. The hand that holds the revolver in the service of the Revolution'. And if he didn't say this, his whole manner expressed it, 'shadow of the great men over whom he watches day and night, formidable shadow over the subordinates he commands in the name of danger and of safety, deadly shadow over the captives he sends to their fate in the name of a magnificent future'.\n\nOf the accused exiles, only Rodion manages to escape although he nearly drowns in a river and is saved by a wild man, living completely outside society. He eventually gets to a town where he gets a job on a building site, in the 'Socialist Emulation' brigade. He is befriended by a woman who shows him how to carry the most number of bricks, in the most secure way, 'There was no time to breathe, to exchange a few words, or to smoke'. He discovers that they are building a new district HQ for state security.\n\n* * *\n\nSeveral years after _Midnight in the Century_ , in _The Case of ComradeTulayev_, Serge took the political novel to a new level; compelling, deeply disturbing, above all, sophisticated in its understanding of the political maneuvering of a ruthless dictator who rules, not just by fear, but with the acquiescence or collusion of those around him and his subjects. Tulayev, a leading official, is being dropped off one night at his mistress's flat, when an office worker, Kostia, walking home, sees the official car of a man who is obviously important. He hears his driver say, 'Good night Comrade Tulayev' and immediately realizes who he is, the man responsible for the purges in the universities and for mass deportations. He takes out the gun he has just been given (slightly improbably, it might be said) and shoots him, 'The explosion was deafening and brief'. Kostia carries on home through the snow. We do not hear about him again until the end of the book.\n\nSuspicion immediately falls on Tulayev's driver, who is brutally questioned and tortured. The account of this is particularly harrowing. The fact that he has been a good and trusted employee, is not only no help to him, but itself becomes a cause of suspicion when it is discovered that there are testimonials in his file from Nikolai Bukharin, whose driver he once was. Once a leading Bolshevik, Bukharin now stands convicted as a traitor and shot.\n\nThe case is being investigated by Erchov who, before his appointment, had thought himself 'happily forgotten' by the Personnel Service. In a particularly chilling scene, he is appointed by The Chief himself, amid a sea of smiling faces in the Kremlin. 'A heavy responsibility, Comrade Erchov.' he says, 'Bear it well.' It is as if Erchov knows, just as we imagine, his likely fate. Erchov had reached 'the pinnacle of his life', but is now afraid, now he faces three thousand dossiers all calling for the death penalty, 'three thousand nests of hissing vipers'. Erchov comes under increasing pressure to investigate Rublev, a former leading Bolshevik, associate of Bukharin and others now dead, but he knows there is nothing to link him to the case, 'not a shadow of a connection'. What there is rather is a trap for him, Erchov.\n\nEventually, Erchov is ordered to take a rest. Chillingly, his superior quotes Goethe to him, 'Kennst du das Land wo die Zitronen bluhn?' ('Do you know the land where the lemon trees blossom?') And he and his wife, Valia, travel on a special train to a resort reserved for party officials. When the train stops at a deserted station, he is summoned to take an important phone call, but is instead shown the order for his own arrest and stripped of his uniform and his authority. He has become such a professional that he even finds himself thinking that whoever organized this has to be complimented. The train, meantime, goes on with his wife. Assurances to him about her future serve only to underline her certain fate.\n\nThe murder investigation also implicates Makeyev, a peasant who has risen in the ranks of the Party and who was known as an enemy of Tulayev. A true mediocrity, brilliantly described, he had 'learned the official phrases which bring peace to the soul' and was 'exceptionally gifted in the art of forgetting in order to grow greater'. Of the little peasant he once he was, he 'preserved only a rudimentary memory, just enough to make him proud of his transformation'. Violent to his wife, he has nevertheless managed to secure a good post for his mistress. He boasts at one point, 'Men like myself have to have hearts of stone. We build on corpses, but we build'.\n\nSerge brilliantly describes how the investigation almost takes on a life of its own:\n\nThe case ramified in every direction, linked itself to hundreds of others, mingled with them disappeared in them, reemerged like a dangerous little blue flame from under fireblackened ruins. The examiners herded along a motley crowd of prisoners, all exhausted, all desperate, all despairing, all innocent in the old legal meaning of the word, all suspect and guilty in many ways; but it was in vain that the examiners herded them along, the examiners always ended up in some fantastic impasse.\n\nFormer investigator Erchov, meanwhile, has himself become one of the main suspects, and is being held in a timeless hell. He doesn't know whether it has been four weeks or five or six since his arrest and, anyway, what did normal time have to do with 'the fermentation of a brain between the concrete walls of a secret prison in the age of the rebuilding of the world'. (Serge himself once spent 85 days, nearly 3 months, in an inner GPU prison without reading or occupation of any sort, 70 of those were spent in total solitude, 'without even taking the air in the grey courtyard reserved for the more tractable prisoners'.) When he is eventually interrogated, he claims the allegations are 'absolutely insane...sheer madness'. And yet, when The Chief himself questions him, he says 'exactly what Erchov would have said in his place, what Erchov, in his despair, ought to be thinking'. His voice is so like Erchov's own inner voice that 'it restored Erchov to complete lucidity, and even to a sort of assurance'. The Chief asks him for 'The objective truth...'\n\nWith considerable insight, another prisoner tells Erchov that the Party cannot possibly admit that it is 'impotent before a revolver shot fired from no one knows where, perhaps from the depths of the people's soul...' and that The Chief is fully aware that a shot fired at Tulayev is aimed also at him. He tells Erchov he should simply confess. For his part, Makeyev does confess: 'He was loyal, body and soul. Adaptable too and he knew the Central Committee was always right, the Political Bureau always right, The Chief always right - the errors of power compel recognition, become Truth'. But when he signs his statement saying he wishes to confess and cease all resistance to the Party, only the M of his name 'was still strong, the other letters looked crushed'.\n\nThe case becomes the case of Makeyev, Rublev and Erchov. An attempt is made to implicate a fourth man, Ryzhik, an old Trotskyist who is living completely alone but still under intense surveillance in a hamlet of five houses called Dirty Hole, 'at the junction of two icy rivers lost in solitude'. (When writing letters he uses the address, 'the Brink of Nothing'.) Ryzhik would normally have been an immediate suspect because of his 'moral solidarity with the guilty', but he is added to the case only for tactical purposes, those of public presentation, 'to make the case more convincing to foreigners', while the prosecution even discuss allowing him to protest his innocence. Ryzhik, however, refuses even to take part in the interrogation and decides to die by hunger strike. News of his dying causes great panic, 'I order him saved!' The Chief says, as though his will must prevail whatever the reality.\n\nIt is because of his political understanding and experience that Ryzhik is able to decipher 'the hieroglyphics...branded...into the very flesh of the country', in other words, to understand the real meaning of what is happening. But this ability to make sense of all the trials, and the endlessly elaborate conspiracies and machinations they claimed to expose, is also a terrible burden, leaving him with an agonizing feeling of vertigo. Moreover, what he sees is not just the machinations of power but the people behind it all, '...each hieroglyphic was human: a name, a human face with changing expressions, a voice, a portion of living history'.\n\nWhen it becomes clear that The Chief wants a trial that will link Tulayev's killers to the Trotskyists in Spain, attention turns to Kondratiev, a Communist who has returned from Spain and who embodies the last of the genuine revolutionary spirit. Kondratiev has spent years doing the unglamorous work of organizing river transport; 'at a time when abandoned barges rotted along the banks, he harangued crafty and discouraged fisherman in forgotten settlements, got together teams of young men, appointed captains seventeen years old...created a School of River Navigation...'\n\nSerge chillingly describes how Kondratiev's colleagues at work at the Combustible Trust start behaving just slightly oddly to him once word gets around that he has fallen under suspicion in some way. He himself has no inkling. His secretary comes into his office 'too silently', her mute lips outlined in 'too harsh a red', her eyes looked frightened and she does not use the word 'comrade'. Others avoid him; a man, once a prot\u00e9g\u00e9, leaves by a back entrance after a lecture in order not to have to speak with him, a colleague shakes his hand in such a strange fashion that Kondratiev rubs his hands to get rid of the feeling, and he does not offer him a lift as he usually does. Only the young female students who genuinely know nothing sit with him. (In the end, Kondratiev is temporarily reprieved with a post in gold production in Siberia.)\n\nXenia Popov, who is in Paris on Party business, hears about the case and tries desperately to save Rublev's life. 'Grace, grace for Kiril Rublev, grace', she wants to telegraph, but to whom? Only The Chief can possibly save him and he will not get the letter in time, even if he reads it. She sends a message to her father, asking him to intervene, and she calls on Professor Passereau, 'famous in two hemispheres', President of the Congress for the Defence of Culture, and a member of the Moscow Academy of Sciences, asking that he send a message of support for Rublev. While claiming to be more moved than he can express, Passereau proceeds to give every reason he can for doing nothing - that he respects Russian justice, that he met Rublev only once, that his committee meets only once a month, that he has little influence, that they have other cases to pursue, and so on.\n\nXenia is also warned off her activities by a senior embassy official, who accosts her in a cafe, reminding her that what she is doing will have consequences for her father who is still in Russia. She is tricked into returning home, where she is of course arrested, while her parents are put under house arrest and their phone disconnected, their contact with the outside world cut off. A friend, Gordeyev, warns him of the seriousness of possible charges, attempted desertion during a mission, 'activities contrary to the interests of the Union' 'Shivering into himself, Popov became so old that he lost all substance'.\n\nMeanwhile Kostia, Tulayev's actual assassin, is living in the 'Road to the Future' kolkhoz, in love with his girlfriend, Maria, and struggling to meet the production targets set by the Plan. It is only when he comes to see his friend, Romachkin, from whom he obtained the gun, and happens to see the newspaper with its brief item about the confession of three men for espionage, treason and murder and their execution, that he learns the consequences of his action. Romachkin tells him it is too early for justice, 'What we have to do is work, believe in the Party, feel pity. Since we cannot be just, we must feel pity for men...' Romachkin had learned of the case at a party meeting and, after an initial moment of hesitation, had raised his hand in support of the verdict and sentence, along with everyone else.\n\nKostia feels utterly alone. There is no one he can talk to about this. Maria does not want to know and, when she senses the true meaning of what he is saying, tells him, 'I know how much harm is done when the struggle is desperate...there is a great and pure force in you...'. In utter desperation, he writes an anonymous letter of confession. Comrade Fleischman, who is sorting out the files, 'thousands of pages, gathered into several volumes', reads it and, sensing the truth of what it says, finds himself close to tears. He lights the candle used for sealing letters, which is stained with red, and 'In the flame of the bloodstained candle' he burns it and crushes the ash in his hands. He drinks some tea and, 'Half aloud, with as much relief as gloomy sarcasm' announces, 'The Tulayev case is closed.'\n\nSerge based his novel on the actual assassination of Sergei Kirov, a party functionary in Leningrad in December 1934. The assassin was a party member, Leonid Nikolayev, who would be tried in secret and shot before the end of the year. But Stalin used the murder for a brutal suppression of the opposition, described by Serge in a particularly harrowing chapter in _Destiny of a Revolution_ , his detailed account of the state of the country 20 years on. He tells us that 114 prisoners, imprisoned before the shooting on terrorism charges, mostly people who had simply entered the country illegally, were summarily shot after the retroactive application of a decree speeding up executions after sentence. Later that month, 15 former leaders of the Leningrad Opposition were arrested, including Zinoviev and Kamenev, both old Bolsheviks and even associates of Stalin. As they could not be clearly linked to the murder, they were sentenced to long periods in prison for having formed a tendency in the Party. There were also mass deportations from all the major cities. Serge quotes a French technician living in Leningrad who estimated the number at 'close to one hundred thousand...The railway stations were bottled up for two weeks...The unfortunates sold their personal property on the railway platforms and eight days later the State stores could be seen chock-full of second-hand furniture'. As to those deported, this technician who knew several described them as 'very honest collaborators in Soviet technique and science'.\n\nThe novel is a terrifying account of how a state can exercise power over individuals leaving them helpless, using the threat of reprisals against their loved ones: Xenia acts according to her conscience, but in so doing she puts her father and mother at grave risk. And how, seemingly effortlessly, it can weave a web of accusations to suit whatever purpose it has in mind. Also how personally terrifying the leader had become; Kondratiev's secretary takes a call from him in 'terrified reverence', and Erchov, as we saw, has internalized him so much he has lost his own identity. And also how the state implicates thousands of ordinary citizens in its behavior in seeking public demonstrations of support for its actions and, in the process, eliminates the individual conscience.