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Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page i

Browse’s Introduction to
The Symptoms and Signs
of Surgical Disease

Fourth edition
NORMAN L. BROWSE Kt, MD, FRCS, FRCP
Professor of Surgery, Emeritus, University of London, UK
Honorary Consulting Surgeon, St Thomas’ Hospital, London, UK
Formerly, Chairman, London University MBBS and MS Examiners
Formerly, Member of Court of Examiners, Royal College of Surgeons of England, UK
Formerly, Member of Council and Chairman of Examinations Committee and
Academic Board, Royal College of Surgeons of England, UK
Past President, Royal College of Surgeons of England, UK

JOHN BLACK MD, FRCS

Consultant Surgeon, Worcestershire Royal Hospital, UK
Member of Council, Royal College of Surgeons of England, UK
Examiner, Intercollegiate Board in General Surgery, UK

KEVIN G. BURNAND MS, FRCS, MBBS

Professor of Vascular Surgery and Chairman of the Academic Department of Surgery
and Anaesthesia in the Cardiovascular Divison of King’s College at the St Thomas’ Campus,
University of London, UK
Honorary Consultant Surgeon to Guy’s and St Thomas’ Foundation Trust, London, UK

WILLIAM E.G. THOMAS MS, FRCS

Consultant Surgeon and Clinical Director, Sheffield Teaching Hospitals Trust
Member of Council, Royal College of Surgeons of England, UK
Formerly, Member of Court of Examiners, Royal College of Surgeons of England and
Panel of Examiners for the Intercollegiate Board in General Surgery, UK

with Hodder Arnold

Sponsored by AstraZeneca PLC
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Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page iv

We dedicate this book to all those who have supported

us thoughout our clinical careers:

Our wives,
families,
consultant colleagues,
registrars and house officers,
nurses in the wards, outpatients and operating rooms,
secretaries and laboratory staff,

but, above all,

our patients.

Without the support of everyone mentioned above, it would have been

impossible to write this book.

Acknowledgements

The advice and contributions of many surgical four editors themselves, at home, but we are most
colleagues throughout the UK to previous editions grateful for the secretarial assistance of Elizabeth
have already been acknowledged but they are Webb and Patricia Webb of the Academic Depart-
still part of the substance of this edition. Added to ment of Surgery at St Thomas’ Hospital.
this group must be Dr Jane Terris, Consultant in Over the past 2 years we have received and
A&E Medicine, Dr Elizabeth Graham, Consultant in are most grateful for the constant support given by
Medical Ophthalmology and Mr Kieran Healey, all the editorial team of Hodder Arnold led by
Consultant Plastic Surgeon, all of St Thomas’ Hospi- Georgina Bentliff.
tal, who gave valuable advice on Chapters 2 and 3, Last, but by no means least, we thank our wives
and Mr David Douglas, Consultant Orthopaedic and families for accepting the disruptions to family
Surgeon, Sheffield Teaching Hospitals NHS Founda- life that the preparation of this fourth edition has
tion Trust, who advised on Chapter 4. imposed upon them.
In these days of word processors and computers,
much of the secretarial work has been done by the
Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page v

Contents

Preface to the First Edition viii Soft tissues 106

Preface to the Third Edition ix Muscles and muscle disease 106
Preface to the Fourth Edition x Fibrous tissue 110
Tendons and tendon sheaths 112
1 History taking and clinical Bones and bone irregularities 114
examination 1 Examination of bones 114
Fractures 117
How to take the history 2 Bone diseases and deformities 118
History of pain 7 Benign tumours of bone 122
The clinical examination 11 Malignant tumours of bone 123
History and examination of a lump 29 Joints 127
History and examination of an ulcer 32 Examination of a joint 127
2 The symptoms, signs and emergency Examination of the spine 134
management of major injuries 36 Diseases of joints 136

The primary survey and management

5 Conditions peculiar to the hands 143
at the site of the event: first-aid 36 A plan for the examination of the hand 143
The primary survey in the accident and Recording data about the hand 148
emergency department 38 Abnormalities and lesions of the hand 149
The secondary survey 41 The nails 160
Infections in the hand 162
3 The skin and subcutaneous tissues 47
6 Conditions peculiar to the feet 165
The diagnosis of skin conditions 47
Congenital skin disorders 50 Congenital and acquired deformities
Genetic skin disorders 50 of the foot and ankle 165
Non-genetic skin disorders 51 The toe nails 170
Haemangiomata/lymphangiomata 53
7 The arteries, veins and lymphatics 175
Acquired dermatological conditions 57
Conditions of the skin caused by trauma 57 The arteries 175
Infections of the skin 66 Clinical assessment of the arterial
Benign tumours and benign skin lumps 71 circulation of the lower limb 175
Pigmented naevi 75 Symptoms produced by arterial
Benign subcutaneous swellings 78 insufficiency 179
Tumours of the skin appendages 86 Haemorrhage 190
Pre-malignant skin lesions 87 Transient and permanent weakness,
Malignant diseases of the skin 89 paralysis and blindness 190
Other common skin conditions Cold, blue digits, hands and feet 192
often seen in surgical patients 99 Hypertension 196
Subcutaneous infections 100 Intestinal ischaemia 196
The veins 196
4 Muscles, tendons, bones and joints 104
Clinical assessment of the venous
A general plan for examining the circulation of the lower limb 196
muscles, bones and joints of a limb 104 The lymphatics 209
Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page vi

vi Contents

8 General and facial appearance 214 The nipple 326

Breast abscess 328
Colour 214
Pregnancy 329
General appearance 217
The male breast 329
Diseases affecting facial appearance 224
Carcinoma of the male breast 330
The eyes 226
The nose 230
Shape of the skull 230 13 The external genitalia 331
The ears 232 Examination of the male genitalia 331
Meningocele 234 The penis 334
The chest wall 234 The scrotal skin 342
The testes 343
9 The salivary glands 239
The female external genitalia 357
The submandibular salivary gland 239
The parotid gland 242 14 The abdominal wall, herniae and the
Autoimmune disease 248 umbilicus 359
10 The mouth 250 Abdominal herniae 360
Inguinal hernia 361
Congenital abnormalities of the lips
Femoral hernia 373
and palate 250
Umbilical hernia 375
The lips, buccal mucosa and tongue 251
Epigastric hernia 378
Other conditions of the tongue 261
Incisional hernia 378
The palate 261
Divarication of the recti 379
The tonsils 263
Rare abdominal herniae 381
The floor of the mouth 263
The umbilicus 381
The gums 266
Swellings of the jaw 267
The jaw 268 15 The abdomen 386

11 The neck 270 The examination of the abdomen 386

Abdominal pain 391
The history and examination of Upper abdominal pain – acute and/or
swellings in the neck 270 chronic – caused by inflammatory and
Cervical lymphadenopathy and other malignant conditions 393
neck swellings 271 Central abdominal pain – acute
The thyroid gland 288 and/or chronic 401
Symptoms of thyroid disease 288 General abdominal pain – acute
Examination of the thyroid gland 290 and/or chronic 403
Different forms of goitre 295 Lower abdominal pain – acute and/or
Thyrotoxicosis and myxoedema 299 chronic – caused by inflammatory
Carcinoma of the thyroid gland 303 and/or malignant conditions 405
Thyroiditis 307 Symptoms and signs resulting from
the perforation of a viscus 411
12 The breast 312
Symptoms and signs caused by an
History and examination of obstructed viscus 412
breast disease 312 Infarction of a viscus causing
Presentation of breast disease 318 abdominal pain 414
Carcinoma of the female breast 318 Abdominal pain caused by intra-
Benign breast tumours 322 abdominal or retroperitoneal
Benign breast disease 323 haemorrhage 415
Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page vii

Contents vii

Extra-abdominal and medical conditions Retention of urine 441

causing acute abdominal pain 418 The prostate gland 443
Alimentary conditions presenting The urethra 445
with dysphagia or vomiting 419
17 The rectum and anal canal 447
Conditions presenting with diarrhoea 420
The abdominal mass: causes and signs 421 Symptoms of ano-rectal disease 447
Causes of a mass in the right iliac fossa 427 Technique for ano-rectal examination 448
Causes of a mass in the left iliac fossa 430 Sigmoidoscopy and proctoscopy 451
Causes of a lump in the groin 430 Conditions presenting with rectal
Abdominal distension 431 bleeding 454
Conditions presenting with anal pain 459
16 The kidneys, urinary tract and
Conditions presenting as an anal lump
prostate 435
with or without pain 465
Symptoms of renal and urinary tract
disease 435
Index 471
Diseases of the urinary tract 437

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Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page viii

Preface to the First Edition

I believe that the main object of basic medical edu- site, shape and surface are constantly repeated in
cation is to train the student to talk to and to exam- an unobtrusive way. I hope that when you have fin-
ine a patient in such a way that he can discover the ished reading the book you will have these headings
full history of the patient’s illness, elicit the abnor- so deeply imprinted in your mind that you will
mal physical signs, make a differential diagnosis and never forget them. If so, I will consider that the book
suggest likely methods of treatment. The object of has succeeded, for you will always take a proper history
further medical training is to amplify these capabil- and perform a correct and complete examination.
ities in range and depth through practical experi- Because the main object of the book is to empha-
ence and specialist training. size the proper techniques of history taking and
It is surprising, but a fact, that some students clinical examination, I have described only the com-
present themselves for their qualifying examination mon conditions that you are likely to see in a surgi-
unable to take a history or to conduct a physical cal clinic. Indeed the whole book is presented in a
examination in a way that is likely to detect all the manner similar to that used by most teachers when
abnormal symptoms and signs. Even more are they are in the presence of the patient. Special inves-
unable to interpret and integrate the facts they do tigations and treatment are completely excluded
elicit. I think there are two reasons for these defi- because neither can be applied sensibly if you get
ciencies. First, and most important, students do not the history and physical signs wrong.
spend enough time seeing patients and practising To make the book useful for revision, I have put
the art of history taking and clinical examination. It a number of the lists and classifications in special
is essential for them to realize at the beginning of Revision Panels. The photographs are close to the
their training that the major part of medical educa- relevant text but their legends contain enough
tion is an apprenticeship, an old but well-proven information to make the picture-plus-legend a use-
system whereby the apprentice watches and listens ful revision piece.
to someone more experienced than himself and I hope this book will be more of a teach-book
then tries it himself under supervision. The second than a text-book, which will be read many times
reason is the lack of books which describe how to during your basic and higher medical training.
examine a patient and explain how the presence or There is a well-known saying ‘A bad workman
absence of particular symptoms and signs lead the always blames his tools’. The doctor cannot make
clinician to the correct diagnosis. this excuse because his basic tools are his five senses.
In this book I have attempted to describe, in detail, If he has not trained his senses properly in the man-
the relevant features of the history and physical signs ner described in this book and kept them finely
of the common surgical diseases in a way which honed by constant practice, he will practise bad
emphasizes the importance of the routine application medicine but he will have only himself to blame.
of the techniques of history taking and examining.
The details of these techniques are fully described, Norman Browse
and headings such as age, sex, symptoms, position, 1978
Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page ix

Preface to the Third Edition

The diseases and abnormalities described in this difficult to obtain. Unfortunately, the current trend
book have not changed for many thousands of is for patients to be unwilling to be photographed
years, nor have their symptoms and signs. Why then for illustrations to be used in books for teaching,
produce a third edition? The main reason is to thus making the compilation of a comprehensive
improve and modernize the presentation of the library of clinical photographs far more difficult
information within the book in the belief that better than it used to be.
presentation facilitates and improves learning. I have also added a considerable number of new
Whereas the symptoms and signs of surgical dis- Revision panels, now on a blue background, as stu-
ease have not changed in the past 20 years, methods dents find them particularly helpful.
of printing and publishing have. Computer graphics To remind students of their importance, the
and colour printing now enable publishers to produce illustrations of methods of clinical examination
books of superb design, with infinite varieties of (mostly black-and-white photographs) are outlined
colour, at acceptable costs. The main changes in this in Revision Panel blue.
new edition are therefore the introduction of colour I hope this revised presentation will give the
into the general presentation and design, and the con- book a new modern appearance and that it will con-
version of all ‘blackboard-style’ line drawings into tinue to be attractive to new readers in the same way
coloured illustrations – still simple – but giving them that it has been to the gratifyingly large number of
the added impact on the memory provided by colour. students who have acquired it for their libraries over
At the same time I have tried to illustrate all the past 20 years.
the clinical conditions with colour photographs –
except for the few rare conditions, worthy of pre- Sir Norman Browse
sentation, for which modern colour photographs are 1997
Browse-Power-Prelims.qxd 12/17/10 5:49 PM Page x

Preface to the Fourth Edition

The first edition of this book was written, 25 years Medical students know and appreciate this. The
ago, to help medical students develop their bed- continuing success of this book indicates that it helps
side clinical skills, namely, their ability to take a to fill the deficit that exists in those new courses of
full clinical history and to conduct a complete clin- medical education that have mistakenly reduced the
ical examination – the prime purpose of medical apprenticeship aspects of learning medicine.
education. Having retired from clinical practice, I felt it was
Although the symptoms and signs of the com- important to ask three surgical colleagues with an
mon ‘surgical’ diseases have not changed for cen- approach to clinical teaching similar to my own, but
turies, the style in which they are presented in who are still clinically active, to join me as editors.
textbooks and our understanding of the underlying They have combined Chapters 2 and 3 and Chapters
pathological processes and, in some instances, their 13 and 15 of the third edition into single chapters
classification have. These changes have prompted (now Chapters 3 and 14) and added a new chapter
the production of this fourth edition. on the symptoms and signs of trauma (Chapter 2).
The past 25 years have also seen changes in the In this edition, John Black has revised Chapters 8,
style and methods of medical education, especially 12, 13, 14, 16 and 17; Kevin Burnand has revised
in the UK, with the term ‘problem-orientated med- Chapters 1, 3, 7 and 15 and written the new Chapter
icine’ purporting to describe the current popular 2; and William Thomas has revised Chapters 4, 5, 6,
approach. This is not a new approach. Students 9, 10 and 11. I have collated and edited their revi-
beginning their medical training have always been sions to ensure that the book’s original systematic
taught to begin the taking of a history by asking approach and style of presentation were maintained.
the patient ‘What are you complaining of?’. To me, I am most grateful for their hard work and willing
this is and always has been a problem-orientated co-operation. When the fifth edition is needed, in
approach. 5–8 years’ time, I know it will be in excellent hands.
Having asked all the questions about the patient’s I hope this edition retains its style as a ward-round
main complaint, together with those concerning all ‘teach-book’ aimed directly at the individual student
the other bodily systems, the student’s growing rather than a library-shelf textbook. Whenever possi-
knowledge of the symptoms and signs of individual ble, the illustrations have been kept on the same page
diseases inevitably begins to guide them to those as the relevant text, as have many of the revision pan-
further questions which are likely to illuminate the els. All are there to help you reinforce those vital
cause of the main complaint. This is why it is helpful items of knowledge which must be in your mind
to learn the symptoms and signs of the common dis- when sitting in front of a patient – not hidden some-
eases from a book at the same time as acquiring that where in the memory of a computer.
knowledge through growing clinical experience. Note. Throughout the book, whenever a particu-
This book seeks to expedite that learning. lar complaint is more common in one sex, the
I firmly believe that what some criticize as dog- patient has been referred to as ‘he’ or ‘she’ accord-
matic teaching – following a strict ritual when taking ingly. If there is no sexual predominance, ‘they’ has
a history and performing an examination – must been used in the singular sense.
remain a vital part of clinical education because it
accelerates diagnosis and helps avoid errors and Sir Norman Browse
omissions. 2005
Chap-01.qxd 4/19/05 13:40PM Page 1

