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THE REQUISITES

Breast Imaging
The Requisites Series
SERIES EDITOR TITLES IN THE SERIES
James H. Thrall, MD Breast Imaging
Radiologist-in-Chief Emeritus Cardiac Imaging
Massachusetts General Hospital Emergency Imaging
Distinguished Juan M.Taveras Professor of Radiology Gastrointestinal Imaging
Harvard Medical School Genitourinary Imaging
Boston, Massachusetts Musculoskeletal Imaging
Neuroradiology Imaging
Nuclear Medicine
Pediatric Imaging
Thoracic Imaging
Ultrasound
Vascular and Interventional Imaging
 THE REQUISITES

Breast Imaging
THIRD EDITION
Debra M. Ikeda, MD, FACR, FSBI
Professor
Department of Radiology
Stanford University School of Medicine
Stanford, California

Kanae K. Miyake, MD, PhD

Program-Specific Assistant Professor
Department of Diagnostic Imaging and Nuclear Medicine
Kyoto University Graduate School of Medicine
Kyoto, Japan
Visiting Assistant Professor
Department of Radiology
Stanford University School of Medicine
Stanford, California
3251 Riverport Lane
St. Louis, Missouri 63043

THE REQUISITES: BREAST IMAGING,THIRD EDITION ISBN: 978-0-323-32904-0

Copyright © 2017 by Elsevier Inc.

Previous editions copyrighted 2011 and 2004

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Library of Congress Cataloging-in-Publication Data

Names: Ikeda, Debra M., author. | Miyake, Kanae K., author.

Title: Breast imaging / Debra M. Ikeda, Kanae K. Miyake.
Other titles: Requisites series.
Description:Third edition. | St. Louis, Missouri : Elsevier, [2017] |
Series: Requisites | Includes bibliographical references and index.
Identifiers: LCCN 2016032302 | ISBN 9780323329040 (hardcover : alk. paper)
Subjects: | MESH: Mammography | Breast Diseases--diagnosis | Ultrasonography,
Mammary | Magnetic Resonance Imaging--methods
Classification: LCC RG493.5.R33 | NLM WP 815 | DDC 618.1/907572--dc23 LC record available at
https://lccn.loc.gov/2016032302

Executive Content Strategist: Robin Carter

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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 For my mother, Dorothy Yoshie Kishi Ikeda
Pearl City, Hawaii
and
For my father, Otto Masaru Ikeda, and brother
Clyde Seiji Ikeda
Puowaina (Punchbowl), Honolulu, Hawaii
Debra M. Ikeda

For my mother, Chikako Miyake

Gifu, Japan
and
For my father, Akihide Miyake
Tokiwacho, Kyoto, Japan
Kanae K. Miyake
Contributors
Bruce L. Daniel, MD Ellen B. Mendelson, MD, FACR, FSBI, FSRU
Professor of Radiology Lee F. Rogers Professor of Medical Education in Radiology
Stanford University School of Medicine Professor of Radiology
Stanford, California Department of Radiology
Feinberg School of Medicine, Northwestern University
Frederick M. Dirbas, MD Chicago, Illinois
Associate Professor of Surgery
Stanford University School of Medicine Kanae K. Miyake, MD, PhD
Leader, Breast Disease Management Group Program-Specific Assistant Professor
Stanford Cancer Center Diagnostic Imaging and Nuclear Medicine
Stanford, California Kyoto University Graduate School of Medicine
Kyoto, Japan
Dipti Gupta, MD Visiting Assistant Professor
Assistant Professor Department of Radiology
Section of Breast Imaging Stanford University School of Medicine
Northwestern Memorial Hospital Stanford, California
Chicago, Illinois
Camila Mosci, MD, MSc
R. Edward Hendrick, PhD, FACR, FSBI, FAAPM, FISMRM Professor of Nuclear Medicine
Clinical Professor of Radiology Department of Radiology
University of Colorado-Denver School of Medicine University of Campinas
Aurora, Colorado Campinas, Sao Paulo, Brazil

Kathleen C. Horst, MD Dung H. Nguyen, MD, PharmD

Assistant Professor Clinical Assistant Professor
Department of Radiation Oncology Stanford University
Stanford University School of Medicine Stanford, California
Stanford, California Director of Breast Reconstruction
Stanford Cancer Center
Debra M. Ikeda, MD, FACR, FSBI Palo Alto, California
Professor
Department of Radiology Andrew Quon, MD
Stanford University School of Medicine Medical Director, Clinical PET-CT
Stanford, California Associate Professor of Radiology
Stanford University School of Medicine
Stanford, California