\n\n# 4  \nA stranger to no land: the experience of exile\n\nSerge spent many years of his life in some form of exile, first in Orenburg, near Kazakhstan, 1,000 miles from the Soviet capital, then in Europe and, finally, in Mexico. Not only was he able to understand what this actually meant as a human experience; he was able to capture it in his writing in ways that no one else had done. In _Midnight in the Century_ (1939) and in _The Long Dusk_ (1946), both written in exile, and his poetry, most of which was written in Orenburg, he brought to life the endless fear, uncertainty, loneliness and poverty of exile, but also the incredible solidarity, and love, that was found there.\n\nAlthough those in internal exile had a freedom those in prison did not, the conditions of their lives were generally appalling. They were forced to live in remote, inhospitable places, and were usually ostracized by the local communities. They were expected to survive on even less than the already minimal rations. And they were subject to endless surveillance by the various authorities, and severely restricted in their movements. Their relatives were also subject to constant harassment.\n\nAs mentioned in the last section, _Midnight in the Century_ is the story of five oppositionists in internal exile, their struggles to survive, to keep alive a belief in the possibility of the better kind of world they hoped they were building, and whose exile offers them no protection against forces larger than themselves. The miserable livelihoods which are permitted them are always at the mercy of a minor official's whim. Rodion, who has been working collecting rubbish, is sacked suddenly for no reason. His boss tells him, 'It's not my fault, you understand. I have an order.' This prompts Ryzhik's sardonic observation, 'The Salvageable Rubbish Co-op no longer needs to draw up plans', and he asks if the rubbish is now escaping or if they are simply drowning in it. He is forced to rent just a corner of a room, with a mattress on it. Varvara is blamed for the disappearance of a loaf of bread and is also sacked. (In fact, it was taken by a delivery man.) And when a long-awaited consignment of school notebooks arrive and are found to have a misprint in a multiplication table, Kostrov, who is working in the local education department, is accused of sabotage. Even to take wood out of the river was a serious crime, as it belonged to the State Forest Trust and taking it, as Kurochkin did for firewood, meant 'risking jail or perhaps worse'.\n\nEven doing something as ordinary as buying cigarettes, when a long-awaited consignment arrives at the town, becomes an occasion for them to be harassed and discriminated against. 'They're workers' cigarettes,' they're told, 'The counter-revolution has no right to them.' Others in the shop are glad, as it means there are fewer people to be served and more cigarettes to go round. Elkin is not bothered. 'We'll buy them in the private sector', he quips, 'there are some right here'. (Elkin is mocking Lenin's New Economic Policy, NEP, which allowed a limited form of private enterprise in the economy. and which many believed was a retrograde step.) The 'private sector' in this case is, in fact, 'the hands of a ragged, sunbrowned curly-headed urchin of under twelve'. 'The future of our country', Elkin remarks sardonically. (Elkin works in the State Fishery Trust working on plans for catches, storages and distribution. 'I know how many fish are supposed to be caught in five years,' he says at one point, 'Alas, nobody knows how many will be caught.')\n\nThe exiles decide to stop for a while in the sunlight which streams down on them, on the town, on the food queues and the fuel queues, and on 'the grey newspapers pasted on the wall to proclaim the triumphs of industrialization'. Elkin says, 'One day you'll lie down on a cot in a disheartening darkness. Then remember the sunshine of this moment. The greatest joy on earth, love apart, is sunshine in your veins.'\n\nAnd, there is an ever-present fear of the larger forces against which exile is no defense and which can devour them at any moment. Ryzhik says at one point, 'Listen, brother, I'm uneasy. There are five of us - and not one informer! Do you think that's possible? And if it's like that, what do you think they're preparing for us, those bastards, with their thirty-six thousand dossiers?' What is being prepared for them becomes appallingly clear as the novel progresses.\n\nAs well as being about the terrible conditions of internal exile, this is very much a novel about solidarity. It is this that makes it a book of hope, as well as of tragedy. This solidarity is a bond among the exiles, but also a bond with other exiles and prisoners elsewhere. At one point in the story, Varvara receives a parcel. In it are food, cigarettes and a picture of her daughter, Katia, and also some books, including a copy of _The Arabian Nights_. The package has obviously been unwrapped, then redone by the secret police. Varvara and her friends are sure there is a message contained in it, but they cannot find it. Just as they are about to give up looking, something makes them cut open the back cover of the book: 'From the torn linen emerged, folded lengthwise, the thin slips which Ivanov had covered with microscopic calligraphy in Projects Office No.4 of the SPCC. Special Purpose Concentration Camp, on Kola Peninsula. Avelii could not have felt more joy watching his trained falcon swoop down on a hare in the sweet-smelling grass.' The color drains from Varvara's face, as she looks at these letters, 'words, thoughts, truths for the Revolution. The meaning of our lives, since nothing else is left'.\n\nAnd even in these awful conditions it is still possible for people to love one another; the novel contains one of Serge's most touching depictions of a relationship between a man and a woman in these times:\n\n'Don't bruise me', is all Varvara can think to say to Avelii, 'seeking a tender word for him but not finding one...They didn't go to sleep until they had talked for hours about so many things that it later seemed to them that they had tried to empty their lives in order to mingle them. They would never remember everything. These words exchanged, breath to breath, bodies entwined, hands seeking hands, would always yield new aspects, poignant and revealing. Like clouds scattered by a strong wind into momentary and never-quite graspable shapes.\n\nThe next day, Kostrov takes Varvara's arm in the street. He does so, saying 'How nice it is, Varvara Platonova,' when what he really feels is, 'a kind of gratefulness, as if he had said to her: I thank you for having those bright eyes, this slender neck, for carrying I don't know what joy within you.'\n\nIt is this sense of not being alone, of being part of something bigger than them, which gives them hope and makes it possible for them to live in this darkest hour, at midnight. In the same way, Elkin is elated when he was being transferred, to be allowed by his guard, 'a rather decent bugger', to go and look at an old stall selling all sorts of bits and pieces. There he finds an old copy of a book by Trotsky, the author's name scraped off the cover, 'They turned the first pages together smiling.' And when Rodion escapes and reaches the house of Galia, although she is disappointed that he is _not_ Elkin, as she first imagines when she sees a figure in the bushes, she gives him everything she has, bread, onions, dried fish, a green apple, matches, some money, 'She filled his pockets, happy to touch him'. For his part, he felt 'overwhelmed by a happiness he did not yet deserve...'\n\nAnd once again we see that active acceptance of a given situation that is so often a feature of Serge's characters. When they are sitting in the sun with their cigarettes bought in the private sector, Rodion asks Elkin about the place of thought in these terrible times. Elkin replies that, 'it's something of a midnight sun piercing the skull' and wonders aloud, 'What's to be done if it's midnight in the century?' Rodion replies, 'Midnight's where we have to live then.' and, as he says it, he feels 'an odd elation.' To embrace reality, however awful, can bring a feeling of freedom.\n\nSolidarity, for Serge, was not some romanticized, idealistic notion. It was very much a reality and something that he experienced, again and again, throughout his life. Recalling some of the people he met while in exile in Orenburg, most of them probably dead, he says, 'I am grateful to them for having existed, and because they incarnated an epoch'. He and his family had been able to leave the Soviet Union because of the campaign waged on their behalf by friends and supporters. A 'miracle of solidarity', Serge himself described it, but he was only too aware that others had not been so fortunate and would not be: 'It is humiliating to think that a certain sort of literary solidarity worked in my favor which won't work for others, simple and great revolutionaries without inkwells...No writers' congresses are likely to want to know about them'. And, of course, Serge used his freedom to work in solidarity, on behalf of those left behind, trying to tell people the truth about what was really happening there. He campaigned against the trials, setting up an international committee of enquiry whose members included the surrealist Andre Breton, the writer and militant Magdeleine Paz, and many others. (Serge insisted on the long title of 'Committee for Inquiry into the Moscow Trials and the Defense of Free Opinion in the Revolution' on the grounds that the revolution was not confined to the Soviet Union nor was Stalin's repression limited to there.)\n\nAnd, later, in Marseilles and sliding, despite himself, into a state of despair as he waited for a place of refuge which he thought might never materialize, letters from the writer and editor, Dwight Macdonald, in New York, and from the poet, J-P Sansom, in Switzerland, 'seem to clasp my hands in the dark' and give hope. These were two men that Serge never met. And Serge and his family were able to escape from Europe because of these and many other people who sent him money, gave him work, and worked to get him papers.\n\n* * *\n\nIt was while he was in internal exile in Orenburg, near Kazakhstan, that Serge wrote most of his poetry. The manuscript was one of the things stolen from him as he left the Soviet Union and he had to recompose the poems from memory. They were published as a volume, _Resistance_ in 1938, with an English translation by James Brook in 1972. In his introduction to the English edition, Richard Greeman finds echoes of many of the most interesting French modernist poets including Mallarme, Rimbaud, Appollinaire and Verlaine, along with many Russian writers with whose work he was well-acquainted. Serge was, he says, 'receptive to every mode of poetic intervention'. He was also, as we shall see in the next chapter, an insightful reader of his Russian contemporaries. Serge had loved poetry since he was a young man. It struck him, he said in his _Memoirs_ , as 'a substitute for prayer...so greatly did it uplift us and answer our constant need for exaltation'. The young Serge particularly loved the work of Paul Verhaeren, a precursor of Walt Whitman, for his 'anguished thoughts' on modern life. In his own poetry we see the same forces and values at work as in his other writings.\n\nLike his fictional exiles, Serge in exile was still able to appreciate the natural wonder of the place he found himself in, despite the poverty and harshness of daily existence:\n\nVast, vast horizons, pure, distant, and light\n\nsoft grass, under the hot shimmering air,\n\nvast, vast sky, forgotten blinding sky, impossible to look at.\n\n('On the Ural river')\n\nAnd watching a group of girls crossing the river, laughing and shrieking, he is moved by their delight, although he has to accept that it is, in the end, a simple one:\n\nWhat party, what love, what desire, what pleasure are they talking\n\nabout to have that tinkling bell-like laughter?\n\nProbably none, they're laughing just\n\nbecause it's a nice day...\n\nAnd he is too much of a realist to be caught up in any fantasy:\n\nI know that they will not have their promised joy,\n\nhappiness is not on the other side of the river,\n\nthe other face of the world will stay closed to them...\n\nNevertheless he carries this vision with him:\n\nThey are on the other shore, four real girls,\n\nfrom my village of exile\n\nand their image has not failed in me. ('Four girls')\n\nExile was also a place for remembering, in particular, comrades from the past who are no longer alive, like Andre in Riga and Dario in Spain:\n\nO rain of stars in the darkness\n\nconstellation of dead brothers!\n\nI owe you my blackest silence...('Constellation of dead brothers')\n\nAnd he recalls, in two particularly telling lines, the personal sacrifices revolutionaries like him have had to make, unable even to live their own lives:\n\nWe have never been what we are,\n\nthe faces of our lives are not our own...('Confessions' section of 'History of Russia')\n\nIt was while he was in exile that he learned of the death of his friend, the Romanian writer, Panait Istrati. It was Istrati who had written the original preface to _Men in Prison_ and who had published under his own name a book by Serge. Istrati had returned to Romania where he died from TB. Serge wrote a deeply-felt and moving tribute to him, which is partly an incantation around the word 'Finished':\n\nFinished: the romances, dark lips and golden eyes...\n\nFinished: the paprika dishes and the slightly rough red wine shared with beggars while swapping tall tales...\n\nFinished: the books written...\n\nFinished: the insults.\n\nThey did not stint there.\n\nThe poem ends:\n\nI am listening in your stead,\n\nwhat radiant silence falls on the clamor.\n\n* * *\n\nSerge's long, panoramic novel, _The Long Dusk_ is the story of a different kind of exile, this time about a disparate group of refugees who think they have found refuge in Paris, but are forced to flee once again once when German occupation is imminent. Simon Ardatov, a Russian physician, banned from working in France as a doctor, is forced to make a living of sorts working for a scientific cuttings agency. A man who had 'stood under the gallows without trembling', he is now in fear of his landlady demanding the rent, and his brown suit is presentable only in certain, inelegant areas of the city. Pepe Ortiga, a young refugee from the Spanish civil war, had witnessed the 'senseless massacre' at Teruel, and seen 'in a week more bodies than a man should see in a lifetime'; his smoldering black eyes looked out with insolence at the world. And Moritz Silber(stein), a minor wheeler dealer, his affability was intolerable, took his rent payments lightly.\n\nThe novel brilliantly conveys the moods of fear and panic, the unbearable tension, as people await the inevitable French capitulation, and yet hope it somehow doesn't happen. Shops start to close up and overloaded cars start to leave the city. Some are driven to suicide. Others wrap up important or valuable books and bury them. There are some who carry on as though nothing has happened. And there are always those who welcome the new rulers. 'Well, the medicine's been swallowed. It feels better now, doesn't it?' says one woman. The Jewish area of the city has become an 'asylum for the wretched of all nations'.