1
History taking and clinical
examination

You must be constantly alert from the moment you unable to interpret their significance. At all stages
first see the patient, and employ your eyes, ears, nose explain what you are doing, and why you are doing it.
and hands in a systematic fashion to collect infor- The patient may not be fluent in your own lan-
mation from which you can deduce the diagnosis. guage and require an interpreter. When conducting
The ability to appreciate an unusual comment or an interview through an interpreter, keep your ques-
minor abnormality, which can lead you to the cor- tions short and simple, and have them translated
rect diagnosis, only develops from the diligent and and answered one at a time. You will have to use lay
frequent practice of the routines outlined in this terms if you are to be easily understood.
chapter. Always give the patient your whole atten- You should not use leading questions to which
tion and never take short cuts. there is only one answer. All questions should leave
In the outpatient clinic try to see patients walk into the patient with a free choice of answers. You should
the room, rather than finding them lying, undressed, avoid saying, ‘The pain moves to the right-hand
on a couch, in a cubicle. General malaise and debility, side, doesn’t it?’. This is a ‘leading question’ because
breathlessness, cyanosis, and difficulty with particular it implies that it should have moved in that direction,
movements are much more obvious during exercise. and an obliging patient will answer ‘Yes’ to please you.
It may also be helpful to see and speak to anyone The patient should be asked if the pain ever moves?
who is accompanying the patient. A parent, spouse If the answer is ‘Yes’, you must then ask the supple-
or friend can often provide valuable information mentary question, ‘Where does it go?’. Sometimes,
about changes in health and behaviour not noticed however, patients fail to understand your question
by the patient. Remember, however, that many and you may have to suggest a number of possible
patients are inhibited from discussing their problems answers, which can be confirmed or rejected.
in front of a third person. It can also be difficult if the When a patient is having difficulty communicat-
relative or friend, with the best of intentions, con- ing with you, remember that a question that you do
stantly replies on behalf of the patient. When the time not think is a leading one may be interpreted incor-
comes to examine the patient, the friend or relative rectly by the patient if they do not realize that there
can be asked to leave; further questions can then be is more than one answer. For example, ‘Has the pain
asked in private. It is helpful if a nurse is present. changed?’ can be a bad question. There are a variety of
Patients like to know to whom they are talking. ways in which the pain can change – severity, nature,
They are probably expecting to see a specific con- site, etc. – but patients may be so disturbed by the
sultant. You should tell patients your name and intensity of the pain that they think only of its sever-
explain why you are seeing them. It is particularly ity and forget the other features that have changed. In
important for medical students to do this. such situations, it often helps to include the possible
Talk with patients or, better still, let them talk to answers in the question; for example, ‘Has the pain
you. At first, guide the conversation but do not dic- moved to the top, bottom, or side of your abdomen
tate it. Treat patients as the rational, intelligent or anywhere else?’, ‘Has the pain got worse, better or
human beings they are. They know more about stayed the same?’, or ‘Can you walk as far, less far, or
their complaints than you do, but they are usually the same distance as you could a year ago?’.
Chap-01.qxd 4/19/05 13:40PM Page 2

2 History taking and clinical examination

The patient should provide the correct answer years previously, their description should be included
providing you ask the question correctly. Do not be in this section.
over-concerned about the questions – worry about
the answers, and accept that it will sometimes take a
Remaining questions about the
long time and a great deal of patience and persever-
ance to get a good history.
affected system
When a patient complains of indigestion it is sensi-
ble, after recording the history of the indigestion, to
HOW TO TAKE THE HISTORY ask other questions about the alimentary system
because many of the replies may aid in diagnosing
The history should be taken in the order described
the main complaint.
below and in Revision panel 1.1. Do not write and talk
to the patient at the same time; however, it is impor-
tant to document dates and times and the full drug Systematic direct questions
history with accuracy, which you may not remem-
ber when you have finished the examination and left These are direct questions that every patient should
the room. Brief notes are therefore essential. be asked, because the answers may amplify your
Make sure you know, and always record, the knowledge about the main complaint and will often
patient’s name, age, sex, ethnic group, marital status, reveal the presence of other disorders of which the
occupation and address; and always record the date patient was unaware, or thought irrelevant. Negative
of the examination. answers are just as important as positive answers.
The standard set of direct questions is described
in detail below because they are so important. It is
The present complaint essential to know them by heart because it is very
easy to forget to ask some of them. When you have to
It is customary to ask the patient ‘What are you com-
go back to the patient to ask a forgotten question,
plaining of?’ and to record the answer in the patient’s
you invariably find the answer to be very impor-
own words.
tant. The only way to memorize this list is by taking
It is currently fashionable to talk about ‘problems’
as many histories as possible and writing them out
rather than ‘complaints’. There is no difference,
in full. All the answers to every question, whether
but problem-orientated management sounds more
they be positive or negative, must be recorded.
sympathetic.
If you ask ‘What is the matter?’ the patient will
The alimentary system
probably tell you their diagnosis. It is better not to
know the diagnoses made by the patient, or other Appetite Has the appetite increased, decreased, or
doctors, because none may be correct. It is better to remained unchanged? If it has decreased, is this
try to seek out the patient’s complaints. These should caused by a lack of desire to eat, or is it because of
be listed in order of severity, with a record of pre- apprehension as eating always causes pain?
cisely when and how they started. Whenever possible, Diet What type of food does the patient eat? Are
it should be noted why the patient is more con- they vegetarian? When do they eat their meals?
cerned with one complaint than another.
Weight Has the patient’s weight changed? By how
much? Over how long a time? Many patients never
The history of the present complaint weigh themselves, but they usually notice if their
clothes have got tighter or looser and friends may
The full history of the main complaint or complaints
have told them of a change in physical appearance.
must be recorded in detail, with precise dates. It is
important to get right back to the beginning of the Teeth and taste Can they chew their food? Do they
problem. For example, a patient may complain of a have their own teeth? Do they get odd tastes and sen-
recent sudden attack of indigestion. If further ques- sations in their mouth? Are there any symptoms of
tioning reveals that similar symptoms occurred some water brash or acid brash? (This is sudden filling of
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How to take the history 3

Revision panel 1.1

Synopsis of a history
Names; age and date of birth; sex; marital status; occupation; ethnic group; hospital or practice
record number

Present complaints or problems (PC, CO) Preferably in the patient’s own words.

History of present complaint (HPC) Include the answers to the direct questions concerning the
system of the presenting complaint.

Systematic direct questions

(a) Alimentary system and abdomen (AS)
Appetite. Diet. Weight. Nausea. Dysphagia. Regurgitation. Flatulence. Heartburn. Vomiting.
Haematemesis. Indigestion pain. Abdominal pain. Abdominal distension. Bowel habit. Nature of
stool. Rectal bleeding. Mucus. Slime. Prolapse. Incontinence. Tenesmus. Jaundice.
(b) Respiratory system (RS)
Cough. Sputum. Haemoptysis. Dyspnoea. Hoarseness. Wheezing. Chest pain. Exercise tolerance.
(c) Cardiovascular system (CVS)
Dyspnoea. Paroxysmal nocturnal dyspnoea. Orthopnoea. Chest pain. Palpitations. Dizziness. Ankle
swelling. Limb pain. Walking distance. Colour changes in hands and feet.
(d) Urogenital system (UGS)
Loin pain. Frequency of micturition including nocturnal frequency. Poor stream. Dribbling.
Hesitancy. Dysuria. Urgency. Precipitancy. Painful micturition. Polyuria. Thirst. Haematuria.
Iincontinence.
In men Problems with sexual intercourse and impotence.
In women Date of menarche or menopause. Frequency. Quantity and duration of menstruation.
Vaginal discharge. Dysmenorrhoea. Dyspareunia. Previous pregnancies and their complications.
Prolapse. Urinary incontinence. Breast pain. Nipple discharge. Lumps. Skin changes.
(e) Nervous system (NS, CNS)
Changes of behaviour or psyche Depression. Memory loss. Delusions. Anxiety. Tremor. Syncopal
attacks. Loss of consciousness. Fits. Muscle weakness. Paralysis. Sensory disturbances.
Paraesthesiae. Dizziness. Changes of smell, vision or hearing. Tinnitus. Headaches.
(f) Musculoskeletal system (MSkS)
Aches or pains in muscles, bones or joints. Swelling joints. Limitation of joint movements. Locking.
Weakness. Disturbances of gait.

Previous history (PH) Previous illnesses. Operations or accidents. Diabetes. Rheumatic fever.
Diphtheria. Bleeding tendencies. Asthma. Hay fever. Allergies. Tuberculosis. Syphilis. Gonorrhoea.
Tropical diseases.

Drug history Insulin. Steroids. Anti-depressants and the contraceptive pill. Drug abuse.

Immunizations BCG. Diphtheria. Tetanus. Typhoid. Whooping cough. Measles.

Family history (FH) Causes of death of close relatives. Familial illnesses in siblings and offspring.

Social history (SH) Marital status. Sexual habits. Living accommodation. Occupation. Exposure to
industrial hazards. Travel abroad. Leisure activities.
Habits Smoking. Drinking. Number of cigarettes smoked per day. Units of alcohol drunk per week.
Chap-01.qxd 4/19/05 13:40PM Page 4

4 History taking and clinical examination

the mouth with watery or acid-tasting fluid – saliva Abdominal distension Have they noticed any abdom-
and gastric acid respectively.) inal distension? What brought this to their atten-
tion? When did it begin and how has it progressed?
Swallowing If they complain of difficulty in swal-
Is it constant or variable? What factors are associ-
lowing (dysphagia), ask about the type of food that
ated with any variations? Is it painful? Does it affect
causes difficulty, the level at which the food sticks, and
their breathing? Is it relieved by belching, vomiting
the duration and progression of these symptoms. Is
or defaecation?
swallowing painful?
Defaecation How often does the patient defaecate?
Regurgitation This is the effortless return of food What are the physical characteristics of the stool?
into the mouth. It is quite different from vomiting,
which is associated with a powerful involuntary con- ■ Colour: brown, black, pale, white or silver?
traction of the abdominal wall. Do they regurgitate? ■ Consistence: hard, soft or watery?
What comes up? If food, is it digested or recognizable ■ Size: bulky, pellets, string or tape like?
and undigested? How often does it occur and does ■ Specific gravity: does it float or sink?
anything, such as stooping or straining, precipitate it? ■ Smell?

Flatulence Does the patient belch frequently? Does Beware of the terms ‘diarrhoea’ and ‘constipation’.
this relate to any other symptoms? They are lay words and mean different things to dif-
ferent people. These words should not be written in
Heartburn Patients may not realize that this symptom the notes without also recording the frequency of
comes from the alimentary tract and they may have bowel action and the consistence of the faeces.
to be asked about it directly. It is a burning sensation
behind the sternum caused by the reflux of acid into Rectal bleeding Has the patient ever passed any
the oesophagus. How often does it occur and what blood in the stool? Was it bright or dark? How much?
makes it happen, e.g. lying flat or bending over? Was it mixed in with or on the surface of the stool, or
did it only appear after the stool had been passed?
Vomiting How often do they vomit? Is the vomiting
preceded by nausea? What is the nature and volume Flatus, mucus, slime Is the patient passing more gas
of the vomitus? Is it recognizable food from previ- than usual? Has the patient ever passed mucus or
ous meals, digested food, clear acidic fluid or bile- pus? Is defaecation painful? When does the pain
stained fluid? Is the vomiting preceded by another begin – before, during, after, or at times unrelated to
symptom such as indigestion pain, headache or gid- defaecation?
diness? Does it follow eating? Prolapse and incontinence Does anything come out
of the anus on straining? Does it return spontane-
Haematemesis Always ask if they have ever vomited
ously or have to be pushed back? Is the patient con-
blood because it is such an important symptom.
tinent of faeces and flatus? Have they had any injuries
Old, altered blood looks like ‘coffee grounds’. Some
or anal operations in the past?
patients have difficulty in differentiating between
vomited or regurgitated blood and coughed-up blood Tenesmus Do they experience any urgent, painful
(haemoptysis). The latter is usually pale pink and but unproductive desire to pass stool? This is called
frothy. When patients have had a haematemesis, tenesmus.
always ask if they have had a recent nose bleed. (They
Change of skin colour Have the patient’s skin or eyes
may be vomiting up swallowed blood.)
ever turned yellow (jaundiced)? When? How long
Indigestion or abdominal pain Some people call all did it last? Were there any other accompanying symp-
abdominal pains indigestion; the difference between toms such as abdominal pain or loss of appetite?
a discomfort after eating and a pain after eating may Did the skin itch?
be very small. Concentrate on the features of the
pain, its site, time of onset, severity, nature, progres- The respiratory system
sion, duration, radiation, course, precipitating, exac- Cough How often does the patient cough? Does the
erbating and relieving factors (see pages 7–10). coughing come in bouts? Does anything, such as a
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How to take the history 5

change of posture, precipitate or relieve the cough- should be asked if the pain radiates to the neck or to
ing? Is it a dry or a productive cough? the left arm and whether it is relieved by rest.
Sputum What is the quantity (teaspoon, dessert- Palpitations These are episodes of tachycardia which
spoon, etc.) and colour (white, clear or yellow) of the the patient notices as a sudden fluttering or thump-
sputum? Some patients only produce sputum in the ing of the heart in the chest.
morning or when they are in a particular position.
Ankle swelling Do the ankles or legs swell? When do
Haemoptysis Has the patient ever coughed up blood? they swell? What is the effect on the swelling of bed-
Was it frothy and pink? Were there red streaks in the rest and/or elevation of the leg?
mucus, or clots of blood? What quantity was pro-
Dizziness, headache and blurred vision These are
duced? How often does the haemoptysis occur?
some of the symptoms associated with hyperten-
Dyspnoea Does the patient wheeze? Does he get sion and postural hypotension.
breathless? How many stairs can he climb? How far
can he walk on a level surface before the dyspnoea Peripheral vascular symptoms
interferes with the exercise? Can he walk and talk Does the patient get pain in the leg muscles on exer-
at the same time? Is the dyspnoea present at rest? cise (intermittent claudication)? Which muscles are
Is it present when sitting or made worse by lying involved? How far can the patient walk before the
down? (Dyspnoea on lying flat is called orthop- pain begins? Is the pain so bad that he has to stop
noea.) How many pillows does the patient need walking? How long does the pain take to wear off?
at night? Does the breathlessness wake them up at Can the same distance be walked again? Is there any
night – paroxysmal nocturnal dyspnoea – or get pain in the limb at rest? Which part of the limb is
worse if they slip off their pillows? There are classi- painful? Does the pain interfere with sleep? What
fications that grade dyspnoea numerically, but it is positions relieve the pain? What analgesic drugs give
better to describe the causative conditions rather relief? Are the extremities of the limbs cold? Are
than write down a number. there colour changes in the skin, particularly in
Is the dyspnoea induced or exacerbated by exter- response to a cold environment? Does the patient
nal factors such as allergy to animals, pollen or dust? experience any paraesthesiae in the limb, such as
Does the difficulty with breathing occur with both tingling or numbness?
phases of respiration or on expiration?
Pain in the chest Ascertain the site, severity and The urogenital system
nature of the pain. Chest pains can be continuous, Urinary tract symptoms
pleuritic (made worse by inspiration), constricting
Pain Has there been any pain in the loin, groin or
or stabbing. suprapubic region? What is its nature and severity?
Does it radiate to the groin or scrotum?
The cardiovascular system
Oedema Do any parts of the body other than the
Cardiac symptoms ankles swell?
Breathlessness Ask the same questions as those
Thirst Is the patient thirsty? Do they drink excessive
described above under ‘Respiratory system’.
volumes of water?
Orthopnoea and paroxysmal nocturnal dyspnoea
Micturition How often does the patient pass urine?
Orthopnoea and paroxysmal nocturnal dyspnoea
Express this as a day/night ratio. How much urine
are the forms of dyspnoea especially associated with
is passed? Is the volume and frequency excessive
heart disease.
(polyuria)? Is micturition painful? What is the
Pain Cardiac pain begins in the mid-line and is nature and site of the pain? Is there any difficulty
usually retrosternal but may be epigastric. It is often with micturition, such as a need to strain or to wait?
described as constricting or band-like. It is usually Is the stream good? Can it be stopped at will? Is
brought on by exercise or excitement. The patient there any dribbling at the end of micturition? Does
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6 History taking and clinical examination