vi
Foreword
The first two editions of Breast Imaging: The Requisites
were both outstanding texts and captured the philoso-
phy of the Requisites in Radiology series by presenting
complex material in a concise, logical, and straightforward
way, making the material very accessible to the reader. Drs.
Ikeda and Miyake and their contributors have again suc-
ceeded in achieving these attributes for the third edition
of their book. Important new material has been added, and
material on all enduring methods has been updated.
In light of the trend toward standardized reporting in
radiology, it is noteworthy that breast imaging has been
an exemplar within the specialty for the use of standard-
ized reporting through the use of BI-RADS®. Indeed, un-
derstanding the use of this reporting system is crucial to
successful clinical practice in breast imaging. To this end,
Drs. Ikeda and Miyake have systematically incorporated
the revised BI-RADS® 2013 system that encompasses ul-
trasound and MRI reporting as well as mammography, and
they explain how to use the BI-RADS® 2013 lexicon cor-
rectly. Readers will find this material of daily practical use.
Screening and diagnostic applications of x-ray mammog-
raphy remain the most commonly performed procedures
in breast imaging, but the technology for performing these
studies has changed dramatically over the last decade, with
widespread use of digital imaging and increasing use of
tomosynthesis. These advances in technology are compre-
hensively described in the third edition of Breast Imaging:
The Requisites. Many positive consequences related to the
use of digital mammography and tomosynthesis have been
more firmly established since the previous edition, such
as improved cancer detection and reduced callback rates.
Beyond x-ray–based mammography, no area of special-
ization in radiology has seen more expansion of scope or
complexity than breast imaging. The specialty now en-
compasses the use of all medical imaging methods—x-ray,
ultrasound, MRI, nuclear medicine—and addresses a spec-
trum of applications that includes screening, diagnosis,
surveillance, interventions, and assessment of therapeutic
efficacy. Functional and molecular information is now in-
corporated into the practice of breast imaging. Separate
chapters of Breast Imaging: The Requisites are devoted
to each of these topics. The chapters are laid out in a logi-
cal fashion, with a succinct summary statement of key ele-
ments at the end.
New material in the third edition incorporates substan-
tial advances in our understanding of the challenges of
diagnosing breast cancer and therewith development of
optimal strategies for employing different imaging meth-
ods. For example, strategies for enhanced surveillance us-
ing ultrasound and MRI have been informed by advances
in our understanding of the genetics of breast cancer and
genotype-related risks. Likewise, strategies incorporating
nuclear medicine, ultrasound, and MRI methods have been
developed to help better detect disease in women with
dense breast tissue.
High-quality images are a fundamental basis for success-
ful radiology practice. Presentation of high-quality images is
even more important in textbooks in order to provide the
reader with clear, easily comprehended examples of image
findings. Drs. Ikeda and Miyake and their contributors have
achieved a high standard in this regard. Readers will again
find that this edition of Breast Imaging: The Requisites is
generously illustrated with very high-quality material.
While the technology and scientific understanding of
breast imaging continue to advance, the special relation-
ship of breast imaging specialists and their patients has not
changed. Breast imaging radiologists have a special respon-
sibility as stewards of patient care in going from screen-
ing to diagnosis, to assessment of surgical specimens, to
clinical staging, and finally to assessment of therapeutic
outcome and long-term follow-up. The intimate relation-
ship between radiologists and their patients with breast
disease is unique in radiology practice. As in the previous
editions of Breast Imaging: The Requisites, Drs. Ikeda and
Miyake have captured the importance of this relationship
and especially the philosophy that the fundamental goal is
to save women’s lives.
The Requisites in Radiology series is well into its third
decade and is now an old friend to a large number of ra-
diologists around the world. The intent of the series has
always been to provide residents, fellows, and clinical
­
practitioners with reliable, factual material, uncluttered
with conjecture or speculation, that can serve as a durable
basis for daily practice. As series editor, I have always asked
writers to include what they use in their own practices
and what they teach their own trainees and to not include
extraneous material just for the sake of “completeness.”
Reference books are also valuable but serve a different
purpose.
I would like to congratulate Drs. Ikeda and Miyake for
sustaining the goals of the Requisites series and for pro-
ducing another outstanding book. Readers will benefit
from the authors’ knowledge and also from their experi-
ence and wisdom in one of the most challenging areas of
medical practice.
James H. Thrall, MD
Radiologist-in-Chief Emeritus
Massachusetts General Hospital
Distinguished Taveras Professor of Radiology
Harvard Medical School
Boston, Massachusetts
vii
Preface
The specialty of breast imaging is a uniquely challenging and per-
sonal combination of imaging, biopsy procedures, clinical corre-
lation, advances in technology, and compassion. A breast cancer
diagnosis is intensely personal and potentially devastating for the
patient. The radiologist’s job is to detect and diagnose the can-
cer and gently support the patient through discovery, diagnosis,
treatment, and follow-up.The radiologist’s role has changed from
simply identifying cancers to being deeply involved in diagnosis,
biopsy, and follow-up. Instead of sitting alone in a dark room, the
radiologist is truly part of a team of oncologic surgeons, patholo-
gists, radiation oncologists, medical oncologists, plastic surgeons,
geneticists, and, most importantly, the patient.
This is a very simple book. Its purpose is to help the first-year
resident understand why the mammogram, the ultrasound, and
the MRI look the way they do in benign disease or in cancer.
The other purpose is to help senior residents/fellows pass their
boards.With careful scrutiny of each chapter, residents will know
clinical scenarios in which cancers occur; develop a systematic
method of analyzing images; be able to generate a differential
diagnoses for masses, calcifications, and enhancement; and know
how manage patients.
Even though the book is simple, the pictures and tools in the
book can be adapted to your general clinical practice.Thus, when
you come upon a tough case out in the “real world,” look to the
skills that you learned in this book to solve problems. Use all
the tricks you learned on each tough case, because there will
be tough cases. Adversity is inevitable. If you welcome adversity
as your personal challenge and opportunity, and if you use com-
mon sense, you will most certainly succeed. Remember, the goal
of imaging is for the good of the patient—to diagnose and treat
breast cancer so that the patient will live. Therefore, with each
challenging case, view the adversity of the difficult diagnosis as
your responsibility, your challenge, and your opportunity. Keep
using the tools in this book until you overcome your problem.
As Bruce Daniel told me when I was flailing around in the most
difficult of MRI-guided procedures, within the realm of common
sense, “Never give up!”
viii
Two days before Christmas in 1986, in my junior year as a
resident, my 62-year-old mother’s mammogram showed a 7-mm
suspicious spiculated nonpalpable breast mass. The mass was
detected because the University of Michigan had hired Visiting
Professor Dr. Ingvar Andersson from Malmo, Sweden (principal
investigator of the randomized, controlled, population-based
Malmo Mammographic Screening Project), who updated our
equipment, started a QA program, and taught faculty/trainees
state-of-the-art breast imaging interpretation. Because of him, my
mother underwent a brand-new diagnostic technique brought
from Sweden: fine-needle aspiration under x-ray guidance using a
grid coordinate plate. The aspirate showed cancer. We were dev-
astated. My mom had a second opinion for surgery on Christmas
Eve and underwent mastectomy 2 days after Christmas. On New
Year’s Eve, we got the good news that it was a very small invasive
tumor, that there were negative axillary lymph nodes, and that
she had a good prognosis.
Naturally, I wanted to learn everything about breast imaging
because of my experience of what happens within families when
a loved one is diagnosed with breast cancer. I knew that diagno-
sis and treatment of early-stage breast cancers can result in a long,
healthy life for the woman. I knew that we, as radiologists, could
train to find and diagnose early breast cancer, profoundly affect-
ing women and their families for the better. So I learned breast
imaging from excellent teachers. Dr. Miyake and I want you to
learn breast imaging, find the little cancer like my mother’s tu-
mor, and save her life again.
My mom is now 92 years old and living in Hawaii. Remember
our story. I want everyone who reads this book to have the op-
portunity to perceive and diagnose small cancers, intervene, and
have this outcome. When this outcome is not possible, I want
everyone who reads this book to use their knowledge to help
their patient through her journey. Someday we may not need this
book because there will be further advances in science. Until that
happy day comes, we ask those who read this book to use your
knowledge to help women.
Debra M. Ikeda, MD, FACR, FSBI
Acknowledgments
I would like to thank my mentors, Dr. Edward A. Sickles and
Dr. Ingvar Andersson, who inspired me, taught me breast cancer
imaging, and have always supported my career. I especially thank
my wonderful husband, Glenn C. Carpenter, who is so generously
supportive, giving me the “gift of time” to work on the book. Most
of all, I wish to thank my awesome co-editor, Dr. Kanae Kawai
Miyake, who wrote, reviewed, and cropped images; trained as-
sistants; provided an incredible database for our project; and
has been so wonderful to work with as a meticulous, organized
scientist, making sure every image, reference, and statement had
appropriate scientific or clinical relevance. I was truly blessed
when Dr. Kaori Togashi supported Dr. Miyake’s sabbatical from
Kyoto University to work at Stanford. I have rarely seen anyone so
dedicated and devoted to making complex ideas so very simple
that even I can understand them! Dr. Miyake has done outstand-
ing work to improve and update this book, and it could not have
been done without her tenacity and generous nature. Our col-
laboration and friendship is an experience I will never forget.
Dr. Debra M. Ikeda
It was a great pleasure for me to be a part of this book, having the
opportunity to share these educational cases with readers world-
wide. I have been working with Dr. Ikeda as a Visiting Assistant
Professor at Stanford since October 2013, since which time we
have been working on Breast Imaging together. I still remember
that I read a previous edition of this book when I was a young
radiologist and used to keep it on my desk so that I could refer
to it when I met difficult cases. It was an indescribable honor for
me to be able to contribute to the new edition.
The previous edition was an excellent book, providing fun-
damental knowledge and useful tips to diagnose breast cancer,
written in a reader-friendly manner. I was moved to tears when
I read Dr. Ikeda’s preface, filled with her sense of responsibil-
ity for patients, her strong fighting spirit to battle against breast
cancer, and her consideration for all breast radiologists. Through
editing the new edition, I have realized that she is truly such a
person. She is a wonderful expert, an enthusiastic teacher, and
an affectionate woman. Her noble intention and tenacious efforts
inspired me, and her dedication and leading ideas made the book
evolve. I hope that our book will provide practical help to pa-
tients and doctors fighting against breast cancer as they face the
difficulties that lay ahead of them. I greatly thank Dr. Debra M.
Ikeda for including me in this work.
I thank Dr. Kaori Togashi, the current chair of Department of
Radiology at Kyoto University, Japan, who has always supported
me and encouraged me as a radiologist and a nuclear medicine
physiologist. I thank Dr. Junji Konishi, a former chair of Depart-
ment of Radiology at Kyoto University, who helped me have the
wonderful opportunity to work at Stanford. I thank my mentors,
Dr. Yuji Nakamoto and Dr. Shotaro Kanao, who taught me PET
and breast imaging while I was at Kyoto University. I thank my
beloved little son, Toma Kawai, who brings happiness into my
life, and my husband and best friend, Toshiyuki Kawai, who al-
ways supports my work and walks the path of joyful life together
with me. I thank my dad, Akihide Miyake, who has affectionately
looked over our family from the sky since the age of 36, and my
mom, Chikako Miyake, who bravely raised three kids and always
wishes happiness and good health to all.
Dr. Kanae K. Miyake
No book is completed without tremendous efforts on the
part of many people. We wish to acknowledge our co-authors,
Dr. R. Edward Hendrick, Dr. Ellen B. Mendelson, Dr. Dipti Gupta,
Dr. Bruce L. Daniel, Dr. Kathleen C. Horst, Dr. Frederick M. Dirbas,
Dr. Dung Hoang Nguyen, Dr. Andrew Quon, and Dr. Camila Mosci
for their invaluable scientific and educational contributions in
their book chapters. We wish to thank our assistants Adrian C.
Carpenter, Catherine M. Carpenter, and John Chitouras for their
dogged, painstaking, but cheerful help with the massive files of
images, references, tables, and text. We thank Mark Riesenberger
for his fabulous HIPAA compliant, web-based IT support, without
which we would have been frozen 2 years ago. We thank our
Elsevier editors Robin Carter, Angie Breckon, and Julia Roberts
for their support and (sometimes) gentle prodding to complete
the book.
We thank Dr. Jafi Lipson, Dr. Sunita Pal, and Dr. Jennifer Kao
for sharing ideas of what might be good tools or illustrations for
teaching residents and providing images. We thank our physician
contributors at Kyoto University, Japan, Dr. Shotaro Kanao and
Dr. Yuji Nakamoto for their beautiful images and written contri-
butions to the book to increase our knowledge of MRI and PET.
We thank Dr. Kaori Togashi, Radiology Chairman at Kyoto
University, who generously supported Dr. Kanae Kawai Miyake
in writing this book and in her research. We both wish to emu-
late her superb example as a chairman, scientist, physician, and
compassionate mentor to radiologists and women. We thank
Dr. S. Sanjiv (Sam) Gambhir, Radiology Chairman at Stanford
­University, and the late Dr. Gary M. Glazer for their vision and sup-
port of Stanford Breast Imaging, who were always and constantly
seeking ways to provide the best technology and the earliest de-
tection and keenly pursuing newest research for our women to
save them from breast cancer.
We thank all the scientists, doctors, engineers, and physicists
who support our breast cancer patients and women and who
battle breast cancer on their behalf. We especially wish to recog-
nize the struggle of our many breast cancer patients and women
undergoing screening; this book was written for them, directed
to all who wish to help them by learning about breast imaging.
Thank you.
Dr. Debra M. Ikeda and Dr. Kanae K. Miyake
ix
Contents
Chapter 1
Mammography Acquisition: Screen-Film,
Digital Mammography and Tomosynthesis,
the Mammography Quality Standards Act,
and Computer-Aided Detection 1
R. Edward Hendrick, Debra M. Ikeda, and Kanae K. Miyake
Chapter 2
Mammogram Analysis and Interpretation
Debra M. Ikeda and Kanae K. Miyake
Chapter 3
Mammographic Analysis of Breast Calcifications 75
Debra M. Ikeda and Kanae K. Miyake
Chapter 4
Mammographic and Ultrasound Analysis
of Breast Masses 122
Kanae K. Miyake and Debra M. Ikeda
Chapter 5
Breast Ultrasound Principles 171
Dipti Gupta and Ellen B. Mendelson
Chapter 6
Mammographic and Ultrasound-Guided Breast
Biopsy Procedures 218
Debra M. Ikeda and Kanae K. Miyake
x
Chapter 7
Magnetic Resonance Imaging of Breast Cancer
and Magnetic Resonance Imaging–Guided Breast
Biopsy 259
Kanae K. Miyake, Debra M. Ikeda, and Bruce L. Daniel
Chapter 8
Breast Cancer Treatment-Related Imaging
30 and the Postoperative Breast 321
Kathleen C. Horst, Kanae K. Miyake, Debra M. Ikeda, and
Frederick M. Dirbas
Chapter 9
Breast Implants and the Reconstructed Breast 357
Kanae K. Miyake, Debra M. Ikeda, Dung H. Nguyen, and
Bruce L. Daniel
Chapter 10
Clinical Breast Problems and Unusual Breast
Conditions 397
Debra M. Ikeda and Kanae K. Miyake
Chapter 11
18F-FDG PET/CT and Nuclear Medicine
for the Evaluation of Breast Cancer 439
Camila Mosci, Kanae K. Miyake, and Andrew Quon
Index 466
Video Contents
Chapter 1
Video 1-1A: Digital Breast Tomosynthesis,
Projection Images
Video 1-1B: Digital Breast Tomosynthesis,
Reconstructed Slices
Video 1-2: Digital Breast Tomosynthesis of the
American College of Radiography
Mammography Phantom
Chapter 2
Video 2-1: Digital Breast Tomosynthesis in
Mediolateral Oblique Projection:
Cancer in a “Danger Zone”
Video 2-2A: Digital Breast Tomosynthesis,
Mediolateral Oblique Projection:
Workup for a Possible Mass—Cancer
Video 2-2B: Digital Breast Tomosynthesis,
Craniocaudal Projection: Workup for a
Possible Mass—Cancer
Video 2-3A: Digital Breast Tomosynthesis,
Mediolateral Oblique Projection:
Workup for a Possible Mass—Cancer
Video 2-3B: Digital Breast Tomosynthesis,
Craniocaudal Projection: Workup for a
Possible Mass—Cancer
Video 2-4A: Digital Breast Tomosynthesis,
Mediolateral Oblique Projection:
Workup for a Possible Mass—
Summation Artifact
Video 2-4B: Digital Breast Tomosynthesis,
Craniocaudal Projection: Workup for a
Possible Mass—Summation Artifact
Video 2-5A: Digital Breast Tomosynthesis Showing
Asymmetry
Video 2-5B: Digital Breast Tomosynthesis with
Spot Compression, Original View:
Workup for a Possible Mass—
Summation Artifact
Video 2-5C: Digital Breast Tomosynthesis with
Spot Compression, Magnified
View: Workup for a Possible Mass—
Summation Artifact
Video 2-6A: Digital Breast Tomosynthesis,
Mediolateral Oblique Projection:
Characterization of a True Finding in
the Extremely Dense Breast—Cancer
Video 2-6B: Digital Breast Tomosynthesis,
Craniocaudal Projection:
Characterization of a True Finding in
the Extremely Dense Breast—Cancer
Chapter 3
Video 3-1A: Systematic Search to Find Calcifications
on Tomosynthesis, Standard View
Video 3-1B: Systematic Search to Find
Calcifications on Tomosynthesis,
Magnified View
Video 3-2: Skin Calcifications on Tomosynthesis
Video 3-3: Noncalcified Vessels Leading to
Calcified Vessels on Magnified
Tomosynthesis
Chapter 4
Video 4-1: Tomosynthesis for Evaluating Masses,
Mediolateral Oblique Projection
Video 4-2: Tomosynthesis showing
Circumscribed Mass in Dense Breast
Tissue
Video 4-3A: Spiculated Mass on Tomosynthesis,
Original View
Video 4-3B: Spiculated Mass on Tomosynthesis,
Magnified View
Video 4-4A: Tomosynthesis Showing Spiculated
Mass in the Outer Left Breast,
Original View
Video 4-4B: Tomosynthesis Showing Spiculated
Mass in the Outer Left Breast,
Magnified View
Video 4-5A: Tomosynthesis Showing Summation
Artifact, Original View
Video 4-5B: Tomosynthesis Showing Summation
Artifact, Magnified View
Video 4-6A: Asymmetry: Summation Artifact on
Tomosynthesis, Original View
Video 4-6B: Asymmetry: Summation Artifact on
Tomosynthesis, Magnified View
Video 4-6C: Asymmetry: Summation Artifact on
Spot Compressed Tomosynthesis,
Original View
Video 4-6D: Asymmetry: Summation Artifact on
Spot Compressed Tomosynthesis,
Magnified View
Video 4-7A: Focal Asymmetry/Mass: Atypical
Ductal Hyperplasia on Spot
Compressed Tomosynthesis,
Original View
Video 4-7B: Focal Asymmetry/Mass: Atypical
Ductal Hyperplasia on Spot
Compressed Tomosynthesis,
Magnified View
xi
xii Video Contents
Video 4-8: Architectural Distortion: Radial Scar
on Tomosynthesis
Video 4-9A: Associated Feature: Nipple Retraction
on Tomosynthesis, Original View
Video 4-9B: Associated Feature: Nipple
Retraction on Tomosynthesis,
Magnified View
Video 4-10A: Spiculated Mass: Invasive Ductal
Carcinoma on Tomosynthesis,
Original View
Video 4-10B: Spiculated Mass: Invasive Ductal
Carcinoma on Tomosynthesis,
Magnified View
Video 4-11A: Spiculated Mass: Postbiopsy Scar on
Tomosynthesis, Original View
Video 4-11B: Spiculated Mass: Postbiopsy Scar on
Tomosynthesis, Magnified View
Video 4-12A: Spiculated Mass: Radial Scar on Spot
Compressed Tomosynthesis,
Original View
Video 4-12B: Spiculated Mass: Radial Scar on
Spot Compressed Tomosynthesis,
Magnified View
Chapter 6
Video 6-1: Vacuum-Assisted Ultrasound Biopsy
Video 6-2: Tomosynthesis-Guided Needle
Localization
Video 6-3: Tomosynthesis for the Evaluation of
Specimen
Chapter 9
Video 9-1: Silicone-Specific Magnetic Resonance
Images of Intact Silicone Implants—
Radial Fold
Video 9-2: Silicone-Specific Magnetic Resonance
Images of Intracapsular and
Extracapsular Rupture
Video 9-3: Silicone-Specific Magnetic Resonance
Images of Direct Silicone Injections
Video 9-4: Tomosynthesis of Direct Paraffin
Injections
Video 9-5: Mediolateral Oblique Tomosynthesis
of Breast after Reduction Mammoplasty
Video 9-6: Tomosynthesis Showing Skin
Calcifications around Replaced Nipple
after Reduction Mammoplasty
Chapter 1
Mammography Acquisition
Screen-Film, Digital Mammography and Tomosynthesis,
the Mammography Quality Standards Act, and
Computer-Aided Detection
R. Edward Hendrick, Debra M. Ikeda, and Kanae K. Miyake
CHAPTER OUTLINE
TECHNICAL ASPECTS OF MAMMOGRAPHY IMAGE
ACQUISITION
Screen-Film Mammography Image Acquisition
Digital Mammography Image Acquisition
Tomosynthesis Acquisition
Views and Positioning
Image Labeling in Mammography
IMAGE EVALUATION AND ARTIFACTS
QUALITY ASSURANCE IN MAMMOGRAPHY AND THE
MAMMOGRAPHY QUALITY STANDARDS ACT
Mammography is one of the most technically challenging areas
of radiography, requiring high spatial resolution, excellent soft-­
tissue contrast, and low radiation dose. It is particularly challeng-
ing in denser breasts because of the similar attenuation coeffi-
cients of breast cancers and fibroglandular tissues. The Digital
Mammographic Imaging Study Trial (DMIST) and other recent
studies have shown that digital mammography offers improved
cancer detection compared with screen-film mammography
(SFM) in women with dense breasts (Pisano et al., 2005b). As of
March 2015, 96% of the mammography units in the United States
are digital units, and some sites are using digital breast tomosyn-
thesis (DBT) systems for screening and diagnostic mammogra-
phy. Computer-aided detection (CAD) systems specific to mam-
mography are also in common use.
Randomized controlled trials (RCTs) of women invited to
mammography screening conducted between 1963 and 2000
based on SFM have shown that early detection and treatment of
breast cancer have reduced the proportion of late-stage breast
cancers and led to a 20% to 30% decrease in breast cancer mor-
tality among these women. More recent observational studies of
screening programs in Europe have shown that screening mam-
mography reduces breast cancer mortality by 38% to 48% among
women screened compared with unscreened women (Broed-
ers et al., 2012). A similar observational study in Canada showed
breast cancer mortality reduced by 44% among screened women
aged 40 to 49, 40% in screened women aged 50 to 59, 42% in
screened women aged 60 to 69, and 35% in screened women
aged 70 to 79 compared with unscreened women (Coldman
et al., 2007). The different mammography screening recommen-
dations of several major organizations are shown in Box 1.1 (Lee
et al., 2010; Oeffinger et al., 2015; Siu, 2016).
In all of these studies, image quality was demonstrated to
be a critical component of early detection of breast cancer.
Screen-Film Mammography Quality Control
Full-Field Digital Mammography Quality Assurance and
Quality Control
Digital Breast Tomosynthesis Quality Assurance and Quality
Control
COMPUTER-AIDED DETECTION
CONCLUSION
KEY ELEMENTS
SUGGESTED READINGS
To standardize and improve the quality of mammography, in
1987 the American College of Radiology (ACR) started a vol-
untary ACR Mammography Accreditation Program. In 1992,
the U.S. Congress passed the Mammography Quality Standards
Act (MQSA; P.L. 102-539), which went into effect in 1994 and
remains in effect with reauthorizations in 1998, 2004, and
2007. The MQSA mandates requirements for facilities perform-
ing mammography, including equipment and quality assur-
ance requirements, as well as personnel qualifications for
physicians, radiologic technologists, and medical physicists
involved in the performance of mammography in the United
States (Box 1.2).
This chapter outlines the basics of image acquisition using
SFM, digital mammography, and DBT. It reviews the quality assur-
ance requirements for mammography stipulated by the MQSA
and also describes the essentials of CAD in mammography.
BOX 1.1 Mammography Screening
Recommendations for Normal Risk Women from
Several Major Organizations
American College of Radiology and Society of Breast Imaging:
Annual screening starting at age 40 and continuing until a
woman’s life expectancy is less than 5-7 years
American Cancer Society: Annual screening ages 45-54, then bi-
ennial screening until a woman’s life expectancy is less than
10 years, with the option to begin annual screening at age 40
and to continue annual screening beyond age 54.
United States Preventive Services Task Force: Biennial screening
ages 50-74.
  