\n\nThe swift, and violent, Germanization of the city is well-evoked:\n\nSeveral cities, several different and mutually hostile lives were super-imposed, one upon the other. There were the military staffs, the pleasures of the military staffs, the whisperings of government intrigues, the surveillances...There was espionage, counter-espionage, commissions, sub-commissions, inspections, secret police in factories, banks, offices, railroad stations...reports, memoranda, dossiers, classifications, planning, Order. There were perilous clandestine traffickings, messages to prisoners, liberations at a price, mail to the other Zone at ten francs a letter...Trains rolled eastwards, loaded with machinery and raw materials, luxury articles, Normandy apples, potatoes, furloughed soldiers invigorated by the Paris nights - and in the somber blue light of camouflaged stations, trains full of severe casualties disgorged their loads of the burned and torn, the maimed and the blinded.\n\nAnd when fuel merchant, Augustin Charras, hero of the First World War, goes for a stroll around the city he loves, which is 'all clean, in mournful Sunday dress', he sees all the signs of the occupation - the swastikas flying from official buildings, the Nazi salutes, soldiers having their photos taken beside the tourist attractions. Chaurras, who 'always seemed to come from far away when spoken to', fears more and more for the safety of his teenage daughter, Angele, whom he sends south. And when he puts himself in danger for hiding a deserter, decides that he too must leave the city.\n\nOrtiga and Ardatov, 'experts in defeat', know the best ways out of the city, the safer routes to the south, but they can do nothing about the new threat to populations on the move, attacks from the air. The highway to Moulins was filled with 'a human river' as all across the country, from 'wounded Champagne and the orchards of Normandy', the roads of France are given over to this movement of human ants heading for escape:\n\nToo many autos riddled with bullets, too many brains still filled with the nightmare of columns of refugees machine-gunned by enormous low-flying planes grazing the treetops, too many families carrying away a cold little body under a blanket...In the silent night, everyone seemed to hear the droning of distant planes that surely were flying toward this road, capable of spotting these trucks, prepared to let loose meteors of horror.\n\nWhen they eventually reach the south, there is no safety but only a temporary haven; the exiles have exchanged one form of fear for another and they face the seemingly impossible task of securing papers to leave the country altogether. Serge brilliantly conveys the sheer desperation of people who do not have the right documents, who get over one hurdle just to be faced with another. Leaving the country was never just a question of getting one visa; a whole set of documents had to be put in place, like a suit of cards. One country might well grant a visa, but only to nationals of certain countries; others might grant visas but only for transit and only on proof of onward travel, as well as a visa in place for the final destination. And, of course, papers, authentic or forged, cost money and were usually valid for a short time only: 'The word _visa_ could make asthmatics breathe again, relieve sufferers from heart-trouble, cure neuroses, dispel the temptation of suicide; it reigned over condemned horizons as _mirage_ reigns over a desert strewn with bones - but this word also wrought devastation, giving rise to diseases of the personality hitherto unknown to psychiatry.'\n\nIn this situation, people will go virtually anywhere that will take them, even to countries they haven't heard of. Gaetani, one of the refugees, says, 'I remember the days when we carried a map of the [Paris] Metro around with us. Today, it's the planisphere. Our vision is broadening.'\n\nThere are people of all nationalities, from all possible backgrounds, 'Jews of a hundred nations, the last republicans of strangled republics, the last socialists of banned parties, the last revolutionaries of defeated revolutions, the last liberals of conservative democracies...the last parliamentarians of discredited parliaments...'\n\nAfter 30 days waiting, a woman, clutching her handbag, rushes across the square with enough of her wits intact to demand a lethal dose of veronal. Others have not managed to keep their wits intact, like the 'bearded young American, born in Hungary', who kept 'stamping frantically and shouting in cadence: _Kon-sul ame-ri-cain! Kon-sul ame-ri-cain!'_ He is dragged off somewhere, 'No way to shut him up, you couldn't hit an American'.\n\nArdatov hears of the German attack on Russia and knows that he is now 'doubly hunted', as a Russian and as a communist. He eventually gets French papers, but, knowing he is almost certainly being watched, avoids seeing friends so as not to put anyone remotely at risk, 'Isolation thickened around him.' He had prepared his departure 'as meticulously as a Chinese artisan chisels an ivory charm'. He says goodbye only to Chaurras, who will not leave his country even if he could. Meanwhile, Moritz Silber, has used all his skills to get papers in the name of Silver, a Lithuanian Catholic, and hopes to get to Ecuador. But the possession of papers is no protection against the individuals who have taken it on themselves to inform on people. In this case, he falls victim to the deeply anti-semitic Vibert, the one-time bar-owner. 'Crafty in the performance of duty', Vibert has a fearsome intuition for people who are hiding something and relishes the fact that people called him Viper. Sensing Silber's change of mood to one of hope, once he has secured his false papers, he strikes to deadly effect.\n\nOrtiga finds himself arrested yet again. 'Modern man goes to prison as he takes a train or bus,' he thinks. It's not a problem as long as there is the chance of escape. In prison, he befriends the wonderfully named, Nihil Cervantes, an anarchist who long ago forgot his real name, who offers to share his straw mattress with him. Cervantes tells him they will be sent to build a railway across the Sahara and that, already, he has a plan of escape and invites him to join: 'I know how to say \"I am a man friendly to men\" in all the languages of the desert and since it's the truth it will get us through wherever we go'. When Ortiga gets a small parcel from Angele, including a tin of sardines, Cervantes takes nothing but some of the oil on a piece of bread, leaving half a sardine for each of the weakest prisoners. (Even though he is faint with hunger, Ortiga wishes he could keep the tin intact because the name, 'Angele', has been scratched on it with a knife.) Ortiga's heroic efforts to keep the malnourished Cervantes alive come to nothing.\n\nSerge brilliantly conveys the endless anxiety of those who have to live in this time. An act as simple or ordinary as opening a door is laden with fear, 'Every time I open the door' Angele says, 'I know that bad news is coming. When someone goes out you can't tell if he's coming back. Or if you open the door, you never know who or what. 'Apart from anything else, being in possession of false papers was a very serious offense. In this time and in this place nothing is certain, 'The planks of safety over the abyss of perdition' seemed perpetually on the point of collapsing. At one point, Moritz Silber sees the trucks loaded with a 'human potpourri', the result of raiding parties:\n\nThe - Jewish - director of an art theatre in Berlin; the - Jewish correspondent of Amsterdam's (defunct) leading daily;... the pretty little Catalan girl, who had also escaped - but for love; the aging, crockety German intellectual woman with an expired residence permit; the Tunisian with no papers at all...; the Viennese - Jewish - psychoanalyst whom this absurd arrest might kill, because his papers would never be in order, because his American visa would expire in a week; the lame, painted widow of a pre-Hitlerian German playwright, looking like a figure in a _danse macabre;_ the Italian Freemason who had come to Marseille without a safe-conduct and was wanted by the Armistice Commission...\n\nAnd, then at the same time, something wonderful could happen, 'At the very moment of despair a letter arrived bearing stamps from the other world...'\n\nThe novel ends with the start of armed resistance in the area, a resistance which Augustin Charras has decided to join. Serge closes with, 'The end - (but nothing is ended)'.\n\n# 5  \nMagicians of word and thought: the  \nRussian cultural revolution\n\nStupefied, that was the word Serge used to describe his response to the literary revolution that followed the political revolution, 'this glittering debut of Soviet literature...the audacity and the candor of the writers under a regime barely emerged from the terror'. Small circles of 'young men with hollow cheeks', he wrote, 'wearing the grey greatcoat of the Red Army came together in the evening in very cold (but gold paneled) rooms around poets and prose writers such as Gumilev and Zamyatin, who stoically taught them the art of writing'. This was the time, Serge reminded his readers, 'of the barbed wire fence around Russia, the death of the weak, the conspiracies, the allied intervention, and the war where no prisoners were taken...This time left us no books. And yet, 'entire galaxies of young writers' sprang up in Russia nevertheless, 'new men shaped by the storm'.\n\nThis 'literary renaissance' was the time of novelists like Andrei Bely, Mikhail Bulgakov, Ilya Ehrenburg, Vassily Grossman, Boris Pilnyak, Yevgeny Zamyatin, and Serge himself, as well as the short story writers, Isaac Babel, Andrei Platonov, Varlam Shalamov and Mikhail Zoschenko, and of poets like Anna Akhmatova, Alexander Blok, Osip Mandelstam, Vladimir Mayakovsky, Boris Pasternak and Sergei Yesenin. Also breathtaking was the the revolution in other art forms - painting, architecture, theatre, music and, the still relatively new form of cinema, the men and women involved in these producing the finest work of their lives, people like El Lissitsky, Kasimir Malevich, Lyubov Popova, Alexander Rodchenko and Alexander Tatlin; in theatre, Vsevolod Meyerhold and Constantin Stanislavsky; and in cinema, Alexander Dovzhenko, Sergei Eisenstein and Dziga Vertov.\n\nSerge wrote a great deal about the writers of the time; his articles, mainly for French leftist journals, constitute a sort of literary history of the period, and he was, often, perceptive and generous. Of Mayakovsky, who is probably today the best known poet of the time, Serge was particularly insightful. He acknowledged his energy and commitment: Mayakovsky did what he said, 'helping the Republic out of the mud, and working as a living poet on the street'. (At demonstrations he would emerge from the crowd to declaim slogans - one of them was 'Lion of Britain, whine!' - some of these poems were 'little master-pieces'.) And in the 'heroic years', he agitated, designed posters, wrote a great work, 'One Hundred and Fifty Million', a unique work, Serge commented, in its 'originality, breadth and power of expression'. And yet even this revealed, in every line, what Serge called 'the internal tragedy of Mayakovsky the Futurist', among other things an overwheening ego; maybe 100 lines start with 'me'. What one was seeing in Mayakovsky's life and work was 'the drama of a poet who could not, in spite of his keen desire to do so, escape from the past'. The fatal flaw of futurism, the artistic doctrine to which Mayakovsky subscribed, was that, despite its name, it was 'tragically linked to the past, in its naive pretense of avoiding it'.\n\nThe symbolist poet, Alexander Blok, was Serge said, one of the three or four great lyric poets whom 'nature gives to a privileged people in a hundred years'. He was 'the first, the most admired and the most loved of the master musicians of the Russian language'. Serge praised, in particular, two poems, 'The Twelve' and 'The Scythians', for their understanding of, and support for the revolution. And when he died at only 41, Serge's grief was palpable at the loss of 'one of the magicians of word and thought'.\n\nSo too when Andrei Bely was 'devoured' at the age of 53 (in 1934), Serge spoke of him as 'a musician, seeking to give words a sound which were pure, rich and precise'; he possessed all 'the knowledge of the day without it having become a dead letter for him'. Bely's masterpiece, _Petersburg_ , published just before the revolution, is now widely regarded as one of the founding works of literary modernism, comparable to Joyce's _Ulysses_. It was very influential on Serge's own writing, especially _Conquered City_. Serge said of his legacy: 'When they have conferred, by the reorganization of everything, a new value on life and on living beings, men will feel quite different and much less powerless in the face of death. But even at this boundary, there is no other hope. Bely knew it better than most of us.'\n\nOf the popular novelist Boris Pilnyak, Serge wrote a long appreciation, which acknowledged his gifts - his originality of talent, his dynamic view of things, the breadth of his outlook and so on - but concluded that the reader was saddened by not finding in him 'anything more than intuitive insight and primitive admiration'.\n\nIn the theatre, Serge acknowledged the genius of Vsevolod Meyerhold. Even the propaganda plays he put on, like Mayakovsky's _The Bedbug_ , were 'the only great ones', because he still managed to imbue them with 'so frenzied a spirit', that they became something else.\n\nBut, of course, this explosion of creativity could not last. There had always been strong currents of philistinism opposed to what these men and women were trying to do, as well as narrow-minded views of what art should be about, especially in a period of revolution These merged in the figure of Stalin who was philistine to his core, denounced anything innovative as 'formalism', and regarded creative artists as tools of the revolution; writers he once famously remarked were 'engineers of the human soul'. For Serge, the key point of the official suffocation of creativity was the year 1929. 'There is always an hour,' he wrote, 'when the redeeming choice between cowardice and choice is possible. It was in 1929 that the Soviet writers abdicated their dignity.' Creativity was replaced by 'sterility, of spiritless official propaganda, of stereotypes approved by the bureaus'.\n\nTypically, Serge himself only _started_ writing fiction at this point, when he was in his late 30s, after he came close to death in 1928, from an intestinal occlusion. It was also, significantly, the year he was expelled from the Party, which was a different kind of death sentence. Until then, writing of this kind had seemed secondary, but he became increasingly aware of the limitations of historical work which did not permit showing men as they really were, their inner workings and 'penetrating deep into their souls'.\n\nActual death was the fate of many writers. Isaac Babel, best known for his stories from the civil war, Boris Pilnyak and Meyerhold were all shot. Yesenin and Mayakovsky were driven to suicide, as was the poet, Andrei Sobol. Osip Mandelstam found himself in a camp because of a poem he had written about Stalin which he had shared with a few people only, one of whom betrayed him. He died as a result of his time in prison. The student, Varlam Shalamov, who was involved in distributing Lenin's last testament which had become an illegal document, survived a total of 17 years in prison camps, where he composed the truly shocking stories which would be collected as _Kolyma Tales_ , but they were never published in the Soviet Union during his life time.