the bladder feel empty at the end of micturition or patient get depressed and withdrawn, or are they
do they have to pass urine a second time? excitable and extroverted?
Urine Has the patient ever passed blood in the Brain and cranial nerves Does the patient ever
urine? When and how often? Have they ever passed become unconscious or have fits? What happens
gas bubbles with the urine (pneumaturia)? during a fit? It is often necessary to ask a relative or
Symptoms of uraemia These include headache, a bystander to describe the fit. Did the patient lie
drowsiness, visual disturbance, fits and vomiting. still or jerk about, bite their tongue, pass urine? Was
the patient sleepy after the fit? Was there any warning
Genital tract symptoms (an aura) that the fit was about to develop? Has there
MALE been any subsequent change in the senses of smell,
vision and hearing?
Scrotum, penis and urethra Has the patient any
Is there a history of headache? Where is it experi-
pain in the penis or urethra during micturition or
enced? When does it occur? Are the headaches asso-
intercourse? Is there any difficulty with retraction of
ciated with any visual symptoms?
the prepuce or any urethral discharge? Has the patient
Has the face ever become weak or paralysed? Have
noticed any swelling of the scrotum? Can he achieve
any of the limbs been paralysed or had pins and
an erection and ejaculation?
needles? Has there ever been any buzzing in the ears,
FEMALE dizziness or loss of speech? Can the patient speak
Menstruation When did menstruation begin (menar- clearly and use words properly?
che)? When did it end (menopause)? What is the Peripheral nerves Are any limbs or part of a limb
duration and quantity of the menses? Is menstrua- weak or paralysed? Is there ever any loss of cutaneous
tion associated with pain (dysmenorrhoea)? What is sensation (anaesthesia)? Does the patient experience
the nature and severity of the pain? Is there any any paraesthesiae (tingling, ‘pins and needles’) in
abdominal pain mid-way between the periods (mit- the limbs?
telschmerz)? Has the patient had any vaginal dis-
charge? What is its character and amount? Has she Musculoskeletal system
noticed any prolapse of the vaginal wall or cervix or Ask if the patient suffers from pain, swelling or lim-
any urinary incontinence, especially when straining itation of the movement of any joint. What precipi-
or coughing (stress incontinence)? tates or relieves these symptoms? What time of day
Pregnancies Record details of the patient’s preg- do they occur? Are any limbs or groups of muscles
nancies – number, dates and complications. weak or painful? Can he walk normally? Has he any
congenital musculoskeletal deformities?
Dyspareunia Is intercourse painful?
Breasts Do the breasts change during the men-
strual cycle? Are they ever painful or tender? Has the
Previous history of other illnesses,
patient noticed any swellings or lumps in the breasts? accidents or operations
Did she breast-feed her children? Has there been Record the history of those conditions which are not
any nipple discharge or bleeding? Has she noticed directly related to the present complaint. Ask specif-
any skin changes over the breasts? ically about tuberculosis, diabetes, rheumatic fever,
Secondary sex characteristics When did these allergies, asthma, tropical diseases, bleeding tenden-
appear? cies, diphtheria, gonorrhoea, syphilis, and the likeli-
hood of intimate contact with carriers of the human
The nervous system immunodeficiency virus (HIV).
Mental state Is the patient placid or nervous? Has
the patient noticed any changes in their behaviour Drug history
or reactions to others? Patients will often not appre-
ciate such changes themselves and these questions Ask if the patient is taking any drugs. Specifically,
may have to be asked of close relatives. Does the enquire about steroids, anti-depressants, insulin,
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History of pain 7

diuretics, anti-hypertensives, hormone replacement the duration of the habit. Does the patient have any
therapy and the contraceptive pill. Patients usually unusual eating habits?
remember about drugs prescribed by a doctor but
often forget about self-prescribed drugs they have
bought at a pharmacy. Is the patient sensitive to any
HISTORY OF PAIN
drugs or any topical applications such as adhesive We have all experienced pain. It is one of nature’s
plaster? If they are, write it in large letters on the ways of warning us that something is going wrong
front of the notes. in our body. It is an unpleasant sensation of varying
intensity. Pain can come from any of the body’s sys-
tems but there are certain features common to all
Immunizations
pains that should always be recorded.
Most children are immunized against diphtheria, Be careful in your use of the word tenderness.
tetanus, whooping cough, measles, mumps, rubella Tenderness is pain which occurs in response to a
and poliomyelitis. Ask about these, and smallpox, stimulus, such as pressure from the doctor’s hand,
typhoid and tuberculosis vaccination. or forced movement. It is possible for a patient to
be lying still without pain and yet have an area of
tenderness. The patient feels pain – the doctor elicits
Family history tenderness. But although patients usually complain
Enquire about the health and age, or cause of death, of pain, they may also have observed and complain
of the patient’s parents, grandparents, brothers and of tenderness if they happen to have pressed their
sisters, and ask about any children who have died. fingers on a painful area or discovered a tender spot
Draw a family tree if there is obvious familial dis- by accident. Thus tenderness can be both a symp-
order (e.g. lymphoedema). If the patient is a child, tom and a physical sign.
you will need information about the mother’s preg- The history of a pain frequently betrays the diag-
nancy. Did she take any drugs during pregnancy? nosis, so you must question the patient closely about
What was the patient’s birth weight? Were there any each of the following features, some of which are
difficulties during delivery? What was the rate of depicted graphically in Figure 1.1.
physical and mental development in early life?
Site
Social history Many factors may indicate the source of the pain
but the most valuable indicator is its site.
Record the marital status and the type and place of It is of no value to describe a pain as ‘abdominal
dwelling. Ask about the patient’s sexual life, the sex pain’; you must be more specific. Although patients
and sexual behaviour of their sexual partners and do not describe the site of their pain in anatomical
the nature of their physical relationships. Ask about terms, they can always point to the site of max-
the patient’s occupation, paying special regard to imum intensity, which you can convert into an exact
contact with hazards such as dusts and chemicals. description. When the pain is indistinct in nature and
What are the patient’s leisure activities? Has the spread diffusely over a large area, you must describe
patient travelled abroad? List the countries visited the area in which the pain is felt and the point (indi-
and the dates of the visits if these appear to be cated by the patient) of maximum discomfort. It is
relevant. also worthwhile asking about the depth of the pain.
Patients can often tell you whether the pain is near
Habits to the skin or deep inside.

Does the patient smoke? If so what – cigarettes, cigar Time and mode of onset
or pipe? Record the frequency, quantity and duration
of their smoking habit. Does the patient drink alco- It may be possible to pinpoint the onset of the pain
hol? Record the type and quantity consumed and to the minute, but if this cannot be done, the part of
Chap-01.qxd 4/19/05 13:40PM Page 8

8 History taking and clinical examination

Duration

(a) (a) (a)

(d)
(b) (b) (c) (b)

(c) (c)
Severity

Onset Progression End

(a) Sudden onset at (a) Steady (a) Sudden cessation

maximum severity
(b) Gradual decline (b) Gradual end
(b) Sudden onset and
subsequent decline (c) Gradual worsening (c) Crescendo and
then sudden end
(c) Gradual onset (d) Fluctuating

FIG 1.1 The ways in which a pain can change. (Always record dates and calculate time intervals.)

the day or night when the pain began should be Severity

recorded. You should record the calendar dates on
which events occurred, but it is also very useful to Individuals react differently to pain. What is a severe
add in brackets the time interval between each event pain to one person might be described as a dull ache
and the current examination, because it is these by another. Consequently you must be wary of the
intervals, not the actual dates, which are more rele- adjectives used by a patient to describe the severity
vant to the problems of diagnosis. For example, of their pain. A far better indication of severity is the
‘Sudden onset of severe epigastric pain on 16th effect of the pain on the patient’s life. Did it stop the
September, 1973, at 11.00 a.m. (3 days ago)’: but patient going to work? Did it make the patient go to
remember that such comments are useless if you bed? Did they try proprietary analgesics? Did they
forget to record the date of the examination. have to call their doctor? Did it wake the patient up
Whenever you write a note about a patient, whether at night, or stop them going to sleep? Was the pain
it be a short progress note or a full history, make better lying still or did it make the patient roll around?
certain that you start your notes by writing down The answers to these questions provide a better indi-
the date. cation of the severity of a pain than words such as
Ask if the pain began insidiously or suddenly. mild, severe, agonizing or terrible. Your assessment
Chap-01.qxd 4/19/05 13:40PM Page 9

History of pain 9

of the way the patient responds to their pain, formed ‘Just a pain, doctor’. Most pains have none of the
while you are taking the history, may profoundly features mentioned above and are described by many
affect your treatment. patients as ‘a pain’. This may vary in severity from a
mild discomfort or ache, to an agonizing pain that
Nature or character of the pain makes them think they are about to die. When a
patient cannot describe the nature of their pain, do
Patients find it very difficult to describe the nature not press the point. You will only make them try to
of their pain, but some of the adjectives which fit their pain to your suggestions and ultimately this
are commonly used, such as aching, stabbing, burn- may be misleading.
ing, throbbing, constricting, distending, gripping
or colic, have a similar meaning to the majority of
people.
Revision panel 1.2
Burning and throbbing sensations are within
The features of a pain that must be elicited and
everyone’s experience. We have all experienced a
recorded
burning sensation from our skin following contact
with intense heat, so when a patient spontaneously Site
states that their pain is ‘burning’ in nature, it is likely Time and mode of onset
to be so. We have all experienced a throbbing sensa- Record the time and date of onset and the way
tion at some time in our life, so this description is the pain began – suddenly or gradually.
also usually accurate.
A stabbing pain is sudden, severe, sharp, and Duration
short-lived. Record the duration of the pain.
The adjective constricting suggests a pain that Severity
encircles the relevant part (chest, abdomen, head or Assess severity by its effect on the patient.
limb) and compresses it from all directions. A pain
that feels like an iron band tightening around the Nature/character
chest is typical of angina pectoris and almost diag- Aching, burning, stabbing, constricting,
nostic, but when patients speak of a tightness in throbbing, distending, colic.
their chest or limb do not immediately assume that Radiation
they have a constricting pain. They may be describ- Record the time and direction of any radiation of
ing a tightness caused by distension, which may the pain; remember to ask if the nature of the
occur in any structure that has an encircling and pain changed at the time it moved.
restricting wall, such as the bowel, bladder, an encap-
sulated tumour or a fascial compartment. Tension Referral
in the containing wall may cause a pain which the Was the pain experienced anywhere else?
patient may describe as distension, tightness or a Progression
bursting feeling. Describe the progression of the pain. Did it
A colicky pain has two features. First, it comes change or alter?
and goes in a sinusoidal way. Second, it feels like a
migrating constriction in the wall of a hollow tube The end of the pain
which is attempting to force the contents of the tube Describe how the pain ended. Was the end
forwards. It is not a word which many patients use spontaneous or brought about by some action
and it is dangerous to ask them if their pain is col- by the patient or doctor?
icky without giving an example. This is not difficult,
because most of us have experienced colic during an Relieving and exacerbating factors
episode of diarrhoea, and many women have suffered Cause
the colicky pains of labour. A recurring, intermittent Note the patient’s opinion of the cause of the
pain is not necessarily a colic; it must also have a pain.
gripping nature.
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10 History taking and clinical examination

Progression of the pain antacids, etc., which relieves the pain. The natural
response to a pain is to search for a way to relieve it.
Once it has started, a pain may progress in a variety Sometimes patients try the most bizarre remedies and
of ways. many convince themselves that some minor change
■ It may begin at its maximum intensity and in habit or a personal remedy has been helpful, so
remain at this level until it disappears. accept their replies to this question with caution.
■ It may increase steadily until it reaches a peak or
a plateau, or conversely begin at its peak and Factors which exacerbate the pain
decline slowly.
■ The severity may fluctuate (see Fig. 1.1). The Anything that makes the pain worse is also likely to
intensity of the pain at the peaks and troughs of be known to the patient.
the fluctuations, and the rate of development The type of stimulus that exacerbates a pain will
and regression of each peak, may vary. The pain depend on the organ from which it emanates and its
may go completely between each exacerbation. cause. For example, alimentary tract pains may be
The time between the peaks of an abdominal made worse by eating particular types of food; mus-
colic may indicate the likely site of a bowel culoskeletal pains are affected by joint movements,
obstruction (e.g. in upper small bowel muscle exercise and posture. It is perfectly reasonable
obstruction, the frequency of the colic is every to ask direct questions about those stimuli which
1–2 minutes, in the ileum every 20 minutes). It is you think might affect a pain if the initial description
essential to find out how the pain has progressed has indicated its source.
and ascertain the timing of any fluctuations
before its nature can be determined; for
Radiation and referral
example, colic has two features – its gripping
nature and its intermittent progression. Radiation Radiation is the extension of the pain to
another site whilst the initial pain persists. For exam-
The end of the pain ple, patients with a posterior penetrating duodenal
ulcer usually have a persistent pain in the epigas-
A pain may end spontaneously, or as a result of some trium, but sometimes the pain spreads through the
action by the patient or doctor. The end of a pain is abdomen to the back. The extended pain usually has
either sudden or gradual. The way a pain ends may the same character as the initial pain.
give a clue to the diagnosis, or indicate the develop- A pain may occur in one site, disappear, and then
ment of a new problem. reappear in another. This is not radiation: it is a new
Patients always think that the disappearance of pain in another place.
their pain means that they are getting better. They
are usually right, but sometimes their condition may Referred pain This is a pain which is felt at a dis-
have got worse. tance from its source. For example, inflammation of
the diaphragm will cause a pain which is felt at the
tip of the shoulder. A referred pain is caused by the
Duration of the pain inability of the central nervous system to distinguish
The duration of a pain will be apparent from the time between visceral and somatic sensory impulses. From
of its onset and end, but nevertheless it is worth- the patient’s viewpoint, the pain is where they feel it –
while stating the duration of the pain in your notes. the fact that the source is some distant organ does
The length of any periods of exacerbation or remis- not concern them.
sion should also be recorded.
Cause
Factors which relieve the pain
It is worthwhile asking patients what they think is
Patients will know if there is anything, such as posi- the cause of their pain. Even if they are hopelessly
tion, movement, a hot-water bottle, aspirins, food, wrong, you will get some insight into their worries.
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The clinical examination 11

Sometimes a patient will be obsessed with the cause be made and, as time passes, some parts of the
of his condition and careful questioning may reveal examination will be completely forgotten, with seri-
that he will gain or lose compensation or insurance ous consequences.
money as the result of your opinion. Nevertheless, The easiest way to ensure that you perform a
always listen to the patient’s views with care and complete examination is to learn the routine by heart
tolerance. and repeat it to yourself during the examination.
Whilst looking at a lump, say to yourself, ‘position,
shape, size’, etc. If you do not do this, you will find
THE CLINICAL EXAMINATION when you sit down to write your notes that you have
Each chapter of this book deals with a specific region forgotten to elicit some of the lump’s physical fea-
of the body and its surgical diseases. Those methods tures and will have to go back to re-examine the
of examination peculiar to each region are described patient. Always keep to the basic pattern of looking,
in detail in the relevant chapter. The emphasis in feeling, tapping and listening (inspection, palpation,
this introductory chapter is on the importance of percussion, auscultation), whatever you are exam-
taking an exact and full history, but it would not be ining. Whilst keeping to the routine it is, however,
complete without a description of the basic plan of often best to examine first the part of body that is
a physical examination, with particular reference to the source of the patient’s complaint.
those regions not discussed in later chapters, such as
the heart, the lungs and the nervous system. As this General assessment
is a thumb-nail sketch of clinical examination, your
knowledge will need to be enlarged by additional The first part of the physical examination is per-
reading, but your understanding and ability to solve formed when taking the history. While you are talk-
the practical problems of clinical examination can ing to the patient you can observe and later record
only be clarified by frequent bedside practice. their general demeanour, their intellectual ability
Examine as many patients as you can. Nothing can and intelligence, and their attitudes to their disease,
be learnt without frequent practice. Repetition is to you, to their treatment, and to society in general.
the secret of learning. This axiom applies as much to These observations affect the manner in which you
the doctor as it does to the sportsman or the concert conduct the examination. Your instructions will
pianist. You will become confident of your interpre- need to be extremely simple if the patient is unintel-
tation of your visual, tactile and aural appreciation ligent, or coaxing and gentle if the patient is shy or
of the patient’s body only by repeatedly exercising embarrassed.
these senses. The patient’s general mental state, his memory
Experienced clinicians rarely begin the routine and use of words should be noted. There is a whole
physical examination without some suspicions about vocabulary used by the neurologists to describe var-
the diagnosis suggested by the history. Conse- ious speech and communication disorders. Some of
quently, they often modify the impartial system- the common ones are:
atized examination described in textbooks such as
■ dysarthria: impaired speech caused by muscle
this by specifically looking for signs which confirm
weakness;
or refute their tentative diagnoses, but when a sign is
■ dysphasia or aphasia: impaired or absent
elicited that denies their suspicions they return to
ability to speak caused by a neurological
the textbook routine. Students must not do this.
abnormality;
Although it is a practical and time-saving method in
■ dysgraphia or agraphia: impaired or absent
a busy clinic, and acceptable from someone with
ability to write;
years of clinical experience who can pick out those
■ dyspraxia or apraxia: impaired or absent ability
patients to whom it can be applied, it is fundamen-
to perform purposeful movements in the
tally wrong. Bad habits grow fast enough without
absence of paralysis.
encouragement. Unless students discipline them-
selves to use the standard textbook routine for every When a patient has been admitted as an emergency,
physical examination, many mistakes will inevitably especially if they have been injured, it is important
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12 History taking and clinical examination

to record their level of consciousness using the Hold the patient’s hand and examine it
Glasgow Coma Scale.
You can also observe a number of physical char- Make physical contact with the patient early in the
acteristics when taking the history, such as posture, examination by holding their hand and counting the
mobility, weight, colour of skin, facial appearance pulse. It is very important for the patient to feel that
and general body build. you are willing to get physically as well as mentally
close to them. The physical contact that is essential for
the examination forges an intimate bond between you
and the patient. It is an extraordinary privilege granted
Revision panel 1.3 to you by the patient and must never be abused.
The Glasgow Coma Scale The features that can be observed by examining
Score the hands are as follows.
Pulse See details on page 22.
Eyes Open spontaneously 4
Open to command 3 Nails Look at the colour and shape of the nails.
Open to pain 2 Spoon-shaped nails (koilonychia) are associated with
Do not open 1 anaemia; clubbing of the nails occurs in pulmonary
Speech Sensible/orientated 5 and cardiopulmonary disease (see Fig. 5.24, page 160);
Confused 4 and splinter haemorrhages under the nails are caused
Inappropriate words 3 by small arterial emboli. Pits and furrows are associ-
Incomprehensible sounds 2 ated with skin diseases such as psoriasis. Bitten nails
None 1 may indicate nervousness and anxiety.
Motor Obeys commands 6
responses Localizes stimuli 5 Temperature Observe the temperature of the hands –
Withdraws from stimuli 4 but remember that it will be affected by room tem-
Flexion responses 3 perature and the duration of exposure.
Extension responses 2 Moisture Are the patient’s palms sweating excessively?
None 1
Total Colour Pallor of the skin of the hands, especially
in the skin creases of the palm and in the nail beds,
suggests anaemia. Reddish-blue hands occur in
polycythaemia and cor pulmonale. The fingers may
be stained with nicotine.