1
2 Chapter 1 Mammography Acquisition
BOX 1.2 Mammography Quality Standards Act of
1992
Congressional act to regulate mammography
Regulations enforced by the Food and Drug Administration (FDA)
require yearly inspections of all U.S. mammography facilities
All mammography centers must comply; noncompliance results
in corrective action or closure
Falsifying information submitted to the FDA can result in fines and
jail terms
Regulations regarding equipment, personnel credentialing and
continuing education, quality control, quality assurance, and
day-to-day operations
TECHNICAL ASPECTS OF MAMMOGRAPHY
IMAGE ACQUISITION
Mammography is performed on specially designed, dedicated
x-ray machines using either x-ray film and paired fluorescent
screens (SFM) or digital detectors to capture the image. All mam-
mography units are comprised of a rotating anode x-ray tube
with matched filtration for soft-tissue imaging, a breast compres-
sion plate, a moving grid, an x-ray image receptor, and an auto-
matic exposure control (AEC) device that can be placed under
or detect the densest portion of the breast, all mounted on a
rotating C-arm (Fig. 1.1). A technologist compresses the patient’s
breast between the image receptor and compression plate for a
few seconds during each exposure. Breast compression is impor-
tant because it spreads normal fibroglandular tissues so that can-
cers can be better seen on the superimposed structured noise
pattern of normal breast tissues. It also decreases breast thick-
ness, decreasing exposure time, radiation dose to the breast, and
the potential for image blurring as a result of patient motion and
unsharpness.
Women worry about breast pain from breast compression and
about the radiation dose from mammography. Breast pain during
compression varies among individuals and may be decreased by
obtaining mammograms 7 to 10 days after the onset of menses
when the breasts are least painful. Breast pain is also minimized
by taking oral analgesics, such as acetaminophen, before the
mammogram or by using appropriately designed foam pads that
cushion the breast without adversely affecting image quality or
increasing breast dose.
Current mammography delivers a low dose of radiation to the
breast. The most radiosensitive breast tissues are the epithelial
cells, which, along with connective tissues, make up fibroglandu-
lar elements. The best measure of breast dose is mean glandular
dose, or the average absorbed dose of ionizing radiation to the
radiosensitive fibroglandular tissues. The mean glandular dose
received by the average woman is approximately 2 mGy (0.2 rad)
per exposure or 4 mGy (0.4 rad) for a typical two-view examina-
tion. Radiation doses from digital mammography exposures tend
to be 20% to 30% lower than those from SFM. Radiation doses to
thinner compressed breasts are substantially lower than doses to
thicker breasts.
The main patient risk from mammographic radiation is the
possible induction of breast cancer 5 to 30 years after exposure.
The estimated risk of inducing breast cancer is linearly pro-
portional to the radiation dose and inversely related to age at
exposure. The lifetime risk of inducing a fatal breast cancer as a
result of two-view mammography in women aged 45 years old at
exposure is estimated to be about 1 in 100,000 (Hendrick, 2010).
For a woman aged 65 at exposure, the risk is less than 0.3 in
100,000.The benefit of screening mammography is the detection
of breast cancer before it is clinically apparent. The likelihood
of an invasive or in situ cancer present in a woman screened at
Radiation
X-ray tube
shield
Collimator
Field limiting cone Control panel
Remote hand
Compression paddle switch
Bucky (moving grid)
and digital detector or
film cassette holder
C-arm
C-arm
Foot pedals foot pedal
FIG. 1.1 Components of an x-ray mammography unit.
BOX 1.3 Mammography Generators
Provide 24–32 kVp, 5–300 mA
Half-value layer between kVp/100 + 0.03 and kVp/100 + 0.12 (in
millimeters of aluminum) for Mo/Mo anode/filter material
Average breast exposure is 26–28 kVp (lower kVp for thinner or
fattier breasts, higher kVp for thicker or denser breasts)
Screen-film systems deliver an average absorbed dose to the glan-
dular tissue of the breast of 2 mGy (0.2 rad) per exposure
  