\n\nThe price of survival, albeit temporary, for others was public humiliation, as it was for Pilnyak who was forced to rewrite his novel, _Mahogany_. Officially criticized for its 'pessimistic and counterrevolutionary' portrayal of provincial life he had to make it more optimistic, although even this did not save his life, but only deferred his execution. And when he learned in 1937 of Pilnyak's disappearance, Serge remarked that it was not possible to understand from the outside the terrible pressures of a totalitarian regime. One could not, therefore, judge someone because of their 'small retreats, the little acts of pusillanimity' they engaged in to preserve themselves. (As well as being a writer, Pilnyak had been an important publisher, bringing out works by Bely, Babel, Ehrenburg, Yesenin, Mayakovsky, Mandelstam, Pasternak, Zamyatin, and many others.)\n\nAnd one hears the sadness when Serge writes in 1937 about the fate of the poet Bezymensky, 'in the flood of terrifying news which comes incessantly to us from Moscow'. One of the most remarkable brains of our younger generation, Serge recalled how ten years before, he had always 'joyfully made his way' to his 'miserable dwelling'. He adapted and maneuvered and became a sort of laureate, even going so far as to praise the execution of Marshal Tukachevsky, the leading Soviet general. But not even this could save him.\n\nYevgeny Zamyatin was the only writer besides Serge who was allowed to leave the Soviet Union. Ostensibly permitted to go to Paris for medical treatment, he never returned and died there in 1937. Much influenced by HG Wells, of whom he was a great admirer, his novel, _We_ , is an account of a totally controlled, totally administered world, 'the One State', where people have no names, but numbers, and their lives are completely ruled by a principle of rationality. It's a parody of Taylorism, the principle of 'scientific management' (much admired by Lenin): 'such precise beauty: not one superfluous gesture, deviation, turn. Yes, this Taylor was, beyond doubt, the greatest genius the ancients had'. The book ends with the words 'For rationality must conquer.' _We_ , which was translated into English in 1924, was itself a huge influence on Aldous Huxley's _Brave New World_ , and especially on George Orwell.\n\nOthers were condemned to artistic silence. Mikhail Bulgakov even wrote to Stalin personally in 1929 asking to be allowed to leave the country if he wasn't allowed to work; he was given some dull work in the theatre as a result. At the same time, he was writing his greatest work, _The Master and Margarita_. Now universally acclaimed as a masterpiece, in advance of its time, and hugely influential, it was published only in 1966, six years after Bulgakov's death, and even then could only come out abroad. (One of its most quoted lines is 'Manuscripts don't burn'. Bulgakov himself had burned a version of the book in fear of the consequences; there was no Professor Woland to return it to him with those words, as he does for the Master.)\n\nSo too, around this time, Sigizmund Krzhizanovsky was writing _The Letter Killers Club_ , but this too was never published in the author's lifetime; few of his writings were. The letter killers are a secret group of 'conceivers' who meet on a Saturday and who, to preserve their conceptions, commit nothing to paper, 'if writers prevent each other from writing, they don't allow readers even to form an idea...libraries have crushed the reader's imagination'. The group meet in a room with empty bookshelves. Krzhizanovsky was not writing a political allegory but was aiming at something other than that, something metaphysical, and yet he cannot escape the brutal context of his creation, any more than his club can. The book ends, 'The police may pay a visit. Let them: no one searching emptiness has ever managed to find anything'.\n\nAndrei Platonov chose not to write fiction in the early years of the revolution, believing he could serve it better through his practical skill as an electrical engineer. (His first publication was a pamphlet extolling the values of electrification, which would change the nature of work and the nature of humanity.) He started writing fiction in the late 1920s but few of his writings were published. It is only relatively recently that we are able to read him, this man who, according to John Berger, understood 'living modern poverty more deeply than any other storyteller I have come across', a poverty different from others because its 'desolation contained shattered hopes'.\n\nVassily Grossman, now rightfully acclaimed as a great chronicler of his times, was able to publish some stories in the 1930s, but his monumental masterwork, _Life and Fate_ , was seized in 1959 and only published in Switzerland in 1980. Grossman, who had died in 1964, was told his novel could not be published for two or three hundred years. Ilya Ehrenburg abandoned his innovative writing, such as the truly-groundbreaking, _The Life of theAutomobile_ (1929), and wrote work which was officially approved of, and even got him a Stalin Prize.\n\nSerge himself was told in 1928 by the director of literary publications, Ilya Yenov, a one-time friend, 'Even if you produce a masterpiece every year, not a line of yours will appear!'. The Russian translation of _Men in Prison_ , officially approved, set up to be printed in 10,000 copies, was destroyed. Serge was saved by the fact that he wrote in French and could seek publication abroad, but even this was problematic as he could never be sure that his manuscripts would teach their destinations. He developed the practice of sending detached chapters to France that could be published together, even if some did not arrive!\n\nThe great poet Anna Akhmatova was also forced into a kind of silence. Her former husband, Nikolai Gumilev, had been implicated in an anti-Bolshevik plot in 1921 and shot along with 61 others and, even though they had been divorced for three years, this seemed to taint her in the eyes of the authorities. Her later husband, Nikolai Punin, died after many years in the camps; her son was also harassed and imprisoned. She herself would be publicly insulted by Stalin's cultural commissar, Andrei Zhdanov. Although she was unable to publish, she never stopped writing, and her poem sequence, 'Requiem', spoke for many, 'one hundred million voices cry' through her 'tormented mouth'. Akhmatova recalled how, once in a Leningrad prison queue, she was approached by a woman with blue lips who, in a whisper, asked if she would be able to describe 'this', and when she said yes, 'something like the shadow of a smile crossed what had once been her face'.\n\nIf the greatest minds were prevented from publishing, the Soviet state, Serge caustically remarked, could make 'almost worldwide reputations' in a few days, for people prepared to do as they were asked, using publicity methods 'borrowed from the American trusts'. The order just had be given to all the sections of the Communist International to have their publishing houses translate a seventh rate work; the entire Communist and Communist-inspired press will proclaim its merits.\n\nIn the field of the visual arts, the revolution was, if anything, even more astonishing in its creativity than in literature. The artists Alexander Rodchenko and El Lissitsky were Serge's contemporaries, as was Vladimir Tatlin. Kazimir Malevich and Lyubov Popova were of an older generation, but threw their energies behind the revolution and were far in advance of their time artistically. It was in 1918 that Malevich produced 'Suprematist Composition: White on White', as revolutionary in its own way as much that was happening around him, and which anticipated so-called color field painting by almost four decades.\n\nThis artistic freedom was not limited to individual artists but was extended to the whole field of art education. Vkhutemas, the Higher Art and Technical Studios, was the state sponsored school of art set up in 1920, 'to prepare master artists of the highest qualifications for industry, and builders and managers for professional-technical education'. It was similar in conception to the much better known Bauhaus, set up by Walter Gropius in Weimar in 1919 and forced to close in 1933, many of its staff having gone into exile and the place itself being attacked as degenerate by the Nazis. Like the Bauhaus, Vkhutemas sought to merge the craft tradition with the most modern technology. The constructivist, Alexander Rodchenko, was dean of the metal work faculty. The cubo-futurist painter, Lyubov Popova, taught the use of color. Malevich, advocate of what he called suprematism, taught there, joining the staff in 1925, as did Lissitsky. The textile department was run by the constructivist designer, Varvara Stepanova. At one point it had a teaching staff of 100 and more than 2,500 students. Svomas, free state art studios, were set up in several Russian cities to spread awareness of and competence in the arts to workers and peasants. Entrance examinations were abolished, art history courses were optional, the faculty was replaced by avant-garde artists, and students were free to choose their professors.\n\nTatlin's monument to the Third International, for which Victor Serge would work in a few years time, was designed at Vkhutemas; never built, perhaps unbuildable, wonderfully grandiose, the dream of a time that refused to be constrained by reality. 'Made of glass, iron and Revolution', Viktor Shklovsky the literary theorist said, while for Mayakovsky it was 'the first monument without a beard'. Taller than the Eiffel Tower, and towering over Petrograd, it would have housed a conference centre, a radio station, a cinema, its different sections revolving at different speeds, the proposal has become an icon and highly influential. (Hints of it can even be seen in Val Myer's Broadcasting House, 1932, in central London.)\n\nConstructivists, like Rodchenko, wanted to make objects that were useful, as well as aesthetically pleasing, from cups and plates and cigarette packets to furniture and social clubs for workers, things that would contribute to the new way of life being constructed. Others, like Lissitsky and Malevich, were more interested in pushing the boundaries of what was aesthetically possible, although early on in his career Lissitsky designed the first post-revolutionary Russian flag and he is also, of course, the creator of the well-known propaganda poster, 'Beat the whites with the red wedge', hugely influential and much replicated, even today.\n\nThis was also a period of cross-fertilization in the arts, of breaking down boundaries between different forms. Lyubov Popova, the painter, worked in the theatre with Meyerhold, designing sets for his productions, before her premature death in 1924. Ivan Kudriashev, sent by Malevich to Orenburg in 1919 to set up a branch of Svomas, got involved in doing decorative work for the First Soviet Theater there. Rodchenko and Stapanova worked in theatre too, and Rodchenko also did work for the cinema with Dziga Vertov. He and Lissitsky also designed Mayakovsky's books, and their work influenced generations of book and magazine designers.\n\nThere is an awe-inspiring energy about so much of the work in this period, a seemingly endless creativity, astonishing fertility, that, even today, many of the works from this time still seem ready to burst out of their frames, off the paper. One of Lissitsky's greatest compositions, 'Untitled (Rosa Luxemburg)', dedicated to the German revolutionary, murdered in 1919 by paramilitaries, and her body thrown into a canal. is small, and executed with just pencil, brown paper and some gouache. Karel Ioganson's 'Construction', the polar opposite of Tatlin's tower in its quietness and scale, too is just a sheet of paper marked with some ink and colored pencils, while Varvara Bubnova's 'Untitled' of 1920-21, is just ink and brown paper. How much more creative is it possible to be, one wonders, with these materials, at this time?\n\nOf course, it's impossible for us to look at this work now and not be aware that's its time was very short, that by the end of little more than a decade it would all be over. Maybe this is part of what is moving, this brief flowering, this sense of people seizing an opportunity of real freedom, that they know won't come again, to do something useful to the revolution, however they saw it, but without compromising. And of course, it is deeply dismaying to learn that Lissitsky and Rodchenko both ended up, in effect, as propagandists for the regime. Both worked on the official magazine _USSR in Construction_ , published monthly throughout the years of the terror and whose main aim was to promote a favorable image of the USSR abroad. Rodchenko even took pictures of slave workers on the White Sea Canal project, a huge propaganda effort to show both the success of the first Five Year Plan, and the use of prison labor as a reforming activity.\n\nAs for music, Igor Stravinsky, one of the most important composers of the twentieth century, had left Russia some years before the revolution and was hostile to it when it took place, but he retained a strong artistic connection to the country. He composed some of his most important music of the period for Sergei Diaghilev's Ballets Russes, whose dancers included the legendary Nijinsky and Pavlova, notably _The Firebird_ (1910), _Petroushka_ (1911) and _The Rite of Spring_ (1913), which famously provoked a riot when first performed in Paris. He once quipped that music was 'new just _before_ the Soviets', meaning he was the true revolutionary, but this ignored the work of Nikolai Roslavets, a modernist composer who was persecuted for his artistic beliefs, not to mention Dmitri Shostakovich, who in the most challenging personal circumstances, produced a body of work unequalled in its creativity, poetry and humanity. (Fifty years after the revolution, Shostakovich recalled the revolutionary poet, Alexander Blok, in his song cycle, 'Seven Romances'.) It was during this period, too, that Lev Theremin produced the electronic instrument that bears his name today.\n\nIn cinema, Sergei Eisenstein's _The Battleship Potemkin_ (1925) was hugely innovative and much admired and, indeed, referenced, especially its 'Odessa steps' sequence. Dziga Vertov's _Man with a Movie Camera_ (1929), is even more remarkable in its creativity. A documentary without sound about the lives of ordinary people in the Ukraine and elsewhere, the film is celebrated for its use of many technical innovations and it was much influenced by the photomontage techniques being developed by Rodchenko and Lissitsky. So too was Vsevolod Pudovkin's groundbreaking film, _Mother_ (1928), based on Maxim Gorky's novel of the same name, about a woman's struggle for justice in pre-revolutionary Russia. Rodchenko and Vertov worked on the journal _Kino-fot_ together, and Rodchenko designed posters and tickets for Vertov's films, as well as doing the advertising for Potemkin.\n\nEven in the field of architecture for which, obviously, there was very little scope in a time of extreme shortages, the new order was looking to be as modern as possible. When a trade union body wanted a new headquarters in Moscow it was the great master of modernism himself, Le Corbusier, who they asked to design it. Two years later, however, a competition to build the new Palace of the Soviets in Moscow rejected Corbusier's designs, as it did those of other leading modernists, the preferred design being more bombastic and combined with a memorial to Lenin. (Construction was stopped in 1941 on the outbreak of war.)