Revision panel 1.4 Callosities The position of any callosities may reflect
Some common causes of weight loss the patient’s occupation.
In the young Malnutrition
Diabetes
Malabsorption Examine the head and neck
Anorexia nervosa
Tuberculosis Eyes
From middle age onwards Diabetes Look for any asymmetry of the position, size or
Thyrotoxicosis colour of the eyes and especially any abnormality in
Chronic hypoxia the width of the palpebral fissures. This can be caused
Chronic heart failure by ptosis (droopy eyelids) or proptosis (exophthal-
Malignant disease mos) when the eyeball is pushed forwards, pushing
Senile cachexia the lids apart (see Chapter 11, pages 292–4). The size
Neglect and equality of the two pupils should be recorded
(dilated, constricted or unequal).
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The clinical examination 13

The reaction of the pupil to light is checked by eye against the lens opening and his left hand on the
shining a bright light off and on the pupil. The pupil’s patient’s forehead above their right eye. He then looks
reaction to accommodation is assessed by asking the through the aperture of the ophthalmoscope, brings
patient to look into the distance and then to refocus the instrument very close to the patient’s right pupil
on a finger held close to their eye. by placing his forehead against his left hand on the
The eye movements are examined by fixing the patient’s forehead. The light can be watched illumi-
patient’s head with one hand while asking them to nating the fundus, through the pupil, as the instru-
watch your finger as it travels upwards and down- ment and the patient’s eye are brought close together.
wards and inwards and outwards to the full extremes The approach should be slightly from the temporal
of movement. Patients should be asked if they expe- side, at an angle of 10–15° to the direct line, to avoid
rience any double vision (diplopia) in any particular noses colliding! When the pupils are level, this
position. While the eye movements are being tested, approach usually ensures that the optic nerve disc is
the presence of any strabismus (squint) can usually the first part of the fundus to come into view. If the
be easily seen, which may be concomitant (divergent disc is not seen, a retinal artery should be followed
or convergent) or paralytic. back until the edge of the pale yellow disc is seen.
Look for the presence of nystagmus (oscillations The optic disc is cupped by chronic glaucoma and
of the eye characterized by a slow drift and a rapid swollen by papilloedema (see Fig. 2.3, page 46). Other
jerk back) at the inward and outward extremes of abnormalities that can be detected by careful fun-
movement. doscopy of the rest of the retina include haemor-
Inspect the lids, conjunctiva, cornea and lens. rhages and exudates (in diabetes and hypertension),
Styes, Meibomian cysts, and blepharitis may inflame retinal emboli and infarcts, and occasionally retinal
the lids or cause a swelling. The edges of the eyelids detachment. At the end of the examination, the
may be everted or inverted (ectropion or entropion) patient should be asked to look directly at the light of
and the eye may water if the tearduct or lacrimal sac the ophthalmoscope in order to inspect the macula.
is blocked.
A painful red eye may be caused by acute con- Ears and nose
junctivitis (when there is usually an associated dis- Do not forget to look into the ears to inspect the
charge), acute iritis (when the anterior chamber of external auditory canal and the ear-drum. Look up
the eye is inflamed), acute glaucoma (which is asso- the nose. The ears and nose are often forgotten dur-
ciated with severe pain and a misty cornea), acute ing routine examination but they are important,
keratitis (from a corneal ulcer, seen as a cloudy opac- particularly if there is any possibility of disease in
ity) or episcleritis. the head and neck.
When an elderly patient has a gradual loss of eye- Clinical examination of the ear requires an auro-
sight they are likely to have a cataract (which can be scope. This instrument directs a beam of light down
confirmed by finding a loss of part or the whole of a conical metal speculum which is viewed through a
the ‘red-reflex’ when a powerful light is shone on the lens. The speculum is gently inserted into the exter-
pupil). Other possible causes of gradual loss of vision, nal auditory meatus, while the ear is pulled gently
such as optic nerve or retinal damage, can only be upwards and backwards to straighten the external
detected by inspecting the retina through an oph- auditory canal. Wax may be present and must
thalmoscope. This requires practice, and you should be removed before the tympanic membrane can
take every opportunity to use the ophthalmoscope by be seen.
inspecting the retinae of all the patients you examine. The whole of the tympanic membrane can only be
Ophthalmoscopy is best carried out in a darkened seen if the angle of the speculum is altered. Normal
room to ensure that the pupils are dilated. The oph- tympanic membranes vary in colour, translucence
thalmoscope is an illuminated lens system which can and shape – so you should look at as many normal
be focused on the retina. Patients are asked to stare tympanic membranes as possible. The external audi-
fixedly at a point on the wall behind the examiner. tory canal may contain wax or foreign bodies. You
The instrument is switched on and held by its handle may see otitis externa (dermatitis), blood or pus. The
in the right hand. The examiner then places his right tympanic membrane may be normal, torn (injury),
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14 History taking and clinical examination

bulging and inflamed (acute otitis media), or perfo- III Oculomotor nerve
rated (chronic otitis media).
This nerve supplies all but two of the extrinsic eye
Mouth muscles, as well as the levator palpebrae superioris
and the muscle of accommodation. When it fails to
Note the colour and state of the lips. Ask to see the function, the eye turns downwards and outwards, the
patient’s tongue; observe its movement, symmetry upper lid droops (ptosis) and the pupil becomes fixed
and surface. (not responding to accommodation). Sometimes
Look at the teeth and gums. Use a spatula to individual muscles supplied by the third nerve can
inspect the soft palate, tonsils and posterior wall of be paralysed. To test the superior rectus muscle, ask
the oropharynx. the patient to ‘look up’; the inferior rectus – ‘look
down’; the medial rectus – ‘converge’; and the inferior
Neck oblique – ‘look up and out’.
The important features to examine in the neck are
the jugular veins, the trachea, the thyroid gland and IV Trochlear nerve
the lymph glands. This nerve supplies the superior oblique muscle,
which turns the eye downwards and outwards. The
patient cannot perform this movement if the nerve is
Examine the cranial nerves damaged. The eye will look inwards and the patient
will experience diplopia below the horizontal plane.
‘On Old Olympus Towering Tops A Finn And German
Picked Some Hops’ is the most-used mnemonic for the V Trigeminal nerve
names of the cranial nerves. This nerve has sensory and motor functions. It is
sensory to the whole of the side of the face. The
I Olfactory nerve
cutaneous distribution of its three sensory divisions –
Ask the patient about their sense of smell. If thought ophthalmic, maxillary and mandibular – is shown in
to be abnormal, it can be specifically tested with bot- Figure 1.2.
tles containing cloves, peppermint etc. The trigeminal nerve is also the sensory nerve of
the conjunctiva and the inside of the mouth. The
II Optic nerve conjunctival reflex (ophthalmic division) is lost if
Visual acuity Visual acuity is tested with a Snellen’s
chart at a distance of 6 metres. Vision is expressed as
a fraction of the normal: the smallest letter visible
with comfort is 6/6; if letters twice that size are all
Ophthalmic
that can be read, the vision is 6/12. The larger letter is
division
visible to the normally sighted at 60 metre. Below this
level of vision, ‘counting fingers’, ‘hand-movements’
and ‘perception of light’ are used to grade degrees of
blindness. Near-vision is tested by a card covered
with varying sizes of print. Maxillary
division
Test the visual fields Sit directly in front of the
patient, ask them to close one eye and look straight Mandibular
division
at you with the other eye. Keeping your hand mid-
way between you and the patient, extend your arm
so that your hand is beyond your own peripheral
vision. Then gradually move it towards the mid-line Auricular branch of
until it appears in your visual field. If you and the the vagus nerve
patient have normal visual fields, you will both see FIG 1.2 The distribution of the three sensory divisions of the
your finger at the same time. trigeminal nerve.
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The clinical examination 15

the nerve is damaged. This is tested by touching the VIII Auditory nerve
conjunctiva with a ‘wick’ of cotton or tissue paper to
This nerve innervates the hearing mechanism in the
elicit a ‘blink’. Sensation in the nose, pharynx, roof
cochlea and the position sense organs in the semi-
of mouth, soft palate and tonsil should also be tested.
circular canals. Hearing can be tested very easily by
The palatal reflex (maxillary division) is elicited by
speaking softly and asking the patient to repeat your
placing a speculum against the palate to induce a
words, or by asking them if they can hear your
gag reflex. The sensitivity of the tongue, lower teeth
thumb and finger rubbing lightly together close to
and mucous membrane over the mandible (mandi-
their ear. The deafness is called conductive when it
bular division) is tested by touching each area with
is the result of an obstruction in the external meatus,
a spatula.
tympanic membrane, middle ear cavity or ossicles
The taste fibres of the anterior two-thirds of the
of the middle ear interfering with the normal pas-
tongue travel with the lingual nerve (one of the
sage of airborne sounds. This is tested by striking a
branches of the mandibular division of the trigemi-
tuning fork and holding it next to the external audi-
nal nerve) after leaving the geniculate ganglion as
tory meatus until the patient signals that sound can
the chorda tympani. Taste can be specifically tested
no longer be heard. The base of the tuning fork is
with sweet, sour, salt and bitter substances – such as
then immediately placed firmly on the mastoid
sugar, acid, salt and quinine – if this is felt to be
process. If sound is still heard by bone conduction
important.
(a negative Rinne’s test), the patient has a conductive
The motor fibres of the trigeminal nerve run in
deafness. If the tuning fork is placed on the centre of
its mandibular division to the muscles of mastica-
the forehead, an ear with a conduction deafness will
tion – masseter, temporalis and the pterygoid mus-
appreciate a louder sound. This is Weber’s test.
cles. Ask the patient to clench their teeth and feel if
When there is nerve perception deafness, any
the masseter contracts.
sound that can be heard will be loudest in the better
ear, and louder when the tuning fork is placed by
VI Abducens nerve the ear than when it is placed on the bone, i.e. good
This nerve supplies the lateral rectus muscle, which bone conduction ⫽ a normal cochlea and auditory
turns the eye outwards. The eye will not move when nerve, whereas poor bone conduction ⫽ a defective
the patient attempts to look sideways and they will cochlea and auditory nerve.
experience diplopia. The sensitivity of the vestibular apparatus is tested
by assessing the response to syringing the external
VII Facial nerve meatus with warm and cold water. This is called the
caloric test. These tests should only be done under
This is the motor nerve to the muscles of facial
careful supervision in the ENT department.
expression. When a facial nerve fails to function, the
affected side of the face is flabby, the eyelids cannot IX Glossopharyngeal nerve
be closed properly, and the mouth becomes asym-
metrical when the patient tries to bare their teeth. This nerve is the sensory nerve of the posterior third
Whistling is impossible. The nucleus of the seventh of the tongue. It supplies the taste receptors and the
nerve is in the pons varolii. Any damage to the tract sensory endings of the mucous membrane of the
or the nerve distal to the nucleus causes paralysis of pharynx.
the whole of one side of the face; but a lesion above It is also motor to the middle constrictor muscle
the nucleus misses those fibres coming from the of the pharynx.
opposite hemisphere to the upper part of the face, so The sensory integrity of this nerve can be tested
that the function of the forehead and eyelid muscles by stroking the back of the oropharynx to evoke a
is preserved. To test the facial nerve, ask the patient pharyngeal gag reflex.
to look up (the forehead should wrinkle), to close
their eyes tightly (test the strength of the orbicularis X Vagus nerve
oculi by trying to part the eyelids) and to show you This is the motor nerve of the soft palate, pharynx
their teeth (lips should part symmetrically). and larynx, and the sensory nerve of the heart, lungs
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16 History taking and clinical examination

and gastrointestinal tract. When patients are asked to that side when the patient tries to push it for-
to open their mouths wide and say ‘Aarrh’, the soft wards. The weak side will also be wasted (see Fig.
palate should arch upwards symmetrically. If one 10.14, page 261).
side of the palate is paralysed, it will not move and
the uvula will be pulled over towards the function- Examine the chest wall and lungs
ing side. Loss of function of the recurrent laryngeal
nerves (branches of the vagus) should be suspected Inspection
if there is a change in the patient’s voice or an inabil-
ity to cough. The vocal cords must be examined The colour and respiratory rate of the patient indi-
with a laryngeal mirror to confirm the diagnosis. cate the adequacy of ventilation. Cyanosis caused by
cardiopulmonary disease is most easily appreciated
XI Spinal accessory nerve by inspecting the inner aspect of the lips. Cyanosis
of the nail beds and the tip of the nose and ears may
This nerve supplies the trapezius and sterno-mastoid
be caused by a peripheral or central abnormality.
muscles. The function of these muscles is tested by
Patients may be polycythaemic rather than cyanotic
asking the patient to shrug their shoulders and to
if the peripheral tissues are a deep reddish-purple
press the point of their chin downwards against your
colour and their face is red and plethoric. Cyanosis
hand.
is difficult to detect in anaemic patients.
XII Hypoglossal nerve Count the rate of respiration and notice the
rhythm. A fluctuating respiratory rate and volume,
This is the motor nerve of the tongue. When one
with periods of apnoea interspersed between episodes
hypoglossal nerve is paralysed, the tongue will deviate
of tachypnoea, is called Cheyne–Stokes or periodic
respiration. It is caused by variations in the sensitivity
Revision panel 1.5 of the respiratory centre to normal stimuli, and
Common causes of pleuritic pain occurs commonly in patients with heart failure and
following severe cerebrovascular accidents.
Pleurisy Notice if respiration seems to require voluntary
Pneumonia effort and compare the durations of inspiration and
Pulmonary infarction (thromboembolic) expiration. Watch the chest during inspiration to
Neoplasia (primary and secondary) see if there is any inward movement of the inter-
Fractured ribs costal spaces (paradoxical movement). This is usu-
Muscle strains/prolapsed intervertebral disc ally caused by obstruction to the inflow of air into
Herpes zoster the lungs, but in an injured patient may indicate
Bornholm disease (Coxsackie virus) instability of a segment of the chest wall (e.g. two
Don’t forget pathology below the diaphragm, sets of fractures).
e.g. ruptured spleen, Curtis–Fitz–Hugh Record any abnormality in the shape of the chest.
syndrome (see Chapter 15) The two common deformities are funnel chest (pec-
tus excavatum) and pigeon chest (pectus carinatum)
(see Fig. 8.29, page 235).

Revision panel 1.6 Palpation

Common causes of haemoptysis Trachea Check the position of the trachea at the
Pneumonia suprasternal notch.
Carcinoma of the bronchus Chest expansion Spread your hands around the
Chronic bronchitis chest so that your thumbs just meet in the mid-line.
Pulmonary tuberculosis Ask the patient to take a deep breath. Your thumbs
Pulmonary infarction (thromboembolic) should be dragged apart to a distance roughly
Bronchiectasis equivalent to half the chest expansion. When the
expansion is asymmetrical it will be felt and seen.
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The clinical examination 17

Chest expansion is the difference between the Apex 2.5 cm

circumference of the chest at full inspiration and Clavicle
full expiration, measured at the level of the
nipples.