Mo, molybdenum.
age 45 is about 1 in 500.The likelihood that the cancer would be
fatal in the absence of mammography screening is about 1 in 4,
and the likelihood that screening mammography will convey a
mortality benefit is 15% (RCT estimate for women aged 40–49) to
about 45% (observational study estimate). Hence, the likelihood
of screening mammography saving a woman’s life at this age is
about 1 in 4400 to 1 in 13,000, yielding a benefit-to-risk ratio of
8:1 to 23:1. For a woman aged 65 at screening, the likelihood
of a mortality benefit from mammography is about 1 in 2000 to
1 in 4000 (assuming a 25% to 50% mortality benefit), yielding
a benefit-to-risk ratio of approximately 90:1 to 180:1. Screening
mammography is only effective when regular periodic exams are
performed.
The generator for a mammography system provides power
to the x-ray tube. The peak kilovoltage (kVp) of mammogra-
phy systems is lower than that of conventional x-ray systems,
because it is desirable to use softer x-ray beams to increase both
soft-tissue contrast and the absorption of x-rays in the image
receptor. Low kVp is especially important for SFM, in which
screen phosphor thickness is limited to minimize image blur.
Typical kVp values for mammography are 24 to 32 kVp for
molybdenum (Mo) targets and 26 to 35 kVp for rhodium (Rh)
or tungsten (W) targets. A key feature of mammography genera-
tors is the electron beam current (milliampere [mA]) rating of
the system. The higher the mA rating, the shorter is the expo-
sure time for total tube output (milliampere second [mAs]). A
compressed breast of average thickness (5 cm) requires about
150 mAs at 26 kVp to achieve proper film densities in SFM. If
the tube rating is 100 mA (typical of the larger focal spots used
for nonmagnification mammography), the exposure time would
be 1.5 seconds. A higher output system with 150-mA output
would cut the exposure time to 1 second for the same com-
pressed breast thickness and kVp setting. Because of the wide
range of breast thicknesses, exposures require mAs values rang-
ing from 10 to several hundred mAs. Specifications for genera-
tors are listed in Box 1.3.

BOX 1.4 Anode-Filter Combinations for
Mammography
Mo/Mo
Mo/Rh
Rh/Rh
W/Rh, W/Ag, or W/Al
  
Ag, silver; Al, aluminum; Mo, molybdenum; Rh, rhodium; W, tungsten.
The most commonly used anode/filter combination is Mo/Mo
consisting of an Mo anode (or target) and an Mo filter (25–30 μm
thick).This is used for thinner compressed breasts (<5 cm thick).
Most current manufacturers also offer an Rh filter to be used with
the Mo target (Mo/Rh), which produces a slightly more penetrat-
ing (harder) x-ray beam for use with thicker breasts. Some manu-
facturers offer other target materials, such as Rh/Rh, which is an
Rh target paired with an Rh filter, and a W target paired with a
Rh filter (W/Rh or with an aluminum [Al] filter [W/Al]). These
alternative anode/filter combinations are designed for thicker
(>5 cm) and denser breasts. Typically, higher kVp settings are
used with these alternative target/filter combinations to create
a harder x-ray beam for thicker breasts, because fewer x-rays are
attenuated with a harder x-ray beam (Box 1.4). One of the best
parameters to measure the hardness or penetrating capability of
an x-ray beam is the half-value layer (HVL), which represents the
thickness of Al that reduces the x-ray exposure by one-half. The
harder the x-ray beam, the higher is the HVL. The typical HVL
for mammography is 0.3 to 0.5 mm of Al. The Food and Drug
Administration (FDA) requires that the HVL for mammography
cannot be less than kVp/100 ± 0.03 (in millimeters of Al), so that
the x-ray beam is not too soft (ie, does not contain too many low-
energy x-rays that contribute to breast radiation dose but not to
image contrast because they are all absorbed in breast tissue).
For example, at 28 kVp the HVL cannot be less than 0.31 mm of
Al. There is also an upper limit on the HVL that depends on the
target–filter combination. For Mo/Mo, the HVL must be less than
kVp/100 +0.12 (in mm of Al); thus, for 28 kVp, the HVL must be
less than 0.4 mm of Al.
The usual mammography focal spot size for standard contact
(ie, nonmagnification) mammography is typically 0.3 mm. Mag-
nification mammography requires a smaller focal spot, (about
0.1 mm) to reduce penumbra (geometric blurring of structures
in the breast produced because the breast is closer to the x-ray
source and farther from the image receptor to produce greater
“geometric” magnification). The effect of focal spot size on reso-
lution in the breast is tested by placing a line pair (lp) pattern
in the location of the breast at a specific distance (4.5 cm) from
the breast support surface. For SFM, the larger 0.3-mm mam-
mography focal spot used for standard, contact mammography
should produce an image that resolves at least 11 lp/mm when
the lines of the test pattern run in the direction perpendicular
to the length of the focal spot (this measures the blurring effect
of the length of the focal spot) and at least 13 lp/mm when
the lines run parallel to the focal spot (measuring the blurring
effect of the width of the focal spot). Thus, although the SFM
image receptor can resolve 18 to 21 lp/mm, the geometry of
the breast in contact mammography and the finite-sized larger
focal spot reduce the limiting spatial resolution of the system to
11 to 15 lp/mm in the breast. The limiting spatial resolution of
digital mammography systems is less (5–10 lp/mm), caused by
pixelization of the image by the digital image receptor. In digital,
a line is 1 pixel width, and a line pair is 2 pixels. For example, for
a digital detector with 100-micron (0.1-mm) pixel size or pitch
(the center-to-center distance between adjacent pixels), a line
pair consists of 2 pixels or 200 microns (0.2 mm).Therefore, one
can fit five line pairs (at 0.2 mm each) into a 1-mm length, or the
Chapter 1 Mammography Acquisition 3
detector has a limiting spatial resolution of 5 lp/mm. By similar
reasoning, a digital detector with 50-micron pixels has a limiting
spatial resolution of 10 lp/mm.
The x-ray tube and image receptor are mounted on opposite
ends of a rotating C-arm to obtain mammograms in almost any
projection.The source-to-image receptor distance (SID) for mam-
mography units must be at least 55 cm for contact mammogra-
phy. Most systems have SIDs of 65 to 70 cm.
Geometric magnification is achieved by moving the breast
farther from the image receptor (closer to the x-ray tube) and
switching to a small focal spot, about 0.1 mm in size (Fig. 1.2).
Placing the breast halfway between the focal spot and the
image receptor (see Fig. 1.2B) would magnify the breast by a
factor of 2.0 from its actual size to the image size because of
the divergence of the x-ray beam.The MQSA requires that mam-
mography units with magnification capabilities must provide
at least one fixed magnification factor of between 1.4 and 2.0
(Table 1.1). Geometric magnification makes small, high-contrast
structures such as microcalcifications more visible by making
them larger relative to the noise pattern in the image (increas-
ing their signal-to-noise ratio [SNR]). Optically or electronically
magnifying a contact image, as is done with a magnifier on SFM
or using a zoom factor greater than 1 on a digital mammogram,
does not increase the SNR of the object relative to the back-
ground, because both object and background are increased in
size equally. To avoid excess blurring of the image with geo-
metric magnification, it is important to use a sufficiently small
focal spot (usually 0.1 mm nominal size) and not too large a
magnification factor (2.0 or less). When the small focal spot is
selected for geometric magnification, the x-ray tube output is
decreased by a factor of 3 to 4 (to 25–40 mA) compared with
that from a large focal spot (80–150 mA).This can extend imag-
ing times for magnification mammography, even though the
grid is removed in magnification mammography. The air gap
between the breast and image receptor provides adequate scat-
ter rejection in magnification mammography without the use
of an antiscatter grid.
Collimators near the x-ray tube control the size and shape of
the x-ray beam to decrease patient exposure to tissues beyond
the compressed breast and image receptor. In mammography,
the x-ray beam is collimated to a rectangular field to match the
image receptor rather than the breast contour, because x-rays
striking the image receptor outside the breast do not contrib-
ute to breast dose. By federal regulation, the x-ray field cannot
extend beyond the chest wall of the image receptor by more
than 2% of the SID.Thus for a 60-cm SID unit, the x-ray beam can
extend beyond the chest wall edge of the image receptor by no
more than 1.2 cm.
The compression plate and image receptor assembly hold the
breast motionless during the exposure, decreasing the breast
thickness and providing tight compression, better separating
fibroglandular tissues in the breast (Fig. 1.3). The compression
plate has a posterior lip that is more than 3 cm high and usually
is oriented at 90 degrees to the plane of the compression plate
at the chest wall.This lip keeps chest wall structures from super-
imposing and obscuring posterior breast tissue in the image.The
compression plate must be able to compress the breast for up
to 1 minute with a compression force of 25 to 45 lb. The com-
pression plate can be advanced by a foot-controlled motorized
device and adjusted more finely with hand controls. Because
the radiation dose to the breast is decreased in thinner breasts,
breast compression, which thins the breast, also decreases radia-
tion dose.
Screen-Film Mammography Image Acquisition
In SFM, the image receptor assembly holds a screen-film cassette
in a carbon-fiber support with a moving antiscatter grid in front
of the cassette and an AEC detector behind it (see Fig. 1.3A).
4 Chapter 1 Mammography Acquisition