\n\nArchitects found themselves designing buildings for the rapidly expanding secret police. The impressive constructivist Iset Hotel in Ekaterinburg - still in use - was built for the Cheka, and the city also had specially-built accommodation for Cheka staff and their families. Serge notes without a hint of irony that the traveller visiting a commune in the Middle Ages would have stopped to contemplate the belfry tower or the town hall, rising above the poor dwellings of the artisan and the bourgeois. The traveller visiting the cities of the USSR today, 'stops involuntarily, in Moscow, at the top of the Kuznetsky Most, the liveliest artery of the capital, to take in at a glance the latest architectural ensemble, the most imposing edifices of the GPU...A building of fifteen storeys, huge co-operative stores, dwellings and offices; in the basement and at the rear of vast courts are perfectly silenced prisons; and somewhere behind those facades of fine, polished stone, those shop fronts, those screened windows where the lamplight flares up in the evening, somewhere at the rear of a cellar lighted by neon lights, are the cleverly conceived execution rooms...\n\nNot even the old palaces of St Petersburg, Serge said, could bear comparison with the new GPU building which dominated the Neva and the Volodarsky Prospect; 'The same is true in all of the centres of the USSR. The most imposing building is that of the GPU.'\n\nAnd we remember Rodion at the end of _Midnight in the Century_ who has found work as a laborer on a secret police building...\n\n* * *\n\n# 6  \nA certain sort of courage: the writer as witness\n\n'This age must be witnessed,' Victor Serge said in his _Memoirs_ , 'The witness passes, but his testimony manages to endure - and life still goes on.' Serge was the first of the great historical witnesses of the twentieth century. Witnessing was, for him, 'a means of expressing for people what most of them live without being able to express, as a means of communion, as a testimony about the vast life that flows through us and whose essential aspect we must try to fix for the benefit of those who come after us'. It was something that informed everything he wrote, including his fiction, and was not confined to his reportage, reviews or analysis. Writing was an _act_ of solidarity and nowhere is this more true than in his _Memoirs of a Revolutionary_ , written in exile in Mexico and, of course, never published in his lifetime.\n\nFrom the very first lines the reader is captive. Serge tells how, at an early age, he realized that there was no possible escape from the world and yet there was no alternative but to fight for such an escape. He also tells us early on that he learned from the political milieu into which he was born that the only purpose in life was 'conscious participation in the making of history'. On the walls of their apartment were pictures of men and woman who had been executed for their beliefs. (It was a distant relative who had made the bomb used to kill the Tsar, Alexander II in 1881.)\n\nSerge never attended school. Instead his father worked with him, 'not often and not well' he said, but his 'passion for knowledge and the radiance of a constantly armed intelligence', which had never allowed itself to stagnate, or 'to recoil from an inquiry or conclusion', affected him so powerfully, that he was hypnotized by it. Learning was not separate from life, but life itself, and he learned the concrete meaning of words like, 'bread' and 'rent' and 'hunger'. But he also learned at an early age the value of literature as something which could lift people out of the mundane and give real sustenance.\n\nLooking back on his early years, Serge said he had no personal regrets at all; indeed, he said he pitied those who did not know the cruel side of life and the necessity of fighting for mankind. His only regrets were for the energies wasted in struggles which were bound to be fruitless.\n\nSerge had a knack for catching important things in a few words - 'a time of pot-bellied peace' (France and Belgium just before the war), or 'the sudden conversion to fratricidal patriotism' of the German socialists, French syndicalists and anarchists on the outbreak of war in 1914. And when he reached Russia in 1919 to be part of the revolution, it was 'a world frozen to death'; Petrograd was 'the metropolis of Cold, of Hunger, of Hatred, and of Endurance'. Winter itself was 'a torture (there is no other word for it) for the townspeople': no heating, no lighting, and the ravages of famine'. The young and the old were killed in their thousands.\n\nBecause of his anarchist and syndicalist past, and independent mind, he was respected by people across the non-Bolshevik left, and because of his literary connections and interests he was known in those circles as a man of culture. As a result, he was often asked to intercede for people who had been arrested; 'The telephone became my personal enemy, at every hour it brought me voices of panic-stricken women'. He also came into contact with many of the key figures in the political and cultural life of the times and he wrote arresting little portraits of them; he was repelled by the affectation and calculated elegance of the poet Yesenin, but he could not resist the 'positive sorcery of that ruined voice'; Georg Lukacs, the Marxist philosopher, 'lived bravely in the general fear', yet would not shake Serge's hand in public (Serge says this with not one note of bitterness); 'a single glance was enough to tell the caliber' of men like Joaquin Maurin and Andres Nin, both teachers who would give their lives for the cause in Spain; the Italian communist, Antonio Gramsci, 'fitted awkwardly into the humdrum of everyday existence, losing his way at night in familiar streets, taking the wrong train' but was intellectually 'absolutely alive'; the US anarchist, Emma Goldman, with 'her organizing flair and practical disposition, her narrow but generous prejudices, and her self-importance'.\n\nSerge's recollections convey, as no one else does, the endlessly appalling conditions, physical and emotional, in Russia from the civil war and war communism onwards, the New Economic Policy, ('The sordid taint of money is visible on everything again'), the slow slide of the country into psychosis (Serge's own word), the arrival of Thermidor, the onset of reaction _from within the bureaucracy_ , in November 1927, ('the exhausted Revolution had turned full circle against itself'), the slide also of individuals into despair, ('Nowadays even my friend...has stopped thinking'). Serge took it upon himself to investigate the desperate underbelly of the society and discovered 'the social inferno', where nothing had changed since Dostoyevsky's time. But when Comintern secretary, Angelica Balabanova, sends through the diplomatic bag, an orange and a bar of soap to Serge and his wife, on the birth of their son, these are 'delicacies from another world'.\n\nSerge watched in hope, as did others, the Chinese revolution begin in 1926. A victory there would have meant the salvation of the Soviet Union, but the official line was that the Communists should accept the rule of the Kuomintang under Chiang Kaishek. As a result, Communists were massacred in their thousands. With great courage, Serge spoke out against Stalin himself, who had abandoned support for revolutionary movements abroad, because they would destabilize him, by encouraging renewed revolutionary activity in the Soviet Union, and because they would pose external challenges to his dominance in the Communist world.\n\n'Our crime as Oppositionists', Serge wrote, 'lay simply in existing, in not disowning ourselves, in keeping our friendships and talking freely in each other's company'. As the noose around any kind of opposition tightened, he prepared a document which he sent to friends in Paris asking them to publish it if he were to disappear. It was in this that he was the first to describe the Soviet Union as a totalitarian state. And because of his connections with sympathetic people in the bureaucracy, Serge was made aware of the extent to which the Russian secret police and military were collaborating with the Gestapo. A formal pact between the two countries could not be far off. And, of course, he was right.\n\nToday reading _Destiny of a Revolution_ , Serge's account of Russia after 20 years, one is struck by the appalling accumulation of evidence about the everyday lives of ordinary Russian people - the food shortages, the alcoholism, the fear, the ruthless oppression of any opposition, however minor, the impoverished public culture - the constant lies, the massive gap between the official version and the lived reality. Serge had an eye not just for the terrible conditions but what they led to; it was terrible that people slept 'in the corridors, in garrets, in lofts, in cellars', but also what these led to, 'the ignorance, the alcoholism and the informing...the bitter struggles that can occur, for example, over a room whose occupant, an old woman, seems to be on the point of dying', how people were endlessly divided against each other.\n\nSerge brilliantly describes (in _Conquered City)_ how letters of denunciation were put together; 'unknown hands, laboring in profound secrecy. Obstinately cut alphabets of all dimensions from the papers, collected them, aligned them on notebook sheets: it would take at least five hundred characters for the contemplated letter.' The patient labor of creating the 'demonic alphabet' is carried out in solitude and in silence. The cut papers then have to be sent with a stone to the bottom of a well, for burning would create smoke and 'where there's smoke there's a fire, don't they say?'\n\nBut, for Serge, the greatest evil was not the poverty of means and of men. It was the bureaucratic spirit that prevailed in the schools and which was translated into suspicion, informing, the repetition of formulae devoid of all content, the lessons of pure Stalinism crammed into children eight years old, the stifling of any critical spirit, the repression of all thought, and the hypocritical dissimulation to which the child accustoms himself out of necessity'.\n\nFor Serge witnessing wasn't just about reporting something; it was about understanding. So he didn't just describe what was happening, but offered explanations, and these explanations were always drawn from his first-hand experience, his lived knowledge, not just of the material facts which was always considerable, but of the people and the forces involved. Serge would have been the first to admit that the democratic forces within the revolution had, indeed, been roundly defeated very early on, but he was clear about what had brought this about: 'the revolution hemmed in by its foes, undermined at home by Vendees, by conspiracies, by sabotage, by epidemics, by schisms...the conflict between the battling vanguard of the working-class and its backwards elements, the least conscious and most selfish, those least inclined to sacrifices demanded by the general interest.' In addition there were the activities of dissident groups which served the counter-revolution, for instance the general strike attempted in 1919 by the Mensheviks and social revolutionaries, something which would have been suicidal for the revolution. But in the end it was the failure of the revolution to happen anywhere else, especially in Germany, that was to be the decisive factor. Instead of breaking the 'iron circle in which the soviets were suffocating', the revolution faced 'lasting isolation, increased economic difficulties, a moral depression, the weakening of the internationalist revolutionary tendencies, the strengthening of bureaucratic nationalistic, moderating tendencies...'\n\nSerge was in no way romantic about people; he had had too much experience of personal ambition, betrayal, venality and so on for that. But he was also reluctant to judge, as we saw when he refused to condemn other writers who had maneuvered this way and that to try to save themselves. But he understood, as few people did, the forces at work at particular moments. This is why Serge's account of the Russian revolution is so important today because it stands as a corrective to the popular view that the revolution was somehow fated from the start and, moreover, that this is how all revolutions will end, must end. Not at all, says Serge; there were always choices to be made, courses of action to be decided on. It could have been different. Serge is always also a reminder that one of the reasons the revolution degenerated was the massive external forces ranged against it.\n\n* * *\n\nDaria, in Serge's last novel, _Unforgiving Years_ , working as a teacher in a village in Kazakhstan, has been a witness of sorts. But, because of the times in which she lives, her writings have had to be of a strange kind indeed:\n\nA curious document, this journal, whose carefully chosen words sketched out only the outer shapes of people, events, and ideas: a poem constructed of gaps cut from the lived material, because - since it could be seized - it could not contain a single name, a single recognizable face, a single unmistakable strand of the past, a single allusion to assignments accomplished...No expression of torment or sorrow (this for the sake of pride), no expression of doubt or calculation (for the sake of prudence), and nothing ideological, naturally, for ideology is the sludge at the bottom of the pitfall...\n\nThe construction of the 'featureless record' was like a 'thought puzzle in three dimensions turned entirely toward some undefinable fourth dimension', had become an exhilarating occupation. So there is nothing about the passionate relationship she is having with Klimentii, nothing of the 'surrenders of the flesh, phosphorences of the spirit transmuted into inner riches, she'd had no inkling of before'. Also, she sees that 'no contoured shoulder, no quiver of eyelashes can ever be wholly expressed...'But even this minimal record is potentially too dangerous for the time and must be burned when she is transferred. Her last act there is to distribute 'her riches', some bread and sugar and a bar of rose-scented soap which she carves into slices so it can be distributed more fairly.\n\nOnce in Leningrad, Daria is shocked at how even the buildings seem to have aged by 'a couple of centuries in a few short seasons', just as the men and women 'looked decades older in only a few months', while the children had 'aged a lifetime before knowing what life was'. But it is what she sees in people's faces when they glance at her that disturb her even more. She has never seen this before; it is not the gaze of the hungry:\n\n...this look was inexpressibly different from the looks of the past. She hadn't known that eyes could change so, and cry out so loudly in silence something intolerable. It was neither pain, nor hallucination...What were all those eyes saying? That they had weathered day and night, indefinitely, the storms of snow and terror, of filth, exhaustion, cold, hunger, fright, sickness, with no hope of escape, no hope of healing...That they were watching life die away within themselves.\n\nShe sees the dead being transported, each corpse tied to a sled pulled on a string by its next of kin; a 'new breed of resourceful specialists' earned their food by sewing discarded sheets or squares of sackcloth around the remains. Daria passed several 'such mummies on the street. Rigid pods floating just above the trodden snow. A living man or woman to pull the string, and sometimes a child behind...'\n\nThis part of the novel ends with Daria saving the life of a neighbor by giving her last vodka, vitamins, 'a tin of fish in brine, the half-eaten bar of stale chocolate', and then going home to face her own feelings that she, too, is beginning to die, 'Hunger and loneliness, two tentacles of death'.