Apex beat The apex beat is the lowest and most lat-
eral point at which you can feel the cardiac impulse. Sternum
It will move laterally if the heart enlarges but may
also move medially or laterally if the mediastinum
shifts. The mediastinum (and the trachea) will move
to one side if it is pulled over by a collapsed, con-
Base
tracting lung or pushed over by air or fluid in the
6 Lung
opposite pleural cavity.
8 Pleura
Tactile vocal fremitus (Fig. 1.4, page 18) Place your 10
whole hand firmly on the chest and ask the patient
to say ‘99’. The vibrations that you can feel with your
hand are called the vocal fremitus. Compare the 8
strength of these vibrations on either side of the 10
12
chest, front and back, and over the apical, middle
and basal zones of the lung. To feel vocal fremitus Edge of Mid- Mid-
the sound waves must be conducted through the air erector axillary clavicular
in the bronchi, bronchioles and alveoli to the chest spinae line line
wall. A blocked bronchus or a layer of fluid or air Lung 10 8 6
between the visceral and parietal layers of the pleura Pleura 12 10 8
(a pleural effusion) will suppress the conduction of FIG 1.3 The surface markings of the lung and pleura.
the sound waves and reduces the intensity of the
palpable fremitus. A stiffening of the lung tissue
with patent air passages, which occurs in very early The normal chest gives a resonant sound when
pneumonia, increases conduction through the lung, percussed; a sound which is, to some extent, felt
and tactile vocal fremitus is increased. by the percussing finger as well as being heard.
Palpate both axillae. Anything solid in the pleural space or in the sub-
stance of the lungs decreases the resonance and
Percussion makes the sound dull. Any extra air, whether in the
pleural space (a pneumothorax) or in the lung sub-
The whole of the surface of both lungs must be per-
stance (an emphysematous bulla or multiple bullae),
cussed. The surface markings of the lungs are shown
makes the sound more resonant (hyper-resonance)
in Figure 1.3. Place one hand flat on the chest wall,
(page 19).
keeping the finger you intend to strike straight and
In the presence of a large pneumothorax, a ring-
firmly applied to the underlying skin. Tap the centre
ing resonance can be heard with a stethoscope when
of the middle phalanx of this finger with the tip of
the percussion is performed by tapping a coin held
the middle finger of the other hand. Listen carefully
against the chest wall with a second coin.
to the sound and compare it with the sound pro-
duced by percussing the same area on the other side
of the chest. Auscultation
The two areas most often forgotten when per- The normal sounds of breathing can be heard all
cussing the chest are the lateral zones high in the over the chest except over the heart and spine (page
axillae and the anterior aspect of the apices behind 20). They consist of an inspiratory sound followed
the clavicles. Percuss the latter area by striking the immediately by a shorter, softer, expiratory sound.
clavicle directly with the percussing finger. There is no gap between the two phases. This pattern
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18 History taking and clinical examination

TACTILE VOCAL FREMITIS

Normal Vibrations palpable

Say
'99'

Consolidation
Say Air passages patent Vibrations increased
'99' Lung substance denser

Pleural effusion or
Say Pneumothorax
'99' Air passages pushed Vibrations diminished or absent
away from chest wall

Say Collapse
'99' Air passages blocked Vibrations diminished or absent

FIG 1.4 Tactile vocal fremitus can only be felt if there are patent air passages right out to the chest wall.

is known as vesicular breathing and is caused by called bronchial breathing. The quality of the sound
the movement of air in and out of the smaller bron- and the presence of the gap are the two distinguish-
chioles and alveoli – a rustling noise similar to that ing features.
of gas being blown down plastic tubing. The pitch of bronchial breathing may be high or
The sound of air moving in the larger bronchi- low. The high-pitched variety is sometimes called
oles and main bronchi is heard when the periphery tubular bronchial breathing. The low-pitched vari-
of the lung has been solidified by pneumonia or ety, which sounds like the noise produced by blow-
collapse (atelectasis). This sound is harsher and ing across the mouth of a jar, is called amphoric
louder than the low rustle of vesicular breathing. bronchial breathing. Amphoric sounds are heard
The inspiratory and expiratory phases are of equal when air is passing in and out of a cavity in the lung
length and separated by a short, silent gap. This is such as a tuberculous cavity.
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The clinical examination 19

PERCUSSION

Increased air in the lungs

(Emphysema) Increased resonance

Air in the pleural cavity

(Pneumothorax) Increased resonance

Less air in the lungs

(Consolidation, Collapse) Diminished resonance

Fluid in the pleural cavity

(Pleural effusion, Haemothorax, Diminished resonance
Empyema) ('Stony dull')

FIG 1.5 The causes of changes in lung resonance.

There is a type of breath sound mid-way

between vesicular and bronchial breathing, known Absent sounds
as bronchovesicular breathing. In this variety the Breath sounds are abolished or diminished by any
inspiratory and expiratory sounds are of equal process which reduces the normal conduction of
length and slightly harsher than those of vesicular sound through the lung substance and chest wall.
breathing, but there is no gap between the two The two common causes are bronchial obstruction
phases. Bronchovesicular breathing is often heard (producing collapse of the distal part of the lung)
in normal people over the anterior aspect of the and pleural effusion or pneumothorax.
upper lobes, where there are large bronchi near the When the lung alveoli are full of fluid, exudate
surface of the lung, and must not be mistaken for or pus (consolidation) but the air passages remain
bronchial breathing. patent, the thickened lung transmits the sound
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20 History taking and clinical examination

BREATH SOUNDS

Inspiration Expiration

Vesicular Expiration much shorter and softer

than inspiration
No gap between each phase

Bronchial Inspiration and expiration of equal

length and quality (harsh and loud)
Gap between the two phases

Bronchovesicular Inspiration and expiration of equal

length but expiration is softer and
smoother
No gap between each phase

Asthmatic Prolonged expiration, usually assoc-

iated with inspiratory and expiratory
rhonchi

FIG 1.6 The four types of breath sound.

from the larger bronchi. Thus bronchial breathing wheezes, coarse crackles and fine crackles by the
is heard over an area of consolidated lung. There younger generation of pulmonary physicians.
are, however, no breath sounds over an area of col-
Rhonchi/wheezes These are the whistling noises
lapsed lung.
made by air passing through narrowed air passages.
They are commonly heard in patients with asthma or
Added sounds chronic bronchitis. Their pitch depends upon the
There are three varieties of added sounds: rhonchi, velocity of airflow and the diameter of the bronchioles
râles and crepitations. These are often referred to as from which they originate. They are unmistakable.
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The clinical examination 21

EFFECT OF LUNG DISEASE ON THE BREATH SOUNDS

Normal Vesicular sounds audible

Consolidation Bronchial sounds audible,

caused by increased sound
conduction from large bronchi

Pleural effusion or No sounds audible as layer

Pneumothorax of fluid or air prevents conduction
of sound to the surface

Collapse No sounds audible as obstruction

of bronchus stops sound conduction

FIG 1.7 The causes of abnormal breath sounds.

Râles/coarse crackles These are the coarse bubbling few hairs close to your ear and roll them between
noises caused by air passing through bronchioles con- your thumb and index finger. They are thought to
taining water, mucus or pus. The sound is identical to be produced as the alveoli and their ducts pop open
that made by air bubbling through water. Moving the to allow air to enter when there is interstitial oedema.
fluid may abolish the noise, so ask the patient to take Crepitations are heard over areas of consolidation,
a deep breath and cough, and then listen again. If the such as pneumonia, and often provide important
bubbling sounds disappear, they must have been râles evidence of left ventricular failure. They are not
because crepitations cannot be abolished in this way. abolished by coughing.
Some authorities do not distinguish râles from
Crepitations/fine crackles These are fine crackling crepitations and use the all-embracing term moist
sounds similar to the noise heard when you hold a sounds for either variety.
Chap-01.qxd 4/19/05 13:41PM Page 22

22 History taking and clinical examination

Pleural rub The visceral and parietal layers of the Atrial fibrillation
pleura normally slide easily over one another but, Rhythm and volume
if the pleura is inflamed, the roughened pleural sur- irregularly irregular
faces rubbing together produce a noise which is
similar to the sound heard when a finger is pressed
hard onto a pane of glass and then slid across it. It is Extrasystoles
Premature strong
a mixture of grating and squeaking sounds. A pleural
beat followed by
rub can only be heard when the chest is moving, a pause
i.e. during inspiration or expiration. The patient
usually complains of pleuritic pain over an area
where there is an audible rub. Sinus arrhythmia
Faster during inspiration
Examine the heart and circulation i i

Much will have been learnt about the circulation from

your initial observations of the patient’s colour and Pulsus paradoxus
breathing. It is common practice to feel the pulse when Weaker during
you take the patient’s hand at the beginning of the i i inspiration
examination. Any abnormalities detected at this stage
require reassessment by further careful palpation.
Pulsus alternans
The pulse Alternating strong
and weak beats
The following features should be observed and
recorded. (i = inspiration)
FIG 1.8 Common variations of the rhythm and volume of
The rate Express the rate in beats/minute. Do not
the pulse.
count the pulse for 5 seconds and multiply by 12;
always count for 15 seconds or longer if the beat
feels irregular.
The rhythm The pulse beat may be regular or irreg-
ular. When the pulse is irregular it may have a regular
recurring pattern or be totally irregular. The latter is
sometimes called an irregularly irregular pulse and
indicates atrial fibrillation. Some common varieties
of irregular pulse are shown in Figure 1.8. Normal Flattened Accentuated
The dicrotic Slow rise and Rapid rise and fall,
The volume The examining fingers can appreciate notch is not fall, called called a water-
the expansion of the artery with each beat and con- normally anacrotic, hammer pulse,
sequently get an impression of the amount of blood palpable caused by caused by aortic
passing through the artery. Patients with a high car- aortic stenosis incompetence
diac output have a strong pulse. Patients in haemor- and patent ductus
rhagic (hypovolaemic) shock have a weak, thin, arteriosus
‘thready’ pulse. FIG 1.9 Variations of the pulse wave.

The nature of the pressure wave Every pressure

wave has definable characteristics such as the rate of or water-hammer pulse and is typical of aortic
increase and decrease of pressure and the height of regurgitation. Conversely, a tight aortic stenosis
the pressure (see Fig. 1.9). causes a slow rise and fall.
A steep rise followed by a rapid fall, with a large The shape of the pulse wave can be appreciated
pulse pressure (high peak), is called a collapsing more easily over the carotid than the radial artery.
Chap-01.qxd 4/19/05 13:41PM Page 23

The clinical examination 23

The nature of the artery It is relatively easy to esti- to be more common in people with advanced arte-
mate the diameter of the radial artery and guess the riosclerosis, but in practice is not a reliable indicator
thickness of its wall, but the presence or absence of of the presence of vascular disease (see Chapter 8,
thickening of the radial artery gives no indication page 226). It may indicate the presence of a hyper-
of the thickness of other vessels in the body. lipoproteinaemia if present in a patient under the
age of 40 years.
Measure the blood pressure
The jugular venous pressure The pressure in the
The blood pressure is usually measured in the great veins is slightly greater than the pressure in the
brachial artery with a sphygmomanometer. The cuff, right atrium. The pressure in the right atrium is one
which must fit snugly and be at least 10 cm wide of the most important influences of cardiac activity.
(a narrow cuff gives false readings), should be firmly An increase in the right atrial pressure increases car-
wrapped around the middle of the upper arm and diac output by stimulating an increase of cardiac
inflated above the systolic pressure (250 mmHg). It contractility and rate. The right atrial pressure there-
should then be slowly deflated until the commence- fore ‘drives’ the heart. The pressure in the right atrium
ment of blood flow below the cuff is detected by can be estimated clinically from the pressure in the
listening over the brachial artery at the elbow with a internal jugular veins. In a normal person, reclining at
stethoscope or palpating the pulse at the wrist. The 45°, the great veins in the neck are collapsed. There
pressure at this point is the systolic blood pressure. should be no visible venous pulsations above the
(The sounds which indicate the commencement level of the manubrio-sternal joint, which, when
of flow in the brachial artery below the cuff are caused the patient is reclining at 45°, is at the same level as
by turbulent blood flow. They were first described the mid-point of the clavicles (see Fig. 1.10).
by Korotkoff and are known as Korotkoff sounds.) The right atrial pressure is raised if there are vis-
The cuff pressure is further reduced until the ible pulsations in the internal jugular veins when
Korotkoff sounds suddenly diminish or, more often, the patient is reclining at 45°. The vertical distance
disappear. This is the diastolic pressure. between the upper limit of the venous distension
It is worth repeating both measurements on sev- and the level of the clavicle should be estimated by
eral occasions with the patient sitting and lying down eye and expressed and recorded in centimetres.
and again at the end of the examination when the
patient is less worried.
Whenever there is the possibility of disease of the
aorta and its branches, the blood pressure should be
measured in both arms.
Remember that the readings from a very fat arm
Internal jugular
will be falsely high by as much as 10 mmHg.
vein
Inspect the head and neck again
You will already have looked at the patient’s skin, face
and general demeanour. Look again for the signs
particularly indicative of cardiovascular disease –
cyanosis, plethora and dyspnoea.
Xanthomata These are grey-yellow plaques of lipid
in the skin. They often occur in the skin of the upper Level of
eyelid (see Fig 3.47, page 103). Their presence may manubriosternal
indicate an abnormal lipid metabolism such as hyper- joint
lipidaemia, but they may occur in patients with nor-
mal blood lipids.
45°
Arcus senilis This is a white ring at the junction of
the iris and sclera (see Fig. 8.14, page 227). It is said FIG 1.10 Measurement of the jugular venous pressure.
Chap-01.qxd 4/19/05 13:41PM Page 24

24 History taking and clinical examination

Listen over: impulse can be felt. It should be in the fifth inter-

costal space, near the mid-clavicular line (an imagi-
The carotid nary vertical line which passes through the middle
bifurcations of the clavicle). The apex beat moves laterally and
Origin of the may be felt as far out as the mid-axillary line if the
internal carotid heart is enlarged. It may also be possible to feel vibra-
artery tions, called thrills, which correspond to audible
heart murmurs. Thrills may be felt during systole,
diastole or throughout the whole cardiac cycle.
Remember to palpate the back of the chest. Thrills
from abnormalities of the aorta, such as a patent
ductus arteriosus or a coarctation of the aorta, are
conducted posteriorly as well as anteriorly.
It is advisable to feel the femoral pulses at this stage.
Percussion The area of cardiac dullness should be
delineated by percussion.
Auscultation The whole of the anterior aspect of
the heart must be examined with the stethoscope,
but the areas where the sounds from the four valves
are best heard are shown in Figure 1.12.
The supra- The sterno-
clavicular fossae clavicular joints Aortic area
Origin of the Origin of the innominate Right second
vertebral arteries artery (right) and common costochondral
carotid artery (left) junction

FIG 1.11 The sites of auscultation for vascular bruits on the neck. Lean the patient Pulmonary area
forwards and Left second interspace
Obstruction of the great veins in the superior also listen along
mediastinum will also cause distension of the neck the left side of
the sternum
veins, but there will not be a visible venous pulse wave.

Neck arteries Feel the pulses in the neck and listen

along their whole length, especially over the sterno-
clavicular joints, in the supraclavicular fossae, and
at the level of the hyoid bone just below the angle of
the jaw. These sites correspond to the origins of the
subclavian, vertebral and internal carotid arteries,
respectively (see Fig. 1.11).

Examine the heart

Inspection The heart may be seen to be beating rap-
idly or to be heaving up the chest wall with each beat. Tricuspid area Mitral area
Left fourth interspace Fifth space, mid-
Palpation Place your whole hand firmly on the clavicular line
chest wall, just below the left nipple, and ascertain
the strength of the cardiac impulse. It may be weak, Turn the patient
towards the left
normal or heaving in nature. The apex beat is the
lowest and most lateral point at which the cardiac FIG 1.12 Areas of cardiac auscultation.
Chap-01.qxd 4/19/05 13:41PM Page 25

The clinical examination 25

Begin by listening at the apex of the heart – the Murmurs are caused by turbulent flow and the
mitral area. Identify the first and second heart sounds. vibration of parts of the heart. They may vary in
The heart sounds are traditionally described as sound- nature from a low-pitched rumble to a high-toned
ing like the words lub-dub; that is to say, the first sound swish. Try to decide whether the murmur occupies
is slightly longer and softer than the second sound. As the whole or part of diastole or systole and whether
this is not always the case, it is wise to confirm that the its intensity changes.
sound you believe to be the first sound corresponds to Think of the way you are going to record your
the beginning of the cardiac impulse or coincides with findings (see Fig. 1.13), two blocks for the main
the subclavian or carotid pulse. Having decided which heart sounds (M1 and A2) and a zig-zag line for the
sound is which, listen carefully to the second sound. murmur. Imagine your drawing as you listen to the
It may be sharper and shorter than usual – almost a sound and you will find it easier to define the timing
click – or it may be split. A double, or split, second of the murmur. A detailed description of the many
sound occurs when the aortic and pulmonary valves heart sounds and their interpretation is beyond the
close asynchronously. A double sound can be heard scope of this book. The student must read a text-
when the sounds are 0.2 or more seconds apart and book of cardiology, but Figure 1.13 illustrates the
indicates pulmonary hypertension. common types of murmur and their likely causes.
Next, listen carefully to the intervals between the The exercise just described must be repeated
two main sounds, and between diastole and systole, over the other three areas where the aortic, pul-
for any additional heart sounds or murmurs. monary and tricuspid valve sounds are best heard.