Magnification
stand

A B

C D
FIG. 1.2 Magnification mammography improves resolution. Nonmagnified, or contact, mammography (A) and
geometrically magnified mammography (B). Using a small or microfocal (0.1-mm) focal spot with the configura-
tion shown in (B), higher spatial resolution can be obtained in the breast compared with (A) in which a larger
(0.3-mm) focal spot is used. (C) Craniocaudal mammogram shows a possible benign mass in the inner breast.
(D) Microfocal magnification shows irregular borders not seen on the standard view.

TABLE 1.1 Mammography Focal Spot Sizes and Source-
to-Image Distances
Mammography Nominal Focal Source-to-Image
Type Spot Size (mm) Distance (cm)
Contact film screen 0.3 ≥55
Magnification 0.1 ≥55
The Mammography Quality Standards Act requires magnification factors between
1.4 and 2.0 for systems designed to perform magnification mammography.
Screen-film image receptors are required to be 18 × 24 cm and
24 × 30 cm in size to accommodate both smaller and larger
breasts (Box 1.5). Each size image receptor must have a mov-
ing antiscatter grid composed of lead strips with a grid ratio
(defined as the ratio of the lead strip height to the distance
between strips) between 3.5:1 and 5:1. The reciprocating grid
moves back and forth in the direction perpendicular to the grid
lines during the radiographic exposure to eliminate grid lines
in the image by blurring them out. One manufacturer uses a
hexagonal-shaped grid pattern to improve scatter rejection; this
grid is also blurred by reciprocation during exposure. Use of
a grid improves image contrast by decreasing the fraction of
scattered radiation reaching the image receptor. Grids increase
the required exposure to the breast by approximately a factor
of 2 (the Bucky factor), because of the attenuation of primary,
as well as scattered, radiation. Grids are not used with magnifi-
cation mammography. Instead, in magnification mammography,
scatter is reduced by collimation and by rejection of scattered
x-rays due to a significant air gap between the breast and image
receptor.
The AEC system, also known as the phototimer, is calibrated
to produce a consistent film optical density (OD) by sampling
the x-ray beam after it has passed through the breast support,
grid, and cassette. The AEC detector is usually a D-shaped sen-
sor that lies along the midline of the breast support and can
be positioned by the technologist closer to or farther from the
chest wall. If the breast is extremely thick or inappropriate
technique factors are selected, the AEC will terminate exposure
at a specific backup time (usually 4–6 seconds or 300–750 mAs)
to prevent tube overload or melting of the x-ray track on the
anode.
Screen-film cassettes used in mammography have an inherent
spatial resolution of 18 to 21 lp/mm. Such resolution is achieved
typically by using a single-emulsion film placed emulsion side
 Chapter 1 Mammography Acquisition 5

Compression Compression
paddle paddle

Posterior Posterior
Carbon-fiber surface Carbon-fiber surface
lip 3 cm lip 3 cm
of image receptor of image receptor
support support

90 degrees Grid 90 degrees Grid

Cassette Detector
panel

AEC Screen Film

A detector B
FIG. 1.3 Schematic of a compression paddle and image receptor of screen-film mammography (A) and of digital
mammography (B), showing the components of the cassette holder, the compression plate, and the breast. The
film emulsion faces the screen. AEC, automatic exposure control. (Adapted from Farria DM, Kimme-Smith C,
Bassett LW: Equipment, processing, and image receptor. In Bassett LW, editor: Diagnosis of diseases of the breast,
Philadelphia, 1997, WB Saunders, pp 32 and 34.)

TABLE 1.2 Variables Affecting Image Quality of Screen-

BOX 1.5 Compression Plate and Imaging Receptor
Both 18 × 24-cm and 24 × 30-cm sizes are required
A moving grid is required for each image receptor size
The compression plate has a posterior lip >3 cm and is oriented 90
degrees to the plane of the plate
Compression force of 25–45 lb
Paddle advanced by a foot motor with hand-compression
adjustments
Collimation to the image receptor and not the breast contour
down against a single intensifying screen that faces upward
toward the breast in the film cassette. The single-emulsion film
with a single intensifying screen is used to prevent the paral-
lax unsharpness and crossover exposure that occur with double-
emulsion films and double-screen systems. One manufacturer has
introduced a double-emulsion film with double-sided screens
(EV System, Carestream Health, formerly Eastman Kodak Health
Group) with a thinner film emulsion and screen on top to mini-
mize parallax unsharpness. Most screen-film processing combi-
nations have relative speeds of 150 to 200, with speed defined
as the reciprocal of the x-ray exposure (in units of Roentgen)
required to produce an OD of 1.0 above base plus fog (1.15–1.2,
because base plus fog OD is 0.15–0.2).
Film processing involves development of the latent image
on the exposed film emulsion. The film is placed in an auto-
matic processor that takes the exposed film and rolls it
through liquid developer to amplify the latent image on the
film, reducing the silver ions in the x-ray film emulsion to
metallic silver, resulting in film darkening in exposed areas.
The developer temperature ranges from 92°F to 96°F. The film
is then run through a fixer solution containing thiosulfate (or
hypo) to remove any unused silver and preserve the film. The
film is then washed with water to remove residual fixer, which
if not removed can cause the film to turn brown over time.The
film is then dried with heated air.
Film processing is affected by many variables, and the most
important is developer chemistry (weak or oxidized chemistry
makes films lighter and lower contrast), developer temperature
(too hot may make films darker, and too cool may make films
lighter), developer replenishment (too little results in lighter,
Film Mammograms
Film too dark Developer temperature too high
Wrong mammographic technique
(excessive kVp or mAs)
Excessive plus-density control
Film too light Inadequate chemistry or replenishment
Developer temperature too low
Wrong mammographic technique
Lost contrast Inadequate chemistry or replenishment
Water to processor turned off
Changed film
Film turns brown Inadequate rinsing of fixer
Motion artifact Movement by patient
Inadequate compression applied
Inappropriate mammographic technique
(long exposure times)
lower contrast films), inadequate agitation of developer, and
uneven application of developer to films (causing film mottling;
Table 1.2).
Film viewing conditions must be appropriate (Fig. 1.4).
Because mammography viewboxes have high luminance levels
(>3000 cd/m2 [3000 nit]), mammograms should be masked so
that no light strikes the radiologist’s eye without passing through
the exposed film. Because of high luminance levels film collima-
tion of x-ray exposure should be rectangular and extend slightly
beyond the edge of the image receptor so that film is darkened
to its edges. Viewbox luminance should be reasonably uniform
across all viewbox panels. In addition, the ambient room illumi-
nation should be low (<50 lux, and preferably less) to minimize
“dazzle glare” from film surfaces. Both viewbox luminance and
room illumination should be checked annually by the medical
physicist as part of the site quality control program, as specified
in the ACR Mammography Quality Control Manual.
Digital Mammography Image Acquisition
In digital mammography, the image is obtained in the same
manner as in screen-film mammography, using a compression
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[172]

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In elken hoek werd gezopen, geschreeuwd en

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overschreeuwend.

—Nou ik sel d’r doodvalle.… ik bin d’r op ’t land lieferst

veur.… tien gulde boas.… aa’s veur vàiftien knecht.…

—Nou, ik wil d’r groag.. wa’ binne wai d’r veur

boase?.. je kè je land nie beskaite.… fesoenlik!.… je
sit d’r in d’r aifigheit in smorende sorg.… je loop de
rissieko.… van dit.… en van dat.… en aa’s ’t
November is.… mô je je pachte betoale.… hai je d’r
gain de half van!.… mô je laine.. en borge beklomppe
en ’s winters.. hai je nood.… nood maa’n! nie te
fraite.… En hullie.… de vraigeselle-daggelders.…
hullie hebbe d’r kossie binne.. hullie hebbe d’r nooit
nie-en-sorg!.. hullie fraite.… en snurke.… aa’s wai d’r
onster blind sitte te telle veur sinte.… veur de pacht.…
veur hooi in je poar beeste.. de raise, en.… je soad.…
je hout.. je mest.. En t’met f’rdiene wai minder aa’s
hullie.