\n\nThe third section of the novel, 'Brigitte, Lightning, Lilacs', is a stunning achievement of witnessing. It is a shocking picture of Germany during the final days of the war, when the country has become a waste land, devastated by aerial bombardment, as well as by the war on the land; a country laid waste, where not only topography has been destroyed, cities flattened, landmarks destroyed, but time too has been altered, the future itself has been wiped out, 'the old was obliterated forever'.\n\nRichard Greeman points out in his introduction that Serge was in advance of his time in showing the Germans as themselves victims, something that was unthinkable until relatively recently, when it has become possible to acknowledge the horrors afflicted on ordinary Germans, as in the fire-bombing of cities like Dresden which had no strategic purpose but was designed purely to terrify, and also the use of mass rape of women by Russians, again as a form of terror. But when Serge was writing, in the years just after the war, this was a courageous act, another gesture of solidarity with the victims of history.\n\nSerge evokes the fear that is always present: 'There were daylight raids, nighttime raids, twilight raids, dawn raids, and errors in the warning system, which announced a bombing raid when it had already begun and sounded the all-clear as it was starting over again'.\n\nSerge himself, of course, had spent time in Germany in the 1920s, working for the Comintern and had lived among these people. To him, they were not some faceless enemy, but real men and women, many of whom had thoughts and ideas similar to his own, and who had come very close to making their own socialist revolution. Brigitte of the section title is not a Nazi, but from a social democratic family, and her fianc\u00e9, a soldier, we learn, has himself been executed along with the rest of his tank crew, because of their 'bad attitude', in not supporting the war wholeheartedly. 'A desert is what we have made', he says to her in one of his letters. He describes what it is to like to ride over a group of men who have been hiding in the snow - 'they screamed like mice being crushed' and the tank treads are clogged with bleeding flesh. He also tells her how his unit attacked an enemy tank, even though they wished to surrender. He watches a blonde 20 year old burning, 'I watched his face twist like a paper mask tossed onto a bonfire'.\n\nHe, too, has had to become a witness. He tells Brigitte, 'I had to see it all, since I'm the observer...I told myself: Look at what you're doing, you must look without blinking, you're not allowed to close your eyes'. He vividly describes the gradual brutalization that he sees taking place in his fellow soldiers. Fear, he says with some insight, comes from a surprise inflicted on the imagination, 'Once the surprise has worn off, a hanged man seems perfectly natural'. There were so many, they no longer frightened anyone. 'Was it necessary to unleash hell on earth', he asks.\n\nAnd for Gunther, who has brought Brigitte the letters, 'the only natural coupling is a rape in the barn of some smoldering farm', as he recalls the 'skinny black-haired Slovene' who had tried to hide under some sacks and then opened her mouth to scream, but didn't because others were already doing so. Serge paints an appallingly vivid picture of the inferno that Germany has become:\n\nThunderclaps sent huge waves through the earth, crackling outbursts transmuted into great surges of heat, as though invisible ripples of fire were pulsing outward from a fiery oven, somewhere nearby, to one side, deep underground. \"We're going to be baked like potatoes in ashes,\" an old man calmly remarked...The earth shuddered, smoke crept across it, people dwelt in a volcanic realm of sudden explosions, smoldering dormant fires, smoky eddies of soot, dust clouds, the stench of reeking corpses, charred and splintered trees that persisted in budding and even put out, here and there, tender pale-green leaves as though nothing were amiss.\n\nLife continues, just as the lilac bushes tended by Herr Schiff, the schoolteacher, have survived the heat and the dust, 'The force of simple vegetal vitality. 'Schiff goes back into his house and finds a pillow case which he ties to a ruler and puts it above the door: 'Already white rags were flocking across the ruins, some floating with the gay flutter of doves. As far as the eye could see, the whole city was covering itself with white birds, captives who would never take wing.'\n\n* * *\n\nSerge would be followed as a witness by people such as Nadezhda Mandelstam, widow of the poet, Yevgenia Ginzburg and Alexander Solzhenitsyn who reported, in their own brave ways, from that same place of desolation. And of course Primo Levi, _the_ witness of the Shoah, who, in _If This is a Man, The Truce_ , _The Drowned and the Saved_ and other books, dared to speak of the unspeakable, all the time reminding us that the real witnesses, 'those who saw the Gorgon', were dead; he and other survivors were the exception, an anomaly. It was this which haunted him till he too joined them. And let's remember too that Levi was not always the hugely popular and widely-read figure he became. When he first wrote about his experiences, no major publisher was interested in his book and, when eventually published by a small imprint, it quickly went out of print. People did not want to know.\n\nI think too of Eduardo Galeano, the self-described 'Magical Marxist - one half reason, one half passion, a third half mystery' - who, in his massive counter-history of the Americas, _Memory of Fire_ , as well as in other books like _Mirror_ and _The Book of Embraces_ , has redefined the writing of history, mixing historical fact, popular myth, fiction and poetry, to achieve a deeper truth. I think also of Simon Leys, the Sinologist who became a political commentator in the 1960s and 1970s, only because no one else seemed willing to do it. Indeed, Leys compares the refusal of the Western media to hear the truth about what was happening in Mao's China with Serge's experience regarding Stalin's Russia. Leys remarks that his sources were invariably public, and that his only expertise was his knowledge of Chinese, as well as knowing _how_ to read what is said and not said, crack the code of the official jargon, the 'secret language full of symbols, riddles, cryptograms, hints, traps, dark allusions, and red herrings.'\n\nBut of all the writers who have followed, it was the Spanish Communist, Jorge Semprun, who most embodied the legacy of Serge. Like Serge he came from a political family; his father was the Spanish republic's ambassador to the Netherlands, although his maternal grandfather had been the Conservative prime minister, Antonio Maura. Born in Madrid in 1923, Semprun lived in France after the defeat of the Republic, was a member of the Spanish Communist Party in exile. With the German occupation, he joined the resistance, was arrested in 1943 and sent to the concentration camp at Buchenwald. The five day train journey there would provide the framework for his first novel, _Le Grand Voyage_ , translated as _The Cattle Truck_ , which won the 1963 Formentor prize. Semprun was presented with copies in 12 languages, but the Spanish edition, being specially set up in Mexico, hasn't yet arrived, is blank, 'Finally, I feel moved.'\n\nSemprun's allocation to the camp work administration, effectively run by the Communists there, along with his fluency in German, almost certainly ensured his survival. Bizarrely, horribly, it was this work that would lead many former camp inmates later to fall under suspicion, sometimes fatal, after the war was over. Josef Frank, a leading Czech Communist, found himself in the dock in Prague accused of being a war criminal and a Nazi collaborator. He was hanged a few days later and his ashes scattered 'on the snow somewhere around Prague, so that no trace of his passage on earth would remain'.\n\nIt was his experience at Buchenwald that Semprun used as the centre for his fictionalized memoir, _What a Beautiful Sunday_ (1983). Semprun was, of course, familiar with Goethe's visits to the area the previous century with his friend, the poet Eckermann: 'Not without some degree of intellectual perversity, I was pleased to imagine Goethe's conversation with Eckermann on the subject of the Buchenwald camp. What would Goethe have said if he had noticed, as he walked along the Avenue of Eagles, one December Sunday, for instance, the wrought-iron inscription on the monumental camp gates, Jeden das Seine, TO EACH HIS DUE?. The book begins with the narrator, who has strayed from the area permitted to inmates, gazing at a beech tree from the camp when, behind him, he hears a German officer cocking his pistol, getting ready to kill him. In response to the question what is he doing there, he thinks for a second and says, 'Das Baum, so ein wunderschones Baum.' He then jumps to attention and shouts his number in German, 'Haftling vier-und-vierzig-tausend-neun-hundert-vier', which probably saves his life. 'Between SS Warrant Officer Kurt Krauss and No. 44904 there is all the distance created by the right to kill.'\n\nAfter the war, Semprun became a translator for Unesco, but started working clandestinely in Spain for the Communist Party in 1953, an activity he would carry on courageously for many years. How dangerous the work was shown by the fact that Semprun's replacement was arrested, tortured and executed. He was also member of the party central committee and of the Politburo. His account of this period of his life, _The Autobiography of Frederico Sanchez_ , his _nom de guerre_ , won the prestigious Planeta prize in 1977. But Semprun became increasingly critical of the Party's position, as it more and more lost touch with what was actually happening in Spain. He, and his friend Fernando Claudin, would eventually be denounced at an executive committee meeting in Moscow by the legendary 'La Pasionaria' (Dolores Ibarrurri) as 'feather-brained intellectuals', and expelled from the Party. (Semprun also used this experience for the screenplay of Alain Resnais' subtle and compelling 1966 film, _La Guerre est Finie_ , although he is probably better known for his work with Costa-Gavras.)\n\nIn many ways Semprun and Serge could not have been more different. Semprun was from a well-off family, had an elite education, and was an uncritical, orthodox Communist for many years; he said himself he did _not want_ to know the truth of Soviet Russia and elsewhere. When he did confront the truth, as he did when he wrote the screenplay for Costa-Gavras' 1970 film, _L'Aveu (The Confession)_ about the Czech show trials, he did so with an unrivaled power. With Serge, he shared an emotional honesty - 'There is no such thing as an innocent memory. Not for me any more.' he wrote, as well as humanity and courage. And like Serge, Semprun had postponed his writing, preferring political activity to the word. Hence the title he chose for his memoir, _Litterature ou la vie_ , although as someone remarked, this really ought to have been translated as _Writing or Life_. Above all, they shared a commitment to truth and to witnessing for others, and it was always in the service of these that they wrote.\n\n# 7  \nShared veins: hope and the soul\n\nSerge was in no way a personal writer; there is very little ego in his writing and this is true even of the _Memoirs_. He has a very clear sense of what is private and what is public. When he writes that the worst intimacy of prison was not that of bodies, although that wass awful, but 'not being able to be with yourself...to remove your face from the prying glance of others', we see what a torment this was to a private man. The word 'I' was, he once said, repellent to him, 'a vain affirmation of the self which contains a large measure of illusion and another of vanity or unjustified pride'. He preferred to think instead of a 'we', as his experience illuminated that of the people, 'to whom I feel tied'. Unlike the 'we' of Zamyatin's dystopia in which the individual does not exist, Serge's 'we' is the ground, the context of individuality. It is this sense of a real connection to, and authentic communion with, others, a deep humanism, always on the side of the powerless but which never slides into sentimentality, that gives his work much of its power. For his prose is of a piece with that view, always congruent He had a rare ability to convey things powerfully in ordinary language, without any obvious artifice, literary conceit or stylishness. There is not one word that sends the reader to the dictionary, or a formulation whose meaning is not clear to the attentive reader.\n\nAnd he was always writing about real people, never about abstractions. This was much rarer on the left at the time he wrote than it ought to have been. It is this that makes books like _From Lenin to Stalin_ and _Destiny of a Revolution_ engaging still, 75 years after he wrote them. This short passage from _Conquered City_ about conditions in the countryside, merges both the awful facts of what is happening, with the terrible personal consequences, 'So began the black years. First expropriated, then deported, some seven per cent of the farmers left the region in cattle cars amid the cries, tears, and curses of urchins and disheveled women and old men mad with rage. Fields lay fallow, cattle disappeared, people ate the oil cake intended for the stock...'\n\n* * *\n\nOne of the things that gives depth to Serge's understanding of people was his belief in the soul. This was unusual for someone who was in no way religious and probably had a lot to do with the anarchism, with which he had grown up, and which formed him politically. Whatever its roots, Serge had always believed in, what he called, a 'materialist spirituality'. 'The immaterial,' he wrote in his notebook, 'is not in the least unreal' even if it was 'unexplainable by yesterday's scientific rules'. And the soul, for him, was an embodied soul, 'The soul would be nothing if it were not flesh.'\n\nSerge's interest in these matters was deepened by his friendship in exile in Mexico with the German psychiatrists, Fritz Fraenckel and Hubert Lennhof, both veterans of the German socialist movement and the Spanish civil war. Fraenckel, who was once mistaken by a waitress for Einstein, believed that Freud's thinking was equal to that of Marx with its 'new revelations' of man. Their conversations touched on the role of character and personal psychology in the beginning of the conflict between Trotsky and Stalin, as well as the psychological roots of Nazism and the emotional foundations of totalitarianism. The two men would discuss their dreams on the bus. Serge wrote in his notebook:\n\n_Men are psychological beings;_ impossible to act with them, on them, without taking this fact into account, in the most serious sense of the definition. Socialist schematism didn't...take their souls into account...'No psychology!' I heard this little sentence thousands of times in Russia. It meant, 'We're fighting, we're working, efficiency first, material objectivity!' and it came out of the most narrow-minded industrial pragmatism...The striking thing is that the Russian Revolution came to an end through a psychological drama. The whole of contemporary history revolves round that drama and around the Nazi phenomenon which is both economic and psychological at one and the same time...Psychology will perhaps be the revolutionary science of totalitarian times; socialism will no longer be able to do without it without lowering itself and reducing itself to a kind of sterility.