A
M
Pansystolic murmur
Soft first sound
Mitral incompetence May be a short mid-diastolic
murmur preceded by a third
sound
A
o.s. M
Diastolic murmur with a
presystolic crescendo preceded
Mitral stenosis by an opening snap (o.s.)
Loud first sound

A
M
Early diastolic murmur
Aortic incompetence May be a soft mid-diastolic
murmur

A
M
e
Systolic murmur preceded
Aortic stenosis by an ejection click (e)
Split second sound

A
M
‘Machinery’ murmur
Continuous throughout
Patent ductus arteriosus systole and diastole
FIG 1.13 The sounds of some common cardiac abnormalities (M ⫽ 1st heart sound, A ⫽ 2nd heart sound).
Chap-01.qxd 4/19/05 13:41PM Page 26

26 History taking and clinical examination

Some murmurs will be audible in more than one Examine the abdomen
area. The site of maximum intensity of a murmur
usually indicates its site of origin. Find this by ‘inch- Examination of the abdomen is described in detail
ing’ the stethoscope over the chest wall between the in Chapter 16. It has been put there in the hope that
areas. The same technique should be used to assess you will read it whenever you refer to other parts of
whether murmurs in the aortic area are conducted the chapter. A large amount of the surgical disease
into or coming from the neck. presenting to a surgical clinic is intra-abdominal
The sounds at the apex, from the mitral valve, and so a good technique for abdominal examina-
can be made louder by asking the patient to turn tion is essential.
over onto their left side; the aortic valve sounds can Examination of the abdomen follows the standard
be amplified by asking the patient to lean forwards. pattern.
Always listen to the heart sounds at the back of the ■ Inspection for asymmetry, distension, masses,
chest. The murmur of a patent ductus or coarctation visible peristalsis and skin discolouration.
can often be heard over the aorta, posteriorly, just to ■ Palpation for superficial and deep tenderness,
the left of the mid-line. the normal viscera (liver, spleen and kidneys)
and any abnormal masses.
Test for oedema ■ Percussion of the liver and splenic areas and
Oedema commonly appears first in the feet and any other masses.
ankles, but may be more apparent in the sacral and ■ Auscultation for bowel sounds and vascular
buttock regions if the patient has been bedridden bruits.
for some time. Cardiac oedema is very soft, ‘pits’ eas- ■ Rectal examination and vaginal examination.
ily and often gives the skin a pale, waxy, transparent
There are four things that are easy to forget, so do
appearance.
them before you start general palpation.

Revision panel 1.7 1. Palpate the supraclavicular lymph glands.

Common causes of ankle swelling 2. Palpate the hernial orifices.
3. Feel the femoral pulses.
Dependency/immobility 4. Examine the genitalia.
Pregnancy
Heart failure Two further things which often get forgotten are
Low plasma proteins auscultation and the rectal examination, but you
Chronic venous insufficiency must leave these to the end.
Deep vein thrombosis
Lymphatic insufficiency
Chronic renal failure (nephrotic syndrome) Examine the limbs
There are four main tissues to be examined in a
limb: the bones and joints, the muscles and soft
Revision panel 1.8 tissues, the arteries and veins, and the nerves. The
Classification of muscle strength first three are often involved in surgical disease and
their examination is described in Chapters 4 and 7.
5 Normal Only the examination of the peripheral nerves is
4 Weak but can overcome gentle resistance described here.
3 Cannot overcome gentle resistance but can
overcome gravity
2 Cannot overcome gravity but muscle Examine the peripheral nerves
contracts
1 Barely perceptible muscle contractions The nerves in the limbs serve three functions: motor,
0 No contractions sensory and reflex. Examine each of these functions
in turn.
Chap-01.qxd 4/19/05 13:41PM Page 27

The clinical examination 27

Motor nerve function 3: can work against gravity but not against a
greater resistance
Voluntary movement Ask the patient to move each
2: cannot work against gravity but the muscles
joint in all directions, as far as possible. This will
contract
demonstrate any loss of voluntary muscle function
1: barely perceptible contractions
and the presence of any musculoskeletal abnormal-
0: complete paralysis.
ities, such as arthritis or muscle contractures, which
limit movement. It is, however, better to describe the strength of
the muscles than use a numerical code.
Strength of the muscles Check in a systematic way The segments of the spinal cord and the nerves
the strength of the muscles which move each joint. which control each joint are listed in Revision
Strength is assessed by asking the patient to move the panel 1.9.
joint against a resistance, or by asking them to keep
the joint fixed while you try to move it. The latter is Sensory nerve function
the simplest method because the patient only needs The peripheral nerves transmit the sensations of
to be instructed to keep the limb still. light touch, deep touch and pressure, pain, temper-
It is customary to grade muscle strength as ature, vibration sense, position sense, and muscular
follows: coordination.
5: normal The appreciation of light touch This is tested with a
4: moderate, but not full strength wisp of cotton wool.

Revision panel 1.9

The nerves and spinal segments which innervate the major muscle groups
Muscle groups Spinal segments Nerves

Shoulder Flexion C5, 6 Nerve to pectoralis major, circumflex nerve

Extension C5, 6
Abduction C5, 6 Subscapular nerve
Circumflex nerve
Elbow Flexion C5, 6 Musculocutaneous nerve
Extension C6, 7, 8 Radial nerve
Wrist Flexion C6, 7, 8 Median nerve and ulnar nerve
Extension C6, 7, 8 Radial nerve
Intrinsic hand muscles C8, T1 Median nerve and ulnar nerve
Hip Flexion L2, 3, 4 Lumbar and femoral nerves
Extension L5, S1, 2 Inferior gluteal nerve
Abduction L4, 5, S1 Superior gluteal nerve
Adduction L2, 3, 4 Obturator nerve
Rotation L5, S1, 2
Knee Flexion L4, 5, S1, 2 Sciatic nerve
Extension L2, 3, 4 Femoral nerve
Ankle Flexion L5, S1, 2 Medial popliteal ⫹ posterior tibial nerves
Extension L4, 5, S1 Anterior tibial nerve
Foot Inversion L4, 5 Anterior ⫹ posterior tibial nerves
Eversion L5, S1 Musculocutaneous nerve
Chap-01.qxd 4/19/05 13:41PM Page 28

28 History taking and clinical examination

Make sure that the patient cannot see you when Deep touch and pressure sensation This is tested by
you touch them, and touch the limb in a random pressing firmly on the skin with a blunt object. It is
manner. Move from the normal to the abnormal unlikely to be abnormal if the response to light touch
when mapping out an area of hypo-aesthesia. The is normal.
important dermatomes are shown in Figure 1.14.
Pain The best test of pain sensibility is the response
to a pinprick. A new sterile needle must be used for
THE IMPORTANT DERMATOMES
(the others can be estimated if
each patient to avoid transmitting infection such as
you remember these) hepatitis. The patient must be asked whether the
needle feels ‘sharp’ or ‘blunt’.
Anterior Posterior
Temperature Ask the patient to differentiate between
C7 C7 a hot and a cold object. The simplest method is to
use two test tubes, one filled with hot and the other
C6 C6 with cold water.
C8 C8
Vibration sense Strike a tuning fork firmly. Place its
C5 C3
base on a bony protuberance, such as the malleolus
at the ankle, and ask the patient to describe the sen-
T2 sation they can feel. A description of a ‘buzzing’ or
T5 ‘vibrating’ sensation indicates normal vibration sense.
Do not put these words into the patient’s mind by
T10 using them in a leading question.

Position sense The proprioceptive nerve endings in

T12 S3 a joint tell the brain about the joint’s spatial orienta-
S4&S5 tion. Test this ability by moving the great toe or
3 thumb into different positions of flexion or exten-
sion and ask the patient to identify them. It is easier
S2 to ask patients to state the direction in which the
digit is pointing (e.g. up or down) than to use unfa-
miliar anatomical terms. The patient must keep
S1 their eyes shut.
5
Muscle coordination Test the coordination of the
upper limbs by asking the patient to touch your
upheld finger with their index finger and then to
touch the tip of their nose. You will also be testing
joint position sense if you ask them to do this a sec-
FIG 1.14 The important dermatomes.
ond time with their eyes shut. Coordination in the
lower limbs is tested by asking the patient to slide
Revision panel 1.10 the heel of one foot up and down the shin of the
The segments involved in the common stretch other leg. This should also be done with the eyes
reflexes open and then shut.

Biceps jerk C5, 6

Triceps jerk C6, 7 Reflex function
Finger jerk C8 The limb reflexes are all stretch reflexes and test the
Knee jerk L2, 3, 4 integrity of the spinal segments, and the motor and
Ankle jerk S1, 2 sensory nerves which innervate the muscles being
stretched.
Chap-01.qxd 4/19/05 13:41PM Page 29

History and examination of a lump 29

To stimulate a good stretch reflex you must stretch appeared 6 months ago’, when you mean ‘the
the muscle’s tendon suddenly by striking it with a lump was first noticed 6 months ago’. Many
rubber hammer. A weak reflex can be reinforced by lumps may exist for months, even years, before
asking patients to clench their teeth or to interlock the patient notices them.
their fingers and try to pull them apart. 2. What made the patient notice the lump?
Clonus The increase in muscle tone that occurs with
There are three common answers to this
an upper motor neurone lesion increases the sus- question:
ceptibility of the tendons to the stretch reflex. Sudden ‘I felt or saw it when washing’.
and persistent stretching can cause repeated con- ‘I had a pain and found the lump when I
tractions known as clonus. felt the painful area’.
‘Someone else noticed it and told me about it’.
The plantar reflex Scraping the lateral aspect of the The presence or absence of pain is important,
sole of the foot causes a withdrawal reflex and flex- particularly if it is the presenting feature. In very
ion of the great toe. If the toe extends, there is an general terms, pain is usually associated with
upper motor neurone lesion. This reflex involves the inflammation, not neoplastic change. Most
L5, S1 and S2 spinal segments.
Abdominal reflexes Stroking the upper and lower
abdomen causes the rectus abdominis muscle to Revision panel 1.11
contract. This tests the T8, 9 and 10, and T11 and 12 The examination of a lump or ulcer
segments, respectively. Local examination
Cremasteric reflex Stroking the inner side of the Site
thigh makes the cremaster contract, testing the L1 Size
segment. Shape
Surface
Test the urine, faeces and sputum Depth
Colour
It is important to note the colour and smell of the Temperature
urine before using the modern simple dipstick Tenderness
methods for testing it for sugar, blood, acetone and Edge
protein. Do not forget to measure the specific grav- Composition:
ity of the urine and to inspect any precipitate under ■ consistence
the microscope.
Look at the faeces if the patient complains that
they are abnormal.
Look at the sputum.
■ fluctuation
■ fluid thrill
■ translucence
■ resonance
} Solid, fluid or gas

■ pulsatility

HISTORY AND EXAMINATION OF

A LUMP
■ compressibility
■ bruit
} Vascular

Reducibility
Relations to surrounding structures –
History mobility/fixity
Most patients with a lump feel it frequently and Regional lymph glands
should be able to tell you about the history of its State of local tissues:
clinical features. Therefore you should seek answers ■ arteries
to the following questions. ■ nerves
■ bones and joints
1. When was the lump first noticed?
It is important to be precise with dates and General examination
terminology. Do not write ‘the lump first
Chap-01.qxd 4/19/05 13:41PM Page 30

30 History taking and clinical examination

patients expect cancer to be painful – and do your examination. The patient should always be
themselves irreparable harm by ignoring a lump asked if the lump ever goes away, because this
just because it does not hurt them. physical characteristic is peculiar to only a few
3. What are the symptoms of the lump? types of lump.
The lump may be painful and if it is, you must 6. Has the patient ever had any other lumps?
take a careful history of the pain, as described You must ask this question because it might not
earlier in this chapter. The characteristic feature have occurred to the patient that there could be
of pain associated with acute infection is its any connection between their present lump and
throbbing nature. a previous lump, or even a coexisting one.
A lump may be disfiguring or interfere with 7. What does the patient think caused the lump?
movement, respiration or swallowing. Describe Lumps occasionally follow injuries or systemic
the history of each symptom carefully. illnesses known only to the patient.
4. Has the lump changed since it was first noticed?
This is where you use the patient’s own Examination
knowledge of their physical signs. The feature
Site/position The location of a lump must be
that they notice is the size of the lump. They
described in exact anatomical terms, using distances
should be able to tell you if it has got bigger,
measured from bony points. Do not guess distances;
smaller, or has fluctuated in size and when they
use a tape measure.
noticed a change in size. They may also have
appreciated other changes in the nature of the Colour and texture of overlying skin The skin over a
lump that they can tell you about. They may lump may be discoloured and become smooth and
also have noticed tenderness, which may have shiny or thick and rough.
altered in any of the ways that a pain may change.
Shape Remember that lumps have three dimensions.
5. Does the lump ever disappear?
You cannot have a circular lump because a circle is a
A lump may disappear on lying down, or during
plane figure. Many lumps are not regular spheres, or
exercise, and yet be irreducible at the time of
hemispheres, but have an asymmetrical outline. In
these circumstances, it is permissible to use descrip-
tive terms such as pear shaped or kidney shaped.
Revision panel 1.12
The history of a lump or an ulcer Size Once the shape is established, it is possible to
measure its various dimensions. Again, remember
Duration
that all solid objects have at least three dimensions:
When was it first noticed?
width, length and height or depth. Asymmetrical
First symptom lumps will need more measurements to describe
What brought it to the patient’s notice? them accurately; sometimes a diagram will clarify
Other symptoms your written description.
What symptoms does it cause? Surface The first feature of the lump that you will
Progression notice when you feel it will be its surface. It may be
How has it changed since it was first noticed? smooth or irregular. An irregular surface may be
covered with smooth bumps, rather like cobble-
Persistence stones, which can be called bosselated; or be irregu-
Has it ever disappeared or healed? lar or rough.
Multiplicity There may be a mixture of surfaces if the lump is
Has (or had) the patient any other lumps or large.
ulcers?
Temperature Is the lump hot or of normal tempera-
Cause ture? Assess the skin temperature with the dorsal
What does the patient think caused it? surfaces of your fingers, because they are usually dry
(free of sweat) and cool.
Chap-01.qxd 4/19/05 13:41PM Page 31

History and examination of a lump 31

Tenderness Is the lump tender? Which parts are ten- transmitted equally and at right-angles to all parts of
der? Always try to feel the non-tender part before its wall. When you press on one aspect of a solid lump,
feeling the tender area, and watch the patient’s face it may or may not bulge out in another direction,
for signs of discomfort as you palpate. but it will not bulge outwards in every other direction.
Fluctuation can only be elicited by feeling at least
Edge The edge of a lump may be clearly defined or
two other areas of the lump whilst pressing on a
indistinct. It may have a definite pattern.
third. The lump fluctuates and contains fluid if two
Composition Any lump must be composed of one or areas on opposite aspects of the lump bulge out
more of the following: when a third area is pressed in. This examination is
best carried out in two places, the second at right-
■ calcified tissues such as bone, which make it
angles to the first.
hard;
■ tightly packed cells, which make it solid; Fluid thrill A percussion wave is easily conducted
■ extravascular fluid, such as urine, serum, across a large fluid collection (cyst) but not across a
cerebrospinal fluid (CSF), synovial fluid or solid mass. The presence of a fluid thrill is detected
extravascular blood, which make the lump by tapping one side of the lump and feeling the
cystic; transmitted vibration when it reaches the other
■ gas; side. A percussion wave can be transmitted along its
■ intravascular blood. wall if a swelling is large. This is prevented by plac-
ing the edge of the patient’s or an assistant’s hand on
The physical signs which help you decide the
the lump mid-way between the percussing and pal-
composition of a lump are: consistence, fluctuation,
pating hands.
fluid thrill, translucence, resonance, pulsatility, com-
Percussion waves cannot be felt across small lumps
pressibility and bruits.
because the wave moves so quickly that the time gap
Consistence The consistence of a lump may vary cannot be appreciated or distinguished from the
from very soft to very hard. As it is difficult to mechanical shaking of the tissue caused by the per-
describe hardness, it is common practice to compare cussion. The presence of a fluid thrill is a diagnostic
the consistence of a lump to well-known objects. and extremely valuable physical sign.
A simple scale for consistence is as follows:
Translucence (transillumination) Light will pass easily
■ Stony hard: not indentable – usually bone or through clear fluid but not through solid tissues.
calcification. A lump that transilluminates must contain water,
■ Firm: hard but not as hard as bone. serum, lymph or plasma, or highly refractile fat.
■ Rubbery: but slightly squashable, similar to a Blood and other opaque fluids do not transmit
rubber ball. light. Transillumination requires a bright pinpoint
■ Spongy: soft and very squashable, but still with light source and a darkened room. The light should
some resilience. be placed on one side of the lump, not directly on
■ Soft: squashable and no resilience. top of it. Transillumination is present when the light
can be seen in an area distant from the site in con-
The consistence of a lump depends not only
tact with the light source.
upon its structure but also on the tension within it.
Attempts at transillumination with a poor-quality
Some fluid-filled lumps are hard, some solid lumps
flashlight in a bright room are bound to fail and
are soft; therefore, the final decision about composi-
mislead.
tion of a lump (i.e. whether it is fluid or solid) rarely
depends solely upon an assessment of the consis- Resonance Solid and fluid-filled lumps sound dull
tence. Other features such as those peculiar to fluid when percussed. A gas-filled lump sounds hollow
may be more important. and resonant.
Fluctuation Pressure on one side of a fluid-filled cav- Pulsatility Lumps may pulsate because they are near
ity makes all the other surfaces protrude. This is to an artery and are moved by its pulsations. Always
because an increase of pressure within a cavity is let your hand rest still for a few seconds on every lump
Chap-01.qxd 4/19/05 13:41PM Page 32