—Nainet daa’s dondere!.… moar je bint dur tùg alletait

[174]je aige hair en maister.—Aa’s je d’r knecht bin.…
mó’ je feurt.… aa’s ’t hard stikke raigent.. en je wil
skeule.… d’r uit.… ho! wacht erais effetjes!.… segt de
boas.… werrek aers ka’ je spuite! aa’s je d’r is vaif
menute te langer skoffie houdt.. d’ruit sait de baos! je
 ken d’r je aige nie-en-roere!.. je heb van ochend tut
nacht te werke.… en nie òm te kaike.. fort.. fort.…
nainet, loate sullie d’r moar ’n poar sinte meer hebbe
aa’s wai.… je heb d’r tug je aige mikke.… je hep je
aige lappie grond.… je bin d’r je aige boas.… je hep
d’r ’n aige groentetje.… je kèn d’r boofe òp! je kèn d’r
nog boàs blàife.…

—Ik ruil d’r doalik.… doalik! schreeuwde ’n ander.…

se kenne main lappie-en-kraige … aa’s ik d’r moar ’n
beetje fesoenelike dagwerk hep.. van de honderd
knechte f’rdiene d’r naigtig meer.… aa’s d’rlie aige
boasies.… en de loodpot!.. doar komp d’r alles op
neer, hee?

—Nou betoal jai d’r.… naige, tut tien gulde ’t roe hee?
veur je kwoàje grond.… en tug is d’r veul te wàinig
hee? hoe sit da’? daa’s tug ’n meroakel hee?.… je
weut ’t hee?.… dure mest.… g’koope groente!.…
daa’s alletait sòò.… en ikke twoalf vaiftig ’t roe.…
daa’s bestig hoor!.. en nou, di joar is ’t bai main net
mis.… Ikke seg d’r moar, ’n vroege somer.… ’n goeie
somer hee?

—Moar jai roaskalt.… jai springt d’r van de hak op de

tak.. ’n vroufemond goan de waoreld rond! wel of gain
grond.… ikke bin d’r liefert knecht.. aa’s soo’n
òngelukkig suinig boasie aa’s wai d’r binne.… wai
f’rdiene minder aa’s hullie.… te veul om te sterrefe.…
te wainig om te laife.… En veul meerer sorg.. en wài
binne d’r pachters!.. nou hai je allain fraihaid.. da je
of’r je aige te segge hep.. Daa’s ’m d’r ’n veurdeel!..
nou sel d’r gain besemsteel je bekolle.… en je
 segge.… je mò’ werrekke.… hee?.. je mag d’r nou
heùlegoar uit je àige krepeere! kom ’t is d’r aldegoar ’n
klus.… hier!.… Bi-jai ’t Hain!.. kom boòfe!

Zang, overstemde ’t spreekgeschreeuw van bank naar

bank.

’n Drom kerels trampelde en lolde schorrig als

bezetenen, in [175]rood-groenen rookwoel, beklonken
en rinkelden hun glaasjes.—Dirk was met z’n stelletje
makkers naar dek geklauterd, had z’n kisten
ingehaald, en in woesten sjouw weer bak en mand,
leeg en licht, in stapels, op dek neergesmakt.
Aardbeigloei was weg. Leege duffe mandjes en kisten
stonden omslierd nog van stronken groen en verlepte
bladeren.—Dekknechten en venters sjouwden weer
op, pàf van ploeter, in moordende stofwalm van
zonnebrand, die òpsloeg uit keien en boot.—

—Nou he’k tug nog gain hap daan van f’rmurge eerste
skoft hee? klaagde ’n klein tuindertje, gebarend met
handen, hoofd en schouders tegelijk.

—Wa sou ’t.… jai suipt d’r veur fraite en drinke g’laik,
geep! snauwde ’n meidventster, gauw weghollend om
kisten op te pakken naar achterdek, waar ze haar
naam hoorde schreeuwen in alarm-krijsch.

Al meer venters keerden terug van hun zwerftocht

door groote stad, half-dronken, luidrùchtig ondanks
hun radbraking, of slap in elkaar gezakt, de heele reis
làng zacht-rammelend met geld in d’r zak, waar
zweethand op rustte, de wacht hield.
 De karverhuurder, gewikste Amsterdammer, sloeg
handig tusschen de kerels in, liet hen betalen, onder
lolletjesstoei dòòr, pret waarnaar ze luisterden,
kinderlijk, dronken-naief gierenden goedig, met
huilerige schaters, de oogen nattig, in vaag bewustzijn
verzwommen.

Aan walkant bralden en drongen weer meiden en

joodjes, wachtend op laten aanvoer, geschrikt en
ontnuchterd plots als ze gèèn dronken tuinder
tegenover zich kregen. Tegen half vijf kwam kleine
sloep met nieuwe aardbeibakken aanstoomen, en in
halfdronken strompeling, stovende hette, woelden de
moeë kerels weer tusschen hun kisten in, omdrongen
van koopers, groentekarlui en schorremorrie,
afzetters, gappende en smokkelende ventertjes, die
loerden op afval en verwarring van bezopen boeren.—
Er kraterde weer gevloek los, geprijs en gesjacher.
Weer toeterden en raasden de kerels met verkeerde
bakken, en de nog niet beschonken tuinders, met
klaren hartstocht voor verkoop, scherpten en
snauwden, elleboogden ruw [176]door de òmdringers
heen, in felle taal, om hun dronkeloozen kop te
toonen.—

Laatste stuiptrek van sjouw en ploeter, krampte weer

plots òp, in den snikkenden hittemiddag aan ’t dok, die
stoffig doorzond er geschroeid kookte van licht, en
uitsneed z’n strak-blauwe walmende schaduws op de
keien. De half dronkenen waggelden weer èven
vernuchterd, overeind. Duizenden in drang, driftigden
daar bijéén, in woeling en sjacher, voelend bij instinkt
 dat ’t de laatste aanvoer zijn zou van ’t jaar, aanvoer
zòò hevig, zòò vol en overvloedig.—

—De hoogste praiser hep ’m doalik, schreeuwde Dirk,

in gul-dronken bui, kregel dat ie niet lekker-broeis, stil
en zuipend in de kajuit kon blijven zitten met z’n borrel
en z’n pijp.—

F’rdomme.… die Ouë.… nou hai hier in de smoorkook

die naimt’ d’r van.… Nou.. wie mot d’r?—

’t Werd ’n jacht, ’n roes, ’n duizelende storm op de

beschonken groenboeren, die waggelden in slappen
beenstand, en lolden tegen de wijven.—De meiden
glommen en vleiden weer, met geile mondjes en lok-
lachjes, in glunderige zoete kijkerijtjes. Ze werkten
weer met bloote halzen, blank rokkespul en smijig
geplooi en gekreuk van d’r jakkies om borsten, d’r
spanrokken om dijen.—Flik-zoete lintjes prikten weer
òp en de blanke wellustkoppen gierden, en de handen
friemelden weer.—

Als ’t niet ging met zoetig gestreel en weeïg gezanik,

braakten ze plots uit ’n heeter stroom van
smerigheidjes, met satanisch gevoel, in den laatsten
sjacher, daarmee de kerels te overbluffen, te prikkelen
en te verhitten. Veel venters, bek-àf, stemden toe in
prijs, lam en gebroken van sjouw. Anderen, taaier en
nuchter nog, hielden vol, begrepen hun eigen kansen,
spotten en hoonden, braakten vuil terug uit, weerden
de flikflooierijtjes en zoetigen wellusthuiver af, in
bijtende woede. Onder gevloek en geraas gaf
schorremorrie zich over, omdat ze de waar hebben
moèsten, en kalm sarrend hielden de nuchteren hand
òp, trechtervormig ingediept, om het zweet-plakkerige
geld te ontvangen, vast te zuigen, in d’r zwaar-
bronzen klepzakken van stinkende broek.—Een half
beschonken stoetje kerels, [177]half al geënterd en
vastgenageld in kringetje van brutaal-bijéén gedromd
klusje meiden, kreeg plots besef dat ze door bij elkaar
hoorende koopers, betoeterd werden. Woest
grabbelden de venters terug, rukten hun bakken weer
in de karren, schreeuwden en vloekten als razenden
tegen de beduusde wijven en handlangers, die op
geen verzet meer gerekend hadden. Nu tierden en
krijschten de áángeschoten boeren lànger dan de
nùchtere, bleven taaier hangen aan hoogsten prijs.—
Plots, ’n paar zwaar-beschonkenen, uit de verkoop-
groep, verlekkerd op loktaal van meiden, dwongen ’n
geel-harige Zeedijkster, vijftig mandjes voor niets mee
te nemen. Om ’r heen kletste afgunst van andere
wijven, die ’r verdrongen en aanstootten uit nijd dat ze
dat niet doen kòn voor de politie. Maar de venters,
dreigden de geelharige op ’r bek te ranselen, aa’s se
nie toègreep!

Overal klonk dronken, herrieïg en halsstarrig gewawel,

verbijsterend uitgesponnen gezeur, vast hakend
gestrubbel en gestrij, tusschen de nuchtere koopers,
en lachschreiende half-bezopen venters.—

Hitte braadde, priemde de koppen, de wangen, de

nekken en drankstank walmde hun heete kelen uit. Te
blazen van puf-benauwing, te schelden, vloeken en
bonkeren met de morsige knuisten op de bakken,
stonden ze, lawaaiend tusschen ratel en wegroffeling
van karren, op dreun van gloei-dampende keien. Een
 aangeschoten groenboer was ingekneld tusschen ’n
groepje joodsche vrouwtjes, met lepra-kopjes, gelig,
vol huidbarsten, en groot-zwarte kijkers, àllen met
zondig besef van hun sabbath-ontheiliging op d’r
vergroefde zorgelijke gezichtjes, die klein onder
kleurige mutsjes uitpuntten.—Niet los te woelen wist
de lange tuinder zich uit den taai energischen babbel
en sjàcher der kleine wijfjes, allemaal ’t zelfde
gekleed, donker omsjaald, sprekend op elkaar lijkend,
met lintkleurige mutjes op d’r glad-gekamde toertjes.
En waar hij schoof z’n bewegelijk, zacht-waggelend
lijf, schoof koop-heet kringetje van joden-vrouwtjes
nauwsluitender mèè. Onder getier en geloei van
stemmen, krijscherig en valsch, werkten ze ’m één
voor één de waar uit z’n handen, goedkoop, héél
goedkoop.… [178]

Plots kwam nuchter strenge kapitein,—die nooit iets

anders dronk den heelen snik-heeten dag door, dan
koffie,—zeggen dat ’t tijd was om op stap te gaan. In
jagender tempo nu dromden de prijzers òp, gingen
vloekender schokken door koopers en venters. Na ’n
half uur was alles leeg, stond de wal schoongeveegd
van sjouwers en sjacheraars, kruiers, wijven, meiden,
karren en kisten.