\n\nThese are private notes only, written for himself, but we can see Serge groping towards something important, a whole dimension of being human, one which had been fatally missing from the socialist project. Even if he never theorized it, it was always present in what he wrote, that socialism was not about abstractions, but about real people, and it is real people who inhabit his writing.\n\nSerge knew of psychologist Bruno Bettelheim's courageous article on how different individuals responded to the terrible shock of finding themselves thrown into concentration camps, based on his observations while himself an inmate in Dachau and Buchenwald. He also reviewed the Marxist psychoanalyst, Erich Fromm's, pioneering 1941 book, _Escape from Freedom_ , welcoming it as a 'valuable contribution to what might be called our \"intellectual rearmament\"'. Agreeing with Fromm that people accepted authoritarian regimes partly because they were afraid of their own freedom, Serge argued that totalitarian regimes created, in turn, a new kind of insecurity, 'even worse than the one it remedied'; Germans and Russians now lived in a state of 'permanent catastrophe'. And Serge had seen in his own life what persecution could do to individual people; his wife Liuba Russakova had been driven mad by it; on one occasion, offered a cup of tea by the writer, Boris Pilnyak, she thought she was being poisoned. She spent time in psychiatric clinics in Russia (where the secret police were active) and in France, where, tragically, she had to be left behind when Serge and their children went to Mexico. She died in 1985.\n\n* * *\n\nSerge was not an optimist; he never saw silver linings in the dark clouds, never believed that everything would somehow turn out for the best. Not for him the 'optimism of the will', advised by Gramsci, even if combined with the 'pessimism of the intellect' (whatever that might mean). What he did have was _hope_ , which is something different, and which always carries within it the possibility of disappointment. And unlike optimism, which is just a kind of wishful thinking, hope is based on experience, and, for Serge, this was not just his own but the experience of history, that people would always strive for a better life: 'The course is set on hope', as he ended one of his poems in exile.\n\nAnother contemporary, the free-thinking Marxist philosopher, Ernst Bloch, devoted much of his life to documenting the many manifestations of what he called, 'the principle of hope'. This was evident, Bloch argued, in a great deal of culture, from fairy tales to popular songs, to drama and opera. Unlike the Freudian unconscious which was directed to the past, what Bloch called the 'Not-Yet-Conscious', was disposed 'towards the side of something new that was dawning up'. It was the utopian element in human culture, utopian in the sense of what Bloch called the 'forward dream', the hope for, and anticipation of, something better. Human beings, Bloch argued, were not just beings who craved or had needs, but were beings capable of wishing, and it is this wishing, whether for something personal or something social, that gives rise to desire and hope. (It was this that Marx himself had in mind when he spoke of the 'dream of the matter' that the world had long ago possessed but which it did not know how to bring into being.)\n\nStrangely, it is precisely Serge's hopefulness, Susan Sontag remarked with some insight, that has contributed to his marginality. His work, she said, 'refused to take on the expected cargo of melancholy'. This, she implies, is much preferred, particularly on the left. Sontag brings to mind another of Serge's contemporaries, Walter Benjamin, and about whom she had herself written a perceptive and moving article, where she spoke of his 'unquenchable gloom'. The contrast between the two men is striking. A small industry has grown up around the figure of Benjamin. There have been biographies, a film, endless commentaries, even novels and an authorized collected works, now in several volumes. There is also a major memorial at the place of his death.\n\nThe difference between the reception of the two men is not hard to understand. Benjamin is the man of almost pure theory and, as such, the kind of man feted in our time with its love of 'theoretical practitioners'. (The fact that he was also more than a little mystical in his thinking adds a certain exoticism.) The manner of his death in September 1940 has lent weight to the myth: the hard, and painful, trek over the Pyrenees, the loss of a briefcase with an unpublished manuscript, 'more precious than my life', suicide by poison in a hotel room in Port-Bou when he feared he would be sent back to certain death.\n\nI have no wish here to deny Benjamin's importance, or the value of his thought. His essay on the work of art in the age of mechanical reproduction was genuinely groundbreaking, although even he could not have foreseen that the photograph, which he thought was displacing the original work of painting, would itself become a commodity, despite being, as he remarked, 'infinitely reproducible'. It's impossible also to forget, once encountered, the figure of the angel of history, even if it doesn't really stand up to too much scrutiny. And impossible, too not to be charmed by the idea of this man, the most exacting of intellectuals, doing a series of radio broadcasts for children! Nor do I wish to deny the terrible personal tragedy of his death, but simply to note the acute disparity between the after-lives of the two men.\n\n(Serge did, of course, also write theoretically but, to my mind, this was not his strength. Serge writing about individual writers, like Blok or Mayakovsky, is far more interesting than Serge developing a theory of the proletarian novel.)\n\n* * *\n\nIt is in his hopefulness, that Serge makes me think of John Berger, who has himself sustained hope for very many years, in everything he has done. Himself a long-time and insightful admirer of Serge, as we saw earlier, Berger has always been on the side of the oppressed, not just in his active solidarity with the powerless from Mexico to Gaza, but in his writing. Whatever the form he has inhabited - he has been novelist, poet, artist, critic, film-maker - he has been a storyteller, often in powerful collaboration with others, 'against the great defeat of the world'. His has been a persistent voice, intransigent and angry but also compassionate, that a more just ordering of the world is, not just desirable, but possible. His belief in the power of art has sustained many, whether in his understanding of poetry, with its echoes of Serge, as a secular form of prayer against the cruelty and indifference of the world, or the other voices he has, through his generous celebration, helped make known, like Anne Michaels, Juan Gelman, Andrei Platonov, or the work of the artists he has championed and helped us to appreciate, like Giacometti, Zadkine, Leger, Juan Munoz. This is why so many people feel they have this direct relationship with him, as though he is writing to and for each one of us. This is what makes a book, like _Bento's Sketches_ (2011), which takes, as its starting point, the lost sketchbook of a seventeenth-century philosopher (!), with its drawings of a cat sleeping, a dead badger, some flowers, people in Berger's life, its stories of exile, its meditations on art and the state of the world, so inspiring, like a message of hope. 'Some fight because they hate what confronts them;' Berger wrote many years ago, 'others because they have taken the measure of their lives and wish to give meaning to their existence. The latter are likely to struggle more persistently.' These words about another contemporary of Serge, Max Raphael, the German Marxist art critic, he might equally have said of Serge himself.\n\n* * *\n\nSerge also never forgot that human beings lived in a physical world. Just as there was never an 'I' who was outside of a 'we', so we humans, by definition, inhabited a natural world that is not of our making, that has been given to us. This was a constant source of wonder to him, as well as sustenance, and he never stopped celebrating it. Remember the tree bark the prisoners liked to touch, or the pebbles to hold, or the arrival of spring, or the sunlight on the exiles' faces. Or the lilac that survives the endless bombing. Here is a short passage from _Birth of Our Power_ , which is like a little prose poem:\n\nThe blue waters mirror a pure sky in their shimmering silk folds. Invisible strings tremble on the burning air like the flight of bee swarms. The light hums. In the distance are white sails. Flights of seagulls describe curves of whiteness which fade like a light caress in the crystal blue air. The rocks of Montjuich are tinted with amber.\n\nAnd it is the 'splendidly simple world' of nature that Daria is delighted to find herself connected to, once again, in the final section of his last novel, _Unforgiving Years_. Like Serge, Daria has found a refuge of sorts in Mexico and, standing in her yard in early morning, she sees:\n\nPurple sprays of bougainvillea poured over the broken walls. A thicket of menacing nopals - fleshy green - bristled vehemently, and they bore bulbous flowers of a delicate red. A yellow campanile rose above its surround of tall trees, hairy with creepers trailing from every branch. The brightness of the morning was expanding into a vivid symphony of color that promised to intensify almost beyond endurance after this hour of exquisite softness. A monumental joy...conjoined earth and sky in the embrace of the light.\n\n* * *\n\nIt is true that Serge's hope was, at times, misplaced. He greatly underestimated the power of Stalinism and its successors. Stalin was removed from power, not by a rebellion of those he subjugated, as Serge had imagined he would be, but only by death, in March 1953, while The authoritarian state itself remained in place foralmost a half century after Serge, and countless others, had hoped for its demise; the statue of Felix Dzerzhinsky, first head of the Cheka, remained in the feared Lubyanka Square until 1989. But the regimes were not unchallenged. Many people recall the Prague Spring and Poland's Solidarity movement, but we need to remember, too, the uprisings in East Germany in 1953, in Hungary in 1956, in Poland in 1970, all unbelievably courageous, all ruthlessly crushed.\n\nParticularly in the wake of the collapse of the Soviet empire in 1989, so much has been talked about a supposed end of history. But history is never over; it is always in the making, and people still hope for a better world, for a better future, in which they can be the subjects, not the objects of their lives, and they are prepared to give life itself for it. This much, at least, must be clear from recent events in the Arab world, and not only there. Wherever they are, people are constantly trying to change their lives, to challenge oppression. They may not do so under the banner of socialism, far less communism - has an idea ever been so twisted out of meaning as this one? - but they still want something other than what they have. I'm reminded of the words of William Morris about people fighting for something and when it comes about is not what they meant, 'and other men have to fight for what they meant under another name'.\n\nSo Serge's words about conscious participation in the making of history, of being on the side of all that enlarges human beings and against what diminishes them, and of just requiring a certain sort of courage to speak the truth, are as vital today as they ever have been.\n\n* * *\n\nThe last word he wrote, _Dazzling_.\n\n# Writings by Victor Serge\n\n## Novels\n\n_Men in Prison_ , 1930, translated by Richard Greeman, 1969.\n\n_Birth of Our Power_ , 1931, translated by Richard Greeman, 1967.\n\n_Conquered City_ , 1932, translated by Richard Greeman, 1975.\n\n_Midnight in the Century_ , 1939, translated by Richard Greeman, 1982.\n\n_The Long Dusk_ , 1946, translated by Ralph Manheim, 1946.\n\n_The Case of Comrade Tulayev_ , 1948, translated by Roger Trask, 1950.\n\n_Unforgiving Years_ , 1971, translated by Richard Greeman, 2008.\n\nShort stories\n\n_Le Tropique et le Nord_ , 1972, translated by John Manson at <http:\/\/www.pennilesspress.co.uk>\n\n## Poetry\n\n_Resistance_ , 1938, translated by James Brook, 1986.\n\n## Political writings\n\n_Carnets_ , 1985, translated by John Manson at <http:\/\/www.victorserge.net>.\n\n_Collected Writings on Literature and Revolution_ , translated and edited by Al Richardson, 2004.\n\n_Destiny of a Revolution_ , translated by Max Shachtman, 1937. (Sometimes published as _Russia: twenty years after.)_\n\n_From Lenin to Stalin_ , translated by Ralph Manheim, 1937.\n\n_Memoirs of a Revolutionary_ , translated by Peter Sedgwick, 1963. (New edition with restored material, 2012.)\n\n_Revolution in Danger: writings from Russia 1919 -1921_ , translated by Ian Birchall, 1997.\n\n_What Every Radical Should Know About State Repression_ , anonymous translation, nd.\n\n_Witness to the German Revolution: writings from Germany 1923_ , translated by Ian Birchall, 1997.\n\n_Year One of the Russian Revolution_ , translated by Peter Sedgwick, 1972.\n\n# Further reading\n\n(The literature on Serge is now substantial; these are the things I've found most interesting.)\n\nMurray Armstrong, 'The searchers', _Guardian_ , 22 September 1990.\n\nJohn Berger, 'Victor Serge', _Selected Essays and Articles: the look of things_ , Penguin, 1972.\n\nJulian Gorkin, 'The last years of Victor Serge, 1941-47', _Revolutionary History_ , vol. 5, no. 3, autumn 1994.\n\nRichard Greeman, Introductions\/afterwords to the individual novels. -: 'The Victor Serge affair and the French literary left', <http:\/\/www.marxists.org\/history\/etol\/revhist\/backiss\/vol5\/no3\/greeman.html> -: 'Victor Serge and the novel of revolution', <http:\/\/www.marxists.de\/culture\/greeman\/sergenovel.htm>\n\nJames Hoberman, 'Orphan of history', _New York Review of Books_ , 22 October 2009.\n\nBill Marshall, _Victor Serge: the uses of dissent_ , Berg, 1992.\n\nSusan Sontag, 'Unextinguished: the case for Victor Serge', Introduction to 2004 NYRB edition of _The Case of Comrade_ _Tulayev_ , also in _At the Same TIme: essays and speeches_ , Penguin Books, 2008.\n\nSusan Weissman, _Victor Serge: the course is set on hope_ , Verso, 2001.\n\n# Debt to translators\n\nEnglish language readers of Victor Serge are inevitably indebted to his many translators; without them his work simply would not exist. We are particularly indebted to Richard Greeman and to Peter Sedgwick, not just translators but partisans, key members of what Serge's French publisher, Francois Maspero called, the 'secret international of Serge admirers', trying to make sure he is given his rightful place in the world.\n\nThanks also to Ian Birchall, James Brook, Max Eastman, Ralph Manheim, John Manson, Al Richardson, Roger Trask and the, sadly anonymous, translator of _What Every Radical Should Know about State Repression_. Thanks, too, to the many small publishers who have done so much in the face of commercial adversity to keep Serge in print, in particular, Francis Boutle, Bookmarks, Haymarket, Journeyman, Pluto Press, Redwords and Writers and Readers.\n\n# Endnotes\n\n For Gorkin's account see, 'The last years of Victor Serge, 1941-47', _Revolutionary History_ , vol. 5, no. 3, autumn 1994.