32 History taking and clinical examination

to discover if it is pulsating. When a lump pulsates you Attachment to deeper structures is more difficult
must find out whether the pulsations are being trans- to determine. Underlying muscles must be tensed to
mitted to the lump from elsewhere or are caused by see if this reduces the mobility of an overlying lump
the expansion of the lump. Place a finger (or fingers or makes it easier or less easy to feel. The former
if large) of each hand on opposite sides of the lump indicates that the lump is attached to the fascia cov-
and feel if they are pushed outwards and upwards. ering the superficial surface of the muscle or to the
When they are, the lump has an expansile pulsation. muscle itself; the latter that the lump is within or
When they are pushed in the same direction (usu- deep to the muscles. Lumps that are attached to
ally upwards), the lump has a transmitted pulsation. bone move very little. Lumps that are attached to or
The two common causes of expansile pulsation arising from vessels or nerves may be moved from
are aneurysms and very vascular tumours. side to side across the length of the vessel or nerve,
but not up and down along their length. Lumps in
Compressibility Some fluid-filled lumps can be com-
the abdomen that are freely mobile usually arise
pressed until they disappear. When the compressing
from the intestine, its mesentery or the omentum.
hand is removed the lump re-forms. This finding is a
common feature of vascular malformations and fluid State of the regional lymph glands Never forget to palpate
collections which can be pushed back into a cavity or the lymph glands that would normally receive
cistern. Compressibility should not be confused with lymph from the region occupied by the lump. The
reducibility (see below). A lump which is reducible – skin, muscles and bones of the limbs and trunk drain
such as a hernia – can be pushed away into another to the axillary and inguinal glands; the head and neck
place but will often not reappear spontaneously with- to the cervical glands; and the intra-abdominal struc-
out the stimulus of coughing or gravity. tures to the pre-aortic and para-aortic glands.
Bruits Always listen to a lump. Vascular lumps that State of the local tissues It is important to examine
contain an arteriovenous fistula may have a systolic the overlying and nearby skin, subcutaneous tissues,
bruit. Hernaie containing bowel may have audible muscles and bones, and the local circulation and
bowel sounds. nerve supply of adjacent tissues. This is more relevant
when examining an ulcer; but some lumps are asso-
Reducibility You should always see if a lump is
ciated with a local vascular or neurological abnor-
reducible (disappears) by gently compressing it.
mality, or cause an abnormality of these systems, so
A reducible lump will be felt to get smaller and then
this part of the examination must not be forgotten.
to move into another place as it is compressed. It may
disappear quite suddenly after appropriate pressure General examination It is often tempting to examine
has been applied. If you ask the patient to cough, the only the lump about which the patient is complaining.
lump may return, expanding as it does so. This is This will cause you to make innumerable misdiag-
called a cough impulse and is a feature of herniae noses. You must always examine the whole patient.
and some vascular lumps. The reduction can be
maintained by pressing over the point at which
the lump finally disappeared. In many ways the dif- HISTORY AND EXAMINATION OF
ferences between compressibility (see above) and AN ULCER
reducibility are semantic.
An ulcer is a solution (break) of the continuity of an
Relations to surrounding structures By careful palpa- epithelium (i.e. an epithelial deficit, not a wound).
tion, it is usually possible to decide which structure Unless it is painless and in an inaccessible part of the
contains the lump, and what its relation is to over- body, patients notice ulcers from the moment they
lying and deeper structures. The attachment of skin begin, and will know a great deal about their clinical
and other superficial structures to a lump can easily features.
be determined because both are accessible to the
examiner and any limitation of their movement History
easily felt. The lump should be gently moved while The questions to be asked concerning an ulcer fol-
the skin is inspected for movement or puckering. low a pattern similar to those for a lump.
Chap-01.qxd 4/19/05 13:41PM Page 33

History and examination of an ulcer 33

1. When was the ulcer first noticed? fibroblasts, bacteria and inflammatory cells), but
Ask the patient when the ulcer began and recognizable structures such as tendon or bone may
whether it could have been present for some be visible. The nature of the floor occasionally gives
time before it was noticed. The latter often some indication of the cause of the ulcer.
occurs with neurotrophic ulcers on the sole of ■ Solid brown or grey dead tissue indicates full-
the foot. thickness skin death.
2. What drew the patient’s attention to the ulcer? ■ Syphilitic ulcers have a slough that looks like a
The commonest reason is pain. Occasionally, yellow-grey wash-leather.
the presenting feature is bleeding, or a purulent ■ Tuberculous ulcers have a base of bluish
discharge, which may be foul smelling. unhealthy granulation tissue.
3. What are the symptoms of the ulcer? ■ Ischaemic ulcers often contain poor granulation
The ulcer may be painful. It may interfere with tissue, and tendons and other structures may lie
daily activities such as walking, eating or bare in their base.
defaecation. Record the history of each symptom.
4. How has the ulcer changed since it first The redness of the granulation tissue reflects the
appeared? underlying vascularity and indicates the ability of
The patient’s observations about changes in the ulcer to heal. Healing epidermis is seen as a pale
size, shape, discharge and pain are likely to be layer extending in over the granulation tissue from
detailed and accurate. If the ulcer has healed the edge of the ulcer.
and broken down, record the features of each Edge
episode.
5. Has the patient ever had a similar ulcer on the There are five types of edge (see Fig. 1.15).
same site, or elsewhere? A flat, gently sloping edge This indicates that the
Obtain a complete history of any previous ulcer. ulcer is shallow and this type of ulcer is usually
6. What does the patient think caused the ulcer?
Most patients believe they know the cause of Sloping
their ulcer, and are often right. In many cases it (a healing ulcer)
is trauma. When possible, the severity and type
of injury should be assessed. A large ulcer
following a minor injury suggests that the skin
was abnormal before the injury. Punched-out
(syphilis, trophic)
Examination
The examination of an ulcer follows the same pattern
as the examination of a lump. When an ulcer has an
irregular shape that is difficult to describe, draw it on Undermined
your notes and add the dimensions. When an exact (tuberculosis)
record of size and shape is needed, place a thin sheet
of sterile transparent plastic sheet over the ulcer and
trace around its edge with a felt-tipped pen.
After recording the site, size and shape of the ulcer, Rolled
you must examine the base (surface), edge, depth, (basal cell carcinoma)
discharge and surrounding tissues, the state of the
local lymph glands and local tissues, and complete
the general examination.

Base Everted
(squamous cell carcinoma)
The base, or floor, of an ulcer usually consists of
slough or granulation tissue (capillaries, collagen, FIG 1.15 The varieties of ulcer edge.
Chap-01.qxd 4/19/05 13:41PM Page 34

34 History taking and clinical examination

superficial, often only half-way through the skin.

Revision panel 1.13
Venous ulcers usually have this type of edge, but so
Remember the four basic techniques
do many other types of ulcer. The new skin growing
Inspection in around the edge of a healing ulcer is pale pink
Palpation and almost transparent.
Percussion A square-cut or punched-out edge This follows the
Auscultation rapid death and loss of the whole thickness of the
skin without much attempt at repair of the defect.
This form of ulcer is most often seen in the foot
Revision panel 1.14 where pressure has occurred on an insensitive piece of
A classification of the aetiology of disease skin, i.e. a trophic ulcer secondary to a neurological
defect. The classic textbook example of a punched-
Congenital
out ulcer is the ulcer of tertiary syphilis, but these
Genetic
lesions are rare today in Europe. Most of the
Sporadic
punched-out ulcers that are now seen are caused by
Acquired
the neuropathy of diabetes and peripheral arterial
Traumatic
ischaemia or, outside Europe and North America,
Inflammatory:
leprosy.
Physical
Chemical An undermined edge When an infection in an ulcer
Infection affects the subcutaneous tissues more than the skin,
Viral the edge becomes undermined. This type of ulcer is
Bacterial commonly seen in the buttock as a result of pressure
Rickettsial necrosis, because the subcutaneous fat is more sus-
Spirochaetal ceptible to pressure than the skin; but the classic
Protozoal textbook example is the tuberculous ulcer – which
Fungal is now uncommon in Europe and North America.
Helminthic A rolled edge This develops when there is slow
Mycoplasma growth of tissue in the edge of the ulcer. The edge
Prions looks like the heaped-up mound around an ancient
Neoplastic Roman earthwork. A rolled edge is typical, and almost
Benign diagnostic, of a basal cell carcinoma (rodent ulcer).
Malignant The edge is usually pale pink or white, with clumps
Primary and clusters of cells visible through the paper-thin
Carcinoma superficial covering of squamous cells. Telangiectases
Sarcoma are commonly seen in the pearly edge.
Others
Secondary An everted edge This develops when the tissue in
Degenerative the edge of the ulcer is growing so rapidly that it
Autoimmune spills out of the ulcer to overlap the normal skin. An
Proliferative everted edge is typical of a carcinoma and is seen in
Metabolic all those organs where carcinomata occur – the skin,
Hormonal in the bowel, in the bladder and in the respiratory
Mechanical tract.
Vascular
Self-induced Depth
Psychosomatic Record the depth of the ulcer in millimetres, and
Iatrogenic anatomically by describing the structures it has pen-
etrated or reached.
Chap-01.qxd 4/19/05 13:41PM Page 35

History and examination of an ulcer 35

Discharge The local lymph glands must be carefully exam-

ined. They may be enlarged because of secondary
The discharge from an ulcer may be serous, san-
infection or secondary tumour deposits and they
guinous, serosanguinous or purulent. There may be
may be tender.
a considerable quantity of discharge which is easily
visible, or it may only be apparent from inspection of
State of the local tissues
the patient’s dressings, and you may not be able to
see the features of the ulcer at all if it is covered with Pay particular attention to the local blood supply
coagulated discharge (a scab). This may have to be and innervation of the adjacent skin. Many ulcers in
removed to examine the ulcer properly. Students the lower limbs are secondary to vascular and neu-
should not do this without the permission of the rological disease. There may also be evidence of pre-
doctor in charge of the patient. vious ulcers that have healed.

Relations General examination

Describe the relations of the ulcer to its surrounding This is very important because many systemic dis-
tissues, particularly those deep to it. It is important eases as well as many skin diseases present with skin
to know if the ulcer is adherent or invading deep lesions and ulcers. Examine the whole patient with
structures such as tendons, periosteum and bone – care, looking especially at their hands and facies,
which may indicate the presence of osteomyelitis. which can supply important clues to the diagnosis.
Chap-02.qxd 4/19/05 13:41PM Page 36

2
The symptoms, signs and
emergency management of
major injuries

This is the only chapter in this book that contains of the event, it must be repeated in the hospital.
advice about management. To describe the relatively When ambulance staff are involved, they may radio
small number of symptoms and signs that accom- ahead and warn of their casualty’s likely injuries, a
pany the failure of the body’s life-supporting systems measure that allows the trauma team to be alerted
without describing how, in emergency circum- and immediately available. Patients presumed to
stances, these system failures should be treated from have sustained major injuries should be taken
the moment the signs of failure are observed would straight to the resuscitation area for their primary
be pointless. Furthermore, medical students, even hospital survey.
in their early years of learning the basic clinical Even patients thought to have minor injuries
symptoms and signs of disease, are expected by the should be carefully assessed by an experienced
general public to know how to administer emer- nurse or doctor as soon as possible, as apparently
gency first-aid measures to an injured patient. stable patients may have sustained serious injuries,
The physical signs produced by injury are usually which may have passed undetected during the ini-
more evident and immediately significant than tial assessment, especially when an influx of many
their history, especially if the patient is unconscious. injured patients overwhelms local resources.
Obtaining the history of the type of injury and the
possible forces involved, including information on
the injured person’s habits, such as drug or alcohol THE PRIMARY SURVEY AND
addictions, from the patient, family members, friends, MANAGEMENT AT THE SITE OF
onlookers or first-aiders who witnessed the event is THE EVENT: FIRST-AID
always helpful but must not interfere with the initial
rapid clinical assessment and resuscitation. This is carried out under the three easily remem-
Worldwide adoption of the principles enunciated bered headings of A, B, C, i.e.:
in the Advanced Trauma Life Support course (ATLS) ■ Airway
has established the value of a standardized approach ■ Breathing
to trauma assessment and management, especially in ■ Circulation.
patients who have sustained injuries to more than
one of their systems. This chapter follows the ATLS This approach is particularly important when
approach. assessing patients with multiple injuries.
Some injured patients are brought directly to the
accident and emergency department by ambulance, Airway
some severely injured patients may be brought in by
private vehicles, or even walk into hospital, others The signs of an obstructed airway are cyanosis
may be given treatment at the site of the event. Even (blue), apnoea (not breathing) and stridor (a rasp-
when an initial assessment has been made at the site ing noise on respiration).
Chap-02.qxd 4/19/05 13:41PM Page 37

The primary survey and management at the site of the event: first-aid 37

It is essential to protect and secure an adequate airway, a facemask, an Ambu bag and oxygen are
airway. The lungs cannot oxygenate the blood if the available. Mouth-to-mouth ventilation combined
airway is obstructed by the jaw and tongue falling with external cardiac massage may, however, be life
back, swollen soft tissues, direct damage to the upper saving in patients who have undergone a short period
airway, false teeth, vomitus or blood. of respiratory arrest.
The airway of unconscious patients lying on their There are few indications for heroic attempts at
back often becomes obstructed by their own intra- inserting home-made ‘tracheostomy’ devices at the
oral soft tissues, but before they are rolled into the scene of the accident. The patients are probably better
supine or semi-prone position, or the neck extended, served by a rapid transfer to hospital by experienced
always consider, and if possible exclude, an associ- ambulance staff who have been trained in resuscita-
ated cervical spinal injury tion techniques.
All patients found to be unconscious after an
injury must be assumed to have an associated injury Circulation
of their cervical spine because abrupt or careless turn-
ing may further dislocate or sublux a cervical vertebra It is absurd to concentrate on the detailed drills of
and injure the spinal cord when no injury existed, assessment of the airway and breathing if the patient
or turn partial cord damage into a complete tran- obviously has a normal airway and no neck injuries
section. The neck should therefore be immobilized in but is losing vast amounts of blood – even to the point
all unconscious injured patients by longitudinal, of literally bleeding to death. Severe external bleeding
manual support, the application of a hard collar and at the scene of the accident requires manual compres-
the use of stabilizing sand bags and tape before sion directly over the wound or pressure proximal to
turning the patient onto their side, until clinical the point of bleeding, where the feeding artery can
examination and radiographs have excluded unsta- be compressed against an underlying bony point.
ble fractures of the cervical spine. Tourniquets should only be used to stop distal
Compromises are inevitable if an immobilizing limb bleeding. They rarely work efficiently and often
collar is not available at the site of injury. The presence exacerbate bleeding by obstructing the venous out-
of two first-aiders may allow one to support the neck flow, while failing to occlude the arterial inflow.
while the other assesses and manually clears the air- An effective tourniquet makes the whole limb
way, feels the neck and jaws, and assesses the respira- ischaemic and will cause permanent muscle and
tory effort by palpating the chest during respiration. nerve damage if it is kept in place for more than 1.5
Airway obstruction is often relieved by lifting the to 2 hours. Tourniquets can also theoretically cause
jaw upwards, but may only be relieved by inserting a re-perfusion problems when released – metabolic
finger in the mouth and pulling the jaw or palate acidosis, myoglobulinuria and hypercalcaemia. Never-
forward, especially when the obstruction is associ- theless a tourniquet can sometimes be life saving if it
ated with a fractured maxilla or mandible. is applied at the correct pressure to a mangled bleed-
An oropharyngeal or nasopharyngeal airway ing limb for a short period. The time of application
should be inserted as soon as possible, and then, must be carefully recorded and passed on to ambu-
in an unconscious patient, replaced by an endotra- lance and medical staff.
cheal tube, inserted by an experience anaesthetist, Direct manual pressure, provided it is achieving its
because the absence of a gag reflex in an uncon- desired effect (i.e. stopping or reducing the blood
scious patient makes aspiration of saliva, vomitus or loss), is usually preferable to a tourniquet. This can be
blood into the lungs a major hazard. very tiring because it must be maintained until the
patient reaches the hospital’s accident and emergency
Breathing department.