In woesten smak laadden de kerels hun bakken weer

de boot òp, en dadelijk, nà droeven sein-zang van pijp
in den blakerheeten middag, draaide de kaptein
havenwoel van groote stad uit, ’t dampige,
oversmookte, violet-grauw van hemel, en gloei-
kleuren verspoelende IJwater, instevenend.
 [Inhoud]

V.

Aan de Wierelandsche haven wachtten meisjes en

jongens met karren, klaar om bakken en manden op
te vangen van vader en broers.—

Vier booten, achter elkaar, stoomden in, en van vier

booten tegelijk, meerden de loopers ’t touw vast aan
de palen. Een wild gedrang stootte òp, woest
geschreeuw ratelde los; gekrijsch van tuinders, met
verkeerde bakken, roep òm roep. Rauwe moeheid
klonk door de stemmen, en zwaar de zweetkoppen,
roodgrauw, paars en bietig, vloekten en gromden weer
te moeten sjouwen in den nog smoorhitten
zonnedaver.—

Eén helsch karnaval van dooreenkrioelende zwoegers

en waggelende beschonkenen, brak plots weer los
aan de doorgloeide haven, gestoofd en geschroeid in
den vonkenden zengdag.

Paarden loomden weer stil, achter drom van kleurige

karren, en van allen kant, op de haven, golf-vloeide
gewirwar van kerels en wijven, meisjes, en jochies.
Van de hooge booten reuzigden de werkers, met de
bakken en vrachten op nek en kop, tegen eindlooze
polderlucht violet vuur, dat dampte en smeulde.—
Heele stapels hoekten in dwarsen lijn-opstand de lucht
in, op de hooge boot; wilde kankan van opgeheven
kisten, schuin en [179]vlak, rechtòp, dwars, scheef, en
 mandtorens waggelden geweldig op de
zwoegschouers, en dampende zweetkoppen.

’t Stormde op den wal, en woester krioelden en

afmarcheerden de karren in hotsende ratel-herrie en
bonkering, naar huis; geduwd door jochies en meisjes
in schreeuwerigen konkel.—Het heete gedaver en
gesmak van kisten waarin de leege aardbei-mandjes
nu beèfden van schokken, bulderde weer òp,
cyclopisch, als donderende klankneerstorting van
mokers op aambeelden en houweelen-ring-king op
steenen muren. En òm ’t smak-geraas heen, bleef
roezemoezen bassig gegons van straatgeruchten.

Troepen venters, klaar met hun manden en vrachten,

afgereeën aan d’r kinders, drentelden rond met hun
handen op geldzak, warmpjes de centen ingekneld
tusschen vleesch-hitte en broek-voering, smakkend
naar lekkeren Zaterdagavondzuip.

Afgebeuld of in drinklol opgewonden, strompelden de

groenboeren herbergen in, waar ’t borrelde en gistte
van schurige stemmen, dronk’rige roezemoes; waar ’t
schuiflawaai knarste van stoelen op zandgrond,
tusschen stikwalm, rook-rood.—Buiten woelde ’t
haventje in hellegedaver.

’t Kraakte, klotste, hotste en smakte ’r in gloeiend

zwoeggerucht, arbeids-hellebaardiers, die burchten
sloopten.—In ’t watertje glom, kleurveegde en brio’de
druk beweeg van kramen, sloepen, tjalken en bokken;
op elkaar gedrongen, tusschen engen spoel van
spoor-polderdijk en walkant in. Wemel van
schipkleuren nog blond doorzond, gloeide òp in ’t àl
 zinkender licht. Op hoogen bakkenstapel, midden in
thuiskomst van Zaterdagavondmarkt, herautte nù ’n
kleine jood, met luchtig fluitspel.—

Kring van honderden stond om ’m heengekranst, in

starenden luister naar z’n wonderlokkend, klank-zoet
fluitgevlei. Weinig sprak ’t joodje. Met ’n groot blad
muziek op ijzer lessenaartje vóór zich, wees ie op de
methode, zei wat van de fluit, ’t klank mooie, ’t zuiver-
hooge en lage, en speelde, spéélde.—

Joodje leek verliefd op eigen fluit. In zwierpracht en

zoeten huiver van vloeiende vlei-toontjes, zilverende
koloratuur, zong [180]ie zich uit,—dan één, dan twéé
fluiten den mond induwend, zich zelf begeleidend.
Starre bewondering strakte van de tuinderskoppen. Ze
voelden, voèlden dat ’t ècht was. Prachtig
ebbenhoutig-zwart, glansden de gepolitoerde oktavo-
fluitjes in joodjes hand, en wonderzoete, zilver-
trillende tonen blies ie de heet-zonnige havenlucht in.
Met gratie, in duizelend snelle vingerradheid,
duikelden, trilden, zweefden de toontjes uit z’n fluit, en
z’n vingertoppen leken tien betooverde zieltjes, vol
klank en zaligen galm. Snel dansten de topjes op de
zwart-geglansde fluit, en machtiger zwol z’n toon, fel
in zingende kracht, de havengeruchten overklankend.
Dan plots hield joodje in, droefde ie weemoed uit, in
weeken, donkeren fluister van wiegelende klankjes,
slepend-zoet en innig-ontroerend, droomrige
melankolie van teere toontjes, in klagelijk register.—
Zoo jubileerde z’n wonderfluit tusschen ’t sjacher-
rumoer, dat zacht verstomde onder z’n tooverzang.
Heelemaal méé, in de pathetische zoetheid van z’n
 lied, schokte jood’s lijfje.—Zacht zwierde z’n hoofd,
lichtelijk heen en weer. Op de kadans van z’n lied,
rekte zich z’n postuur als groeide ie boven den
luisterkring uit, kromp ie plots weer in, bij teerdren
melodie-zwenk. En vlak om z’n hoofd geurde en
zweefde ie uit, ’n krans van zangerige kabbelende
klankjes, met iets er in van starende smart;
murmureerde z’n vlei-klankende fluit, diep en vroom ’n
litanie van innigheid; bleef dóórdroeven z’n zang, in
smartlijk mineur, speelde ie uit, ’n lied van tranen en
hartewee. Dan plots, in ’n schater, zwol z’n toon in ’t
hooge register, joelde de klare zilveren klank van z’n
demonische fluit als ’n woeste jubel door de
polderlucht en haven, schaterend en klaterend.
Roerloos stond ’t landvolk in tooverban te luisteren.
Eén laatsten stroom van klankenjubel tremoleerde hij
nog woest en oriëntaal òver de koppen heen, wijd
uitvloeiend de zonnelucht in; klankenpracht, als ’n
vurige hymne rondbruisend door den havengang.
Plots zweeg ’t joodje.—

Dronken en nuchtere kerels stonden gebluft, nà de

plotse fluitstilte, in argelooze luistering.—Zwoegers uit
de donkere bedompte kroegen, waren opgestapt, in
furie en bedwelming, [181]naar den man die daar zóó
gejuicht en geweend had, onder de slavende massa.
—

Joodje, zeker van z’n kunnen, zelf wèg in zoeten

huiver van z’n klankinstrument, speelde weer opnieuw,
gaf zich heelemaal over, aureooleerde zich in een
sfeer van zilveren tonenzang.—Eindelijk, klaar met z’n
spel, stroomden de kwartjes op ’m af. In fijn-gele
 vloeitjes wikkelde ie de glanzige zwarte fluitjes met
goud-vergulde ornamentjes, drukte ie de kerels de
gewichtige methode in de hand.

—Mit dat boekkie, in drie daagh en nachte, kan èllek

manspersoon en vroùspersoon de heele kunsh! ’n
Kind kèn de meledie! wattie wil! as ie ’t marr kèn!
begrijbt u!

Z’n luisterkring van boeren stond als vastgezogen aan

den grond, in verbijstering voor dàt spelen. Zoenen
wouen ze den kerel. Joodje had geen handen genoeg.
Jongens met lach-van-ontroering op d’r gezicht
kochten; mannen, die in hun schemeravondstraatjes
onder de lommerstille zomer-boomen harmonika
speelden, kochten; dronken kerels, betooverd en half
ontnuchterd kochten; meiden, wijven en „notabelen”
kochten.

Strak-zelfbewust bleef gezicht van Joodje, die soms

midden in ’t drukst van z’n verkoop, plots naar zich
toegestrekte armen terug-wees, met stil gebaar z’n
fluit, koester-zacht vatte, en speelde. En alles
roerloos, in tooverban als klonk er geen hond-geblaf,
kargehots en sjouwgekrijsch meer, bleef rond ’m
staan.

Tot heel naar den polderweg verklonk de klaagroep,

van z’n fluit, zoet gefluister, smachtende adagio’s,
plots vervloeiend in stoute schalmei van jubelende
scherzo’s. Begoochelder stonden rond ’m, in broozen
luister, de afgemartelde zwoegwerkers, met verrukking
in de oogen, bevende monden en verlegen handen.
Plots weer brak joodje àf, deelde ie z’n fluiten uit, tot ie
alleen z’n eigen instrument overhield. Eén groenboer,
wou dàt ding hebben, met ’n gulden toe, zei ie sluw
lachend naar de omstanders. Maar Joodje lachte ook,
gaf ’m z’n fluit, ruilde met den boer, die ’t geld klaar
had in z’n hand, en speelde nòg mooier op ’t kwartjes-
instrument. [182]

—’t Sit ’m weràchdig niet in ’t fluitje.. ze binne d’r as

tweeh drobbele water geleik eender!.… ’t zit ’m in ’t
hart meneer!.. in ’t hart!.…

—Hoart?.. hoart? sputterde ’n tuinder.…

—Nou ja.… ik bedoell eigelik in uwès boekkie.… de

methoòde.… lachte Joodje weer ironisch, ’n kind kèn ’t
leere.. in drie daaghe het tie ’t onder de knie!