\n\n Paz speaks of Serge in his memoir, _Itinerary: an intellectual journey_ (trans, Jason Wilson), Harcourt, New York, 1999.\n\n I still find it difficult to use the word 'soviet' in anything other than its true meaning - the workers' councils and factory committees thrown up in the revolution as expres- sions of genuine popular power. They were opposed by the Bolsheviks as early as late 1917, and eventually dominated by them. (See Maurice Brinton, 'The Bolsheviks and Workers' Control', in _For Workers' Power: the selected writings of Maurice Brinton_ , edited by David Goodway, AK Press, 2005). The word also came, especially in the mouths of US politicians and military people, to be a term of cold war abuse: 'the soviets' were the enemy. As for the Union of Soviet Socialist Republics, 'four words, four lies', the great, and greatly-missed, political and social theorist, Cornelius Castoriadis, once quipped, according to Milan Kundera.\n\n John Berger, 'Victor Serge', in _Selected Essays and Articles: the look of things_ , Penguin, 1972, pp. 75-77; Christopher Hitchens, 'Victor Serge: pictures from an inquisition' in _Arguably_ , Atlantic Books, 2011; Susan Sontag, 'Unextinguished: the case for Victor Serge', Introduction to 2004 NYRB edition of _The Case of Comrade Tulayev_ , also in _At the Same TIme: essays and speeches_ , Penguin Books, 2008.\n\n Davd Widgery, _The Left in Britain 1956-68_ Penguin, 1976; Andy Marino, _American Pimpernel_ , Century Hutchinson, 1999, p. 224; John Leonard, _The Last Innocent White Man in_ _America_ , New Press, 1993, p 124.\n\n In the middle of the previous century the great Russian writer Dostoyevsky had spoken of his own imprisonment in similar terms. Having served four years for his part in a political conspiracy, Dostoyevsky wrote to his brother, that he felt he had 'been buried alive and shut up in a coffin...it was an indescribable and unending agony, because each hour, each minute weighed upon my soul like a stone'. Dostoyevsky too would write a novel, _The House of the Dead_ , to come to terms with his experience.\n\n The embassies and military missions of the Allies were, in reality, 'centers of permanent conspiracy', as Serge describes them in his report on state repression, where counter-revolu- tionaries of all kinds 'found subsidies, weapons, political direction'. One of those active against the revolution was the British diplomat and spy, Robert Bruce Lockhart, who was eventually arrested. He was one of those whose freedom was being negotiated for in exchange with the camp inmates in France, who included Serge.\n\n The story is recounted in Susan Weissman, pp.210-213.\n\n Serge's researches were first published in France in 1926 as _Les Coulissses d'une Surete Generale: ce que tout revolutionnaire doit savoir de la repression_. Various editions have been published since, usually dropping the title and using only the sub-title, _What every radical should know about state repression_ , which gives a rather misleading idea of the book's contents. (The first edition I came across was published by one of the more paranoid groups on the far left.)\n\n The Cheka, or Extraordinary Commission, created in 1917 by Lenin, was reorganized in 1922 as the State Political Directorate or GPU, of the NKVD, the People's Commisariat for Internal Affairs.\n\n In his short story, 'The Leningard Hospital', Serge showed how the network of repression extended to the psychiatric system. The patient, Iouriev, has been admitted for a strange misfortune indeed, because he has overcome fear. His psychiatrist explains:  \n\"Iouriev, humble citizen of our times, was ravaged by it for a long time, like you and me. The workers, he explains, are afraid of dying of hunger it they don't steal, afraid of stealing, afraid of the Party, afraid of the Plan, afraid of themselves. The guilty are afraid to own up, the innocent are afraid of their innocence and of having nothing to confess. The intellectuals are afraid of understanding and afraid of not understanding, afraid of seeming to understand or not seeming to understand...The people are afraid of the authorities and the authorities are afraid of the people...the men of the Politburo are afraid of each other, afraid to act, afraid not to act...The Leader is afraid of his subordinates, his subordinates are afraid of him...The revelation came to Iouriev one morning. He woke up, delivered. No fear of anything - anything. The very illumination of feeling clean. He felt he had no right to keep the secret to himself so he spent several days writing forty Appeals to the People...He spent a night sticking them up in the centre of the city, under the eyes of the militia and belated passers-by. They took him for an ordinary bill-poster who was working a little late to have more peace and quiet. And he went home to bed. The next morning he is arrested but his suitcase is already packed.\"  \nSerge was here anticipating the practice whereby the Soviet state would declare 'insane', dissidents and opponents, an abuse of psychiatry that was condemned worldwide. Prominent figures treated in this way included the poet Joseph Brodsky, the scientists Zhores Medvedev and Andrei Sakharov, and people like Natalya Gorbanevskaya who, with unbelievable courage, demonstrated, with a handful of others, in Red Square against the Soviet invasion of Czechoslovakia in 1968.  \nThe story is probably the only work of his to have been adapted for the screen; an adaptation, directed by Sarah Maldoror, was broadcast on French TV in 1983. The cast included Rudiger Vogler, best known for his work in several Wim Wenders films.\n\n _Midnight in the Century_ is dedicated to several comrades, some dead, some in prison. Serge himself says, 'I dedicate these messages' to, Kurt Landau, Andres Nin, Erwin Wolf; to Joaquin Maurin in prison, and to Juan Andrade, Julian Gorkin, Katia Landau and Olga Nin. Andres Nin, one of the leaders of the POUM, kidnapped and murdered in Spain in June 1937 by Stalinist agents, was a hugely important figure also to George Orwell, who had served with a POUM brigade in Spain. In his classic biography, Bernard Crick states, 'The memory of the martyred Nin stayed with Orwell', and the 'hate' figure of Goldstein in _Nineteen Eighty-_ _Four_ 'is Nin quite as much as Trotsky'; much of his testimony in the novel derives from pamphlets in Orwell's possession by, or about, Nin, rather than from Trotsky, as is usually assumed. _(George Orwell: a life_ , Penguin Books, 1992, pp. 227, 365).\n\n A vivid account of Serge's expulsion from Russia, the theft of his poetry and other papers, and the hopeful search for them after the opening up of the Soviet Union, is given by Murray Armstrong in 'The searchers', _Guardian_ , 22 September 1990.\n\n These were helpfully brought together by Al Richardson in _Collected Writings on Literature and Revolution_ , 2004.\n\n Kolyma, an area of north-eastern Siberia, was a source of gold and a vast prison camp. It was administered by a trust, Far Northern Construction, set up by the Soviet state in 1931 to run forced labor in the area. The FNC expanded and may well have been running a prison camp the size of the whole of Western Europe. As many as three million people may have died there - from the cold, hunger, exhaustion, brutality. (Shalamov was asked by Solzhenitsyn to collab- orate on _The Gulag Archipelago_ but declined because of his age.) He died in 1982. (See John Glad's 'Foreword', to his translation of the stories, Penguin, 1994.)\n\n The best introduction to the art of the period remains Camilla Gray's pioneering, _The Russian Experiment in Art_ , _1863-1922_ , revised after her untimely death by Marian Burleigh-Motley, Thames and Hudson, 1962\/1986. See also Norbert Lynton, _Tatlin's Tower: monument to revolution_ , Yale University Press, 2009, and Victor Margolin, _The Struggle for_ _Utopia: Rodchenko, Lissitzy, Moholy=Nagy, 1917-1946_ , University of Chicago Press, 1997. For a different level of analysis from a radical perspective, see TJ Clark, _Farewell to an Idea; episodes in the history of modernism_ (Yale University Press, 1999), especially Chapter 5, 'God is not cast down'.\n\n The only instance I have come across of Serge writing about visual art was when he was in Berlin as a Comintern agent and went to the autumn exhibition of the Academy of Fine Art, where he found nothing but torment, suffering and darkness, and artists, including Barlach, Kollwitz and Kokoschka, who know 'nothing of joy'; it was, he said, the 'decadent art of a dying civilization' _(Witness to the German_ _Revolution_ , pp. 257-8).\n\n Eisenstein himself admired the writing of Charles Olson, whose words I've used as the epigraph, although he did not live to see this poem.\n\n Strangely, the avant-garde film-maker, Maya Deren, who was born in Russia in 1917, did her own translation of Serge's _Conquered City_. It was found in her papers after she died tragically in 1961 at the age of 41.\n\n An architect of a different kind, Berthold Lubetkin, eventually found himself in London where his work continues quietly to astonish. Born in 1901, the son of a railroad engineer who would be murdered in Auschwitz, Lubetkin had been a student of the Vkhutemas, where his teachers included Rodchenko and Tatlin, and later at Svomas in Petrograd. A reservist in the Red Army during the civil war, he had designed the USSR Trades Pavilion used at various locations in Europe in the late 20s. In 1932, he set up his practice, Tecton, which would last until 1948. Lubetkin may be best known for his 1934 penguin pool at London Zoo, but his Highpoint flats in north London continue to stun, especially on a bright day; they were praised by Le Corbusier himself, as 'an achievement of the first rank'. But Lubetkin was aware of the contradiction he found himself in, designing housing for middle class intellectuals. (The original brief by Zigmund Gestetner had been for a building to house his employees at his north London factory. Apart from its successor, Highpoint Two, Tecton would only build public buildings.) In 1935, Tecton was commissioned to build a health centre in the poor borough of Finsbury, in the heart of London; bringing together different facilities previously dispersed, the new centre would be, Lubetkin thought, a 'megaphone for health'. The building was poorly looked after, but continues in use, and is impressive still, as is Tecton's public housing, for instance the Hallfield Estate, near London's Paddington Station, living testimony to a belief in good quality housing, that is also architecturally innovative. They are, in architectural historian John Allan's beautiful summation, 'buildings that cry out for a world that has never come into being'.  \nAfter the war, Lubetkin agreed to be the architect\/planner for Peterlee, near Durham, one of the new towns being built as part of the reconstruction after the devastations of the war. But two years of opposition to his innovative ideas, and incessant bureaucratic wrangling, left him defeated. and eventually he resigned. The town was then built on the more usual lines of anonymous urban sprawl. He went into semiretirement, but still was involved in new work and in teaching, before his death in 1990. (See Malcolm Reading and Peter Coe, _Lubetkin and Tecton: an architectural study_ , Triangle Architectural Publishing, 1992).\n\n My copy of _Destiny of a Revolution_ was published by Hutchinson, along with something called the National Book Association and looks, at first sight, like one of those classic Left Book Club editions of the 1930s. It carries a printed leaflet by Arthur Bryant, a popular historian, who became an admirer of Hitler and the Nazis. (Two years after they published Serge, they published a new version of Hitler's _Mein Kampf!)_ Bryant says Serge is an 'unrepentant Communist', who fails to see that what he describes is the 'inevitable result of applying the Marxian doctrine to the real world'. (Even he praises Serge for 'lucidly and dispas- sionately' portraying the details of life in Russia: 'Not Dante himself painted such a picture of horror and inhumanity as this lifelong Communist'.) Bryant's corrective is necessary because there is not one word in the book that justifies its use as right-wing propaganda. Bryant was also involved in the Right Book Club, set up in 1937 by WA Foyle, owner of the prestigious London bookshop, and actively led by his daughter, the autocratic Christina who, infamously, never allowed trade unions in the shop.\n\n 'The art of interpreting nonexistent inscriptions written in invisible ink on a blank page' in Simon Leys, _The Angel and the Octopus: collected essays and articles 1983-1999_ , Duffy and Snellgrove, 1999, and _Chinese Shadows_ , Penguin, 1978.\n\n Dan Gretton, and others from Platform, the political arts organization, inspired by Semprun's book, walked from Goethe's house in Weimar to Buchenwald: 'the distance from humanism to barbarism is 10,166 steps'. Semprun's memoir, _Literature or Life_ (1997), also begins at Buchenwald on the day of its liberation. Semprun, who has not had a mirror for years, sees himself reflected in the faces of his British liber- ators, 'in that terror-stricken gaze, I see myself - in their horror'.\n\n The English translation was published with the title, _Communism in Spain in the Franco Era_ , which makes it sound like a politics text-book, which it most certainly is not.\n\n See the obituary by Michael Eaude, _Guardian_ 20 June 2011. Semprun also wrote the compelling and sophisticated novel of political intrigue, _The Second Death of Ramon Mercader_ (1973), as well as others never translated into English.\n\n An article by Fraenckel and Lennhof, 'On the psychology of National Socialism', (translated by Eileen Holly and Ursula Ott), was published in _Free Associations_ , 2002, pp. 216 - 226.\n\n Bettelheim's article was first published in Dwight Macdonald's journal, _Politics_ , to which Serge was also a contributor. He incorporated it into his classic book, _The_ _Informed Heart_ (1960).\n\n Fromm's book was published in Britain in 1942 as _The Fear of_ _Freedom_. A later book, _Marx's Concept of Man_ (1961), making use of Marx's early writings, in particular the 'Economic and philosophical manuscripts', helped bring the humanist Marx to a wide audience.\n\nContemporary culture has eliminated both the concept of the public and the figure of the intellectual. Former public spaces \u2013 both physical and cultural \u2013 are now either derelict or colonized by advertising. A cretinous anti-intellectualism presides, cheerled by expensively educated hacks in the pay of multinational corporations who reassure their bored readers that there is no need to rouse themselves from their interpassive stupor. The informal censorship internalized and propagated by the cultural workers of late capitalism generates a banal conformity that the propaganda chiefs of Stalinism could only ever have dreamt of imposing. Zer0 Books knows that another kind of discourse \u2013 intellectual without being academic, popular without being populist \u2013 is not only possible: it is already flourishing, in the regions beyond the striplit malls of so-called mass media and the neurotically bureaucratic halls of the academy. Zer0 is committed to the idea of publishing as a making public of the intellectual. It is convinced that in the unthinking, blandly consensual culture in which we live, critical and engaged theoretical reflection is more important than ever before.\n","meta":{"redpajama_set_name":"RedPajamaBook"}}