Vier honderd fluiten had ie verkocht in één uur. En

overal op de haven, door Wierelandsche straatjes en
steegjes verklonk fluitgejoedel, valsch en onbeholpen,
stooterig-monotoon lawaai, dat joodje sarkastischer
lachte op z’n bakkenstapel en inpakkend z’n
lessenaartje, nog spottend nariep:

—In drie daaghe te leere.… voor ’t kleinste kind!.… de

meledie.…

Rond de bakken, honden en paarden, bleef ’t laat, tot

in den schemer ratelhossen van karren, klakkeren van
hoeven en orkanen van hellegeblaf.—

Bij aansluip van avond, begon éérste drinkmaal van

venters. Lichte zuip was er geweest in de stad. Echte
zuip barstte nu pas los. Ontembaar zouden ze zich
 gaan geven aan den heerlijken zoeten brand van
dronk, als koelst ijs in hun stoffige ventstrotten
verglijend. Bij wijven thuis was alleen gemor,
kinderenherrie, schoonmaakploeter, geharrewar en
zaterdagavond-afboenerijtjes. Geen zitje, geen likje.
Niets lekkerder en plakkeriger noù, dan samenbroei in
de stikheete kroeg, met gesuis van havenlawaai nog
èven in de ooren, roezemoezigen verdoofden naklank
van sjacher.

En niks doen dan lollen en babbelen, verdoofd tòch

alles hoorend, maar van verre gebeurend, in ’n warrel.
Zacht geklots, gezoen en getikker van biljardballen,
kleurig en glanzend, robbelden over ’t gehavende
lakengroen, bemorst en ingescheurd. Fel gevlam van
gaspitten dampte hette uit.—Vuur en rook van pijpen
en sigaren, rood-smokerden in een sfeer van kroeg-
zwijmel.—

Scherpe jenevergeuren, spiritusachtig zuur, walmden

uit buffet [183]van tafel naar tafel. Ze voelden zich
smoorheet, de groenboeren, maar lekker, paf-verhit in
de kroeg.

Dirk en Klaas Grint bleven vlak bij elkaar. Dirk zoop

zwaar dat z’n hoofd heet-kleurig rood te zwellen stond,
en z’n kale, blond behaarde nek in vuur schroeide.
Grint had stille drinkerskleur, zachtpaars, maar toch
keek ie nog helder uit z’n oogen, zonder dat iemand
merken kon dat ie al vet was.

Op de haven had Dirk Kees, die karren en bakken

terugreed, nog even gesproken. Hij wilde ’m ’n borrel
opdringen, maar ’t was niet gelukt. Ze hadden Kees
ook èrg schuwerig bekeken weer, als voelden ze zich
niet gerust bij den stillen Strooper. Uit angstigen bijval
wilden hem ’n paar tuinders nog wat borrels
aansmeren, maar Kees bleef weigeren, toèn met ’n
vloek.—Dat was z’n kracht! Hij voelde dat, àls ie
zuipen ging, hij niet meer ophouên zoù al z’n verdriet,
z’n huiselijke ellende en getob over Wimpie’s
beroerderigheid weg te spoelen. Nou z’n ventje ’r nog
was, hield ie zich sterk.

Nou had Kees Dirk gezeid, dat Ouë Gerrit d’r strak-en-
an nog rais ankwam, op de haven. Dat maalde Dirk ’n
beetje. Hij voelde dat dàn z’n centen in den zak,
bedreigd stonden; dat ie niet meer doen kon wat ie
wou, als d’Ouë neerstrijken kwam. Toch verdoezelde
die gedachte tot vage verwachting in z’n kop. ’t Heetst
in ’m woelde ’t denken aan de mooie meiden van
Klaas Grint, vooral aan Geert en de heete Trijn, waar
de neven Hassel òòk op loerden. Naast Grint aan ’t
stomphouten tafeltje opgedrongen, zaten Jan en
Willem Hassel. Klaas Grint sluwigjes, voelde zich
lekker tusschen de gesmoorde geilheid der knapen.
Hij kon tegen ’n borrel als geen ander.

En nou vond ie ’t ’n zalige lol, zoo happie nà happie in

te zuigen, zonder ’n cent te dokken, in woesten naijver
van drie kanten opgepookt tot vrij zuipen; dàn door
Willem, dàn door Jan, dàn door Dirk.—Piet
mankeerde nog, hinnik-lachte ’t cynisch in ’m.
Tusschen hùn halsstarrige, zwijg-nijdige boerenpassie
in, wreed en moordend, warmde hìj z’n zuipbegeerte.
En telkens als Willem zag, dat Dirk trakteerde, riep hij
ook den kastelein, bestelde voor Grint in ’t wild erop
 los. Grinneken [184]bleef Klaas er om, en trotsch
voelde ie zich, in z’n dronken kop, dat hij toch de
vader was van zulke lekkere meiden.

—Nou, drink jullie d’r moàr, d’rfeur binne jullie

vraigesellekerels hee?.… Moar.… van màin goant nie
hee?.. van màin hee?.… ikke hep d’r maide en klain
goed.…

Hij grinnikte Grint, veegde met z’n dikmorsige vingers

langs z’n neus.—De kerels knikten, grinnikten mee.
En Grint lachte erger, met dronken stemmeschuur in
z’n schater, omdat zij grinnikten.

In tijen had ie zooveel zaken niet gedaan, als

vandaag. En hij, helsch genietend als ie iets niet
hoefde te betalen, z’n duitjes bezuinigen kon, maar
toch loerend op wat lekkers, hij kòn ’r niet over uit, dat
’t nou bij hèm puur was: mond ope, portemenee
dicht.…

Joliger klokkerde ie z’n borrel in, langzaam roerend,

elk happie, dat dadelijk weer aangeschoven stond
onder z’n hand. En iedere borrel als ’n lafenis door z’n
keel, spoelde wèg vermoeiing van smorenden
dagzwoeg.—

Stiller, in dronken zwijg,—zwijg toch van huilend,

woedend-woesten hartstocht, op z’n neven, schooiers
die loerden op zìjn meid,—bleef Dirk naast Klaas Grint
geblokt.—En lolliger werd Klaas, aangeprikkeld door
den gonswarrel van stemmen in de herberg, den
dronken zoem van kakelaars, venters en koopers en
allerhande kroegtypen dooréén. Laag en diep, met z’n
 gloeiende glasvlammen, rookerig, verweerd van hitte,
verronkte de kroeg z’n dronken reutel van geluiden.
Jan en Willem schoven al dichter naar Grint toe en
trakteerden weer. Langzaam genot-innigend ging de
zuip rond, langzaam en demonisch. Dirk zag den ouen
Gerrit niet opdagen. Vond ie lekker! Rond ’m woelde
de herberg al voller met drommen bestoven
zweetkerels, bek-af van sjouw. Waggelend en
krijscherig sloegen hun lijven, massaal en reuzig door
den heet-rooien rooknevel.—

Troepjes met blazende, gloeiende zweettronies bleven

waggelen voor ’t buffet, de glaasjes tegen ’t licht
geheven, dronken zeurderig en spraak-zangerig;
plasten het vocht hun kelen in, onder knars van hun
klompen op zandgrond. Van alle hoeken [185]spogen
groenboeren en venters in de bezande spuwbakken
hun pruimen, zopen en vloekten ze. Op klein
bankpuntje, dat open kwam tusschen ’t kroeggedrang,
smakte zich haastig ’n werker neer, met grauw-moeën
kop, en reuzige geknauwde handen bevend-
uitgestrekt naar ’t buffet, in snak naar drank-koeling.

Tegen tien uur stapte Grint òp, z’n schitteroogen

verkleind van stille beschonkenheid. Dirk mokkend en
pruttelend, waggelde zacht mee òp, grabbelde
duizelig in z’n diepe klepbroek, waarvan de grove
voornaad vettig spande tusschen glimmig smeer. Alles
betaalde ie.—

Willem en Jan opstuivend, streden, duwend en

vechtend, dat zij de helft er moesten bijplakken. Dirk
zei niets, gaf, zachtwaggelend, ’n stommen nijdigen
 wenk aan kastelein dat ’t, zóó als hij ’t wou, in orde
was. Kalm schoof herbergier kleingeld terug op
natbeplaste tafel, dat Dirk naar zich toeharkte,
kleverig, maar vallen liet op zandgrond en in spuwbak.

—Nie d’r strooie hei Dirk? baste ’n kerel met diepe

fagotstem.

—Aa’s je te veul hep, is màin d’r nog! gierde ’n ander.

Nieuwe drom kerels klomperde in, stapte langs en

voorbij Dirk, die gebukt zoekend, in zachten rondtast,
lijf-zwaaiend, ruw op z’n handen getrapt werd. Bloed
zakte ’m naar den kop. Rauw vloekte ie uit, en flauw
loerde ie rond op den grond, maar half beseffend of
van hèm of van Grint wat duiten weggerold waren.—
Lodderig staarde ie òp naar Klaas die gierde, z’n buik
met z’n vuisten betamboerijnde van lol.

Plots vloekte Dirk weer, stapte in wijen waggel,

onzeker naar de deur. Grint had ’t geld uit den
spuwbak gegrabbeld, ’t nattig en bevuild Dirk in de
hand geduwd. Maar die beweerde nou, met dikken
tongstotter, dat ’t van hèm niet was, dat hij d’r puur
nies verloren had.

—Zoo’n geep! gierde Willem Hassel hoonend.

Stom bleef Dirk voor zich uitkijken met z’n neus bijna
op de deur gedrukt. En toch nijdig, gloeiend nijdig was
ie, als ’n bromvlieg onder vangstolp. Niks nog kon ’r bij
’m uit. Alles zat opgepropt. Hij voelde den roes over ’m
heen gloeien, benevelend, versuffend. Hij hoorde àlles
half verward. Alleen [186]heet-stellig maalde ’t in ’m dat