If the patient remains cyanosed or apnoeic after the General first-aid advice
airway has been cleared, mouth-to-mouth resusci-
tation should be started immediately. This is easier First-aiders should ensure that there is no immediate
and safer (from risks of cross-infections) if a Brook’s danger to themselves before approaching a casualty.
Chap-02.qxd 4/19/05 13:41PM Page 38

38 The symptoms, signs and emergency management of major injuries

Many injured patients are best served by leaving them may all indicate the need for endotracheal or naso-
where they are until experienced help arrives, pro- gastric intubation once the neck has been stabilized.
vided the environment is not continuing to damage
or threaten them. Provided the injured patient has Look for the signs of inadequate ventilation
a strong pulse, is breathing normally and is not The chest should be uncovered and palpated to
overtly bleeding, this is invariably the correct course assess respiratory movements. Confirm the pres-
of action. Patients should only be moved if there is a ence of air entry into the lungs with a stethoscope.
risk of further injury from leaving them where they The neck and jaws should be palpated to check for
are, e.g. inside a burning car. deformity. Insert a finger into the mouth to extract
It is, of course, important to obtain help as soon any foreign bodies and to check for jaw fractures.
as possible so that there is always someone available Occasionally severe damage to the upper airways or
to stay with the patient to monitor their pulse and trachea makes intubation impossible. An emergency
breathing and provide moral support. The wide- tracheostomy is indicated if the patient is deeply
spread availability of mobile phones has improved cyanosed or apnoeic and an endotracheal tube can-
the first-aider’s ability to summon help. not be inserted safely.
Under no circumstances should an injured patient
be given anything to eat or drink. Breathing
Assess the condition and function of
THE PRIMARY SURVEY IN THE the thoracic cage
ACCIDENT AND EMERGENCY Once you are certain that the airway is patent, assess
DEPARTMENT the adequacy of ventilation by inspecting, palpating,
percussing and listening to the chest for symmetry,
All patients who are unconscious or suspected of
movement, dullness and breath sounds. Patients
having multiple or serious injuries should be admit-
with multiple injuries or chest problems causing
ted directly to the resuscitation area of the accident
hypoxia should be given high-flow oxygen through
and emergency department. While medical students
a closed circuit oxygen mask from the moment of
are rarely required to have an active role in the man-
their arrival in the accident and emergency depart-
agement of acute trauma, the opportunity to wit-
ment. An oxygen saturation monitor placed on an
ness assessment and resuscitation in this setting is
extremity is a valuable means of assessing the effec-
extremely valuable, as the principles of the process
tiveness of the patient’s ventilation.
are relevant to many other areas of medical practice.
The clinical assessment (history and examination) Inspection and palpation
and resuscitation must occur simultaneously if lives The presence of open wounds or flail segments in
are to be saved, hence the inclusion of treatment in the chest indicates the need for a chest drain and
this chapter. positive-pressure ventilation. A flail segment occurs
The routine A, B, C assessment must be repeated when several ribs are fractured in two places. The flail
whatever happened before the hospital admission. segments sink inwards during inspiration. Bruising
over the chest indicates that rib fractures are likely,
Airway and the presence of surgical emphysema suggests that
the pleura has been breached. Surgical emphysema
The neck must be protected by a collar and immobi- presents as a crackling sensation in the subcutaneous
lized fully using sand bags and tape. An anaesthetist tissues. A ‘sucking’ chest wound may be present.
should assess the need for better control of the airway.
Percussion
Look for the signs of inadequate oxygenation A tension pneumothorax must be suspected if
Respiratory distress, apnoea, cyanosis, loss of con- breathing is difficult, the trachea is deviated to the
sciousness and the presence of major facial, neck contralateral side and if there is decreased air entry
or chest injuries that might obstruct the airway over the affected lung. Although the clinical diagnosis
Chap-02.qxd 4/19/05 13:41PM Page 39

The primary survey in the accident and emergency department 39

will have to be confirmed with a chest radiograph, a breathing satisfactorily. It can be assessed simultane-
chest drain should be inserted on the evidence of ously with the airway and breathing if an experienced
the clinical signs if the patient is unstable. Bilateral anaesthetist is available to manage ventilation.
tension pneumothoraces are very rare, but cause There are two major causes of circulatory embar-
severe cardiac and respiratory compromise, mani- rassment – cardiac damage/tamponade and haemor-
fest as cyanosis, severe air hunger, a weak pulse and rhage. The former is rare but life threatening and
hypotension. easily missed. It must therefore be briefly considered
Remember that, with bilateral pneumothoraces, in all patients with major injuries, especially in those
the trachea remains central but air entry is poor into with penetrating injuries of the chest.
both lungs. The rapid insertion of chest drains
which are connected to under-water seal drainage Cardiac tamponade
bottles relieves the situation. Cardiac tamponade occurs when large quantities of
A large haemothorax also causes respiratory and blood collect within the pericardial cavity, around the
circulatory problems, manifest as reduced breath heart, and embarrass its action. This reduces the car-
sounds and a dull percussion note combined with diac output, producing a weak pulse and hypoten-
reduced vocal fremitus and vocal resonance. The sion. The condition should be suspected if the jugular
diagnosis should be confirmed with an erect or venous pressure is markedly elevated and rises
decubitus chest radiograph, but a chest drain may rather than falls with inspiration (Kussmaul’s sign);
occasionally have to be inserted as an emergency however, jugular venous distention may not occur
measure on the basis of the clinical signs. in a patient who has lost a large quantity of blood.
A large amount of blood draining from a chest Pulsus paradoxus, when the pulse volume
may destabilize the patient and need urgent replace- decreases on inspiration rather than increasing, may
ment into the circulation (see below), so intravenous be present. The heart sounds are usually muffled and
lines should be inserted into both antecubital fossae poorly heard.
before a haemothorax is drained. The chest drain may Chest radiographs may show an enlarged car-
occasionally need to be clamped to prevent massive diac shadow. An echocardiogram will confirm the
continuing blood loss. Lost blood should be replaced diagnosis.
with a crystalloid solution at first, but subsequently The patient’s condition may be stabilized by
with blood as soon as this is available (see below). aspirating the blood from the pericardial sac using
The blood pressure must be carefully and contin- echocardiography and electrocardiography to ensure
uously monitored to confirm the adequacy of any correct placement of the needle and catheter before
blood volume replacement. definitive surgery is undertaken.
Flail segments rarely cause major problems ini-
tially but are indicative of a severe underlying lung Revealed haemorrhage
injury. Both these problems are treated by endotra- Visible arterial bleeding presents as a pulsating
cheal incubation and positive-pressure ventilation, stream of bright red blood coming from an open
but it must be remembered that this can cause a wound, whereas venous bleeding is dark and con-
tension pneumothorax and may also make an exist- tinuous. Arterial haemorrhage from an open wound
ing tension pneumothorax worse. This complica- can usually be controlled by direct digital pressure
tion should be suspected if the anaesthetist notices or proximal arterial compression. Sterile vascular
an increasing resistance to ventilation, a decreasing clamps can be applied directly to bleeding arteries for
oxygen saturation and signs of circulatory embar- temporary control before definitive surgery if these
rassment. Decreasing air entry and breath sounds simple measures fail.
indicate the need for chest drainage. Venous bleeding always responds to simple
pressure and may be made worse by the application
Circulation of a tourniquet.
Revealed bleeding should always be assessed and
Restoration of the circulation may take precedence controlled as soon as possible. There is no point in
over the airway and ventilation if the patient is pouring fluid and blood into the circulation through
Other documents randomly have
different content
danger prompted the pen of either party in the war to exhibit the
military strength of this confederacy, in its utmost power; and we
may rest here, as a safe point of comparison, or, at least, we cannot
admit a higher population.

By the census returns herewith submitted, the aggregate population

of the three full, and four fragmentary cantons, namely, the Oneidas
and Cayugas, &c. still residing within the State, are denoted to be as
follows, namely:

Senecas, 2,441
Onondaga, 398
Tuscaroras, 281
Oneidas, 210
Cayugas, 123
Mohawks, 20
St. Regis Canton, 360

By a statement submitted to Congress, on the 3d of December,

1844,9 the number of Oneidas, settled in Wisconsin, is put at 722;
the number of Senecas, who have removed from Ohio into the
Indian territory west of the Mississippi, at 125, and the number of
mixed Senecas and Shawnees, at the same general location, at 211.
Deducting one-half of the latter, for Shawnees, and there is to be
added to the preceding census, in order to show the natural increase
of the Iroquois, 953 souls. The number of the St. Regis tribe, who
are based, as a tribe, on the Praying Indians of Colden,—a band of
Catholic Mohawks originally located at Caughnawaga is shewn by the
present year’s census to be 360. There are, at the village of
Cornplanter, within the bounds of Pennsylvania, as numbered by me,
the present year, 51 Senecas. Supposing that the Mohawks and
Cayugas who fled to Canada at and after the revolutionary war, and
who are now settled at Brantford on Grand river, Canada West, have
merely held their own, in point of numbers, and deducting the
number of Cayugas, namely, 144, found among the Senecas of
Cattaraugus, and herewith separately returned, and taking Dalton’s
estimate of the Mohawks and Cayugas in 1776, namely, 300 warriors
for each tribe, there is to be added, to the census, to accomplish the
same comparative view, two thousand eight hundred and fifty souls.
From this estimate, there must be deducted, for a manifest error, in
the original estimates of Dalton, in putting the Cayugas on the same
footing of strength with the Mohawks, not less than 150 warriors or
750 souls, leaving the Canadian Iroquois at 2,106—say 2,000 souls.

9 Vide Doc. No. 2, Ho. of Reps., 28th Congress, 2d Session.

Adding these items to the returns of the present census, and the
rather extraordinary result will appear, that there is now existing in
the United States and Canada a population of 6,942 Iroquois, that is
to say, but 2,108 less than the estimated number, and that number
placed as high as it well could be, at the era of the revolution in
1776. Of this number, 4,836 inhabit the United States, and 3,843 the
State of New-York. I cannot, however, submit this result without
expressing the opinion, that the Iroquois population has been lower,
between the era of the revolutionary war and the present time, than
the census now denotes; and that for some years past, and since
they have been well lodged and clothed and subsisted by their own
labor, and been exempted from the diseases and casualties incident
to savage life, and the empire of the forest, their population has
recovered and IS NOW ON THE INCREASE.

I have thus brought to a close, so far as relates to their population

and industrial efforts, the inquiry committed to me respecting this
nation. It would perhaps have gratified statistical curiosity and
philosophical theory, to have exhibited fuller data on the subject of
their longevity and vital statistics generally, but it may be considered
in the light of an achievement to have accomplished thus much. The
general result indicates five, with a large fraction, as the average
number of the Iroquois family. Throughout each canton, the number
of females predominates over the males. This is a fact which has
been long known to hold good with respect to wandering, predatory
and warlike tribes, but was not anticipated among peaceful,
agricultural communities. But few years, however, have supervened
since they dropped the hatchet and took hold of the plough; and in
this time, it is apparent that the proportion of males to females has
approached nearer to an equilibrium. The effects on vitality of
agricultural labor and a cessation from war, are likewise favorable, so
far as we can judge, compared with the known results among the
sparse, ill fed, warring and errating hunters of the western forests
and prairies. The average number of the Iroquois family is not higher
than the common average of the hunter state. The number of
children borne by each female is a considerable fraction over four. Of
a population of 312 Tuscaroras, five have reached to and passed the
age of 80, or over 1¾ per cent. Among the Senecas and Cayugas of
Cattaraugus, the per centage is 1½, with a smaller fraction, 12
persons in 808 having passed that limit. Local causes have
diminished this to one per cent nearly on the Buffalo reservation. On
the contrary, it is found to be increased in the valley of the Alleghany
to full two per cent. The ruling chief of that tribe, Ten won ny ahs, of
Teonegono, commonly called Blacksnake, is now in his ninety-sixth
year, and is active and hale, and capable of performing journies to
the annual assemblies of his people at Buffalo.

I should not have fulfilled the principal object in view, without

directing some attention to the effects of the labors of past years in
the introduction, into the Iroquois cantons, of education, letters and
Christianity. So much of this branch of the inquiry as admits of
arithmetical notice, will appear, either under the ordinary heads of
the census, or the additional columns which have been prepared
under the headings of “statistics of occupation and of morality.” The
residue, comprising some remarks on the schools and churches, the
present state of Iroquois society and manners, and the general
condition and prospects of the cantons, will be included in the
supplementary report and documents. I shall also defer to the same
time, a particular notice of their annuities, and the extent of their
ancient domain, and the periods of its cession to the State or
general government.
In closing this report, it may be well to notice the fact that there are
yet remaining in the State, some vestiges of the Algonquin race,
who, under various distinctive names, occupied the southern portion
of the State at the era of its discovery and colonization. As the
language of the census act refers to such Indians only as live on the
“reservations,” I have not felt it to be within the scope of my
appointment to search out and visit these scattered individuals,
although I should have been gratified to make this inquiry. It is
believed that they are comprised by about twenty of the Shinecock
tribe, who yet haunt the inlets and more desolate portions of Long
island, and by a very few lingering members of the ancient
Mohegans, who, under the soubriquet of Stockbridges, yet remain in
Oneida county. The bulk of this people, so long the object of
missionary care, migrated to the banks of Fox river and Winnebago
lake, in Wisconsin, about 1822. They were followed to that portion
of the west, about the same time, or soon after, by the small
consolidated band of Nanticokes, Narragansetts, and other early
coast tribes, who, in concentrating in the Oriskany valley, after the
close of the revolutionary war, dropped their respective languages,
learned the English, and assumed the name of Brothertons. Both
these migrated tribes were in an advanced state of semi-civilization,
and were good farmers and herdsmen at the era of their removal.

I am, sir,
With respect,
Your ob’t servant,
HENRY R. SCHOOLCRAFT,
Marshal under the 15th section of the census act.

Hon. Nathaniel S. Benton,

Secretary of State.
 SUPPLEMENTARY REPORT.
Of Henry R. Schoolcraft to the Secretary of State.

ANTIQUITIES—HISTORY—ETHNOLOGY.

New-York, January 7th, 1846.

Sir:—I have now the honor to submit a supplementary report,

embracing minutes and remarks on the aboriginal history, antiquities
and general ethnology of Western New-York, made in accordance
with an expression permitting the collection of such materials in your
general instructions of the 26th of June last.

To these details I have prefixed some general considerations on the

early period of the Iroquois history, the affinities of the several
tribes, and the era and principles of their confederation; the
antiquarian remains and general archæology of the western
countries; the ancient state of Indian art; some traits of their
traditions and religion; and a few connected topics which, it is
hoped, will tend to render the report more acceptable and valuable.

I regret, indeed, that time has not permitted me to enter more fully
on some of the topics introduced, and that of others, I have been
obliged to cut them short or omit them altogether, including the
subject of their languages, geographical terminology, and personal
names, the latter of which is a very curious inquiry of itself. I confess
it would have fallen in with my inclinations, as well as my
conceptions of the true nature and extent of the inquiries confided
to me, to have extended them to other parts of the State, and given
a more complete view of our ethnology, had it been practicable to do
so before the meeting of the Legislature.

I cannot, however, close this note without expressing the hope that
the Legislature will authorize you to take further measures for
completing the work. There are a large number of the class of
antique, circular and elliptical works scattered over the western and
southwestern part of the State, of an age anterior to the discovery,
which it would be important to examine and describe. These chiefly
lie west of Cayuga, and upon the sources of the Susquehanna.
Interspersed amid this system of common ring-forts of the west
there are some of a still earlier period, which exhibit squares and
parallelograms, yet without any defensive work in the nature of
bastions.

The area of early French occupancy, or attempt at colonization,

within the State, extends east and west between the waters of the
Cayuga and Oneida lakes, as general boundaries, having the county
of Onondaga as its chief and central point. This area will
comprehend the most striking part of the numerous remains of
implements of art, and other antiquities of European origin, which
have heretofore excited attention. How far these evidences extend
north is not known. But any examination of either the aboriginal or
foreign remains would be incomplete which did not extend also
along the line of the St. Lawrence and the waters of Lake
Champlain.

The valley of the Hudson, and the southern part of the State
generally, although it has not been explored with this view, is known
to have some antiquarian features worthy examination. And were
there none others than the artificial shell mounds and beds on the
sea coast and the fossil bones of the valley, so remarkable in
themselves, these would alone be entitled to the highest interest in
studying the ancient history of the races of man in this area.

Geological action subsequent to the period of the habitation of the

globe, has not been examined with this view, but is believed to be
important in denoting eras of former occupancy; it is known that
various parts of the State have yielded, at considerable depths below
the surface, many curious evidences of artificial remains, along with
relics of the animal and vegetable kingdoms.

There is an apparent extension of the system of works which

characterize the fort and mound period of the Ohio valley, reaching
from the Alleghany waters in Chautauque and Cattaraugus, along
the southern shore of Lake Erie, indefinitely eastward, which it
would be interesting to trace.

One of the most reliable proofs of eras and races of men is found in
the remains of art.

There are some striking coincidences in this respect between the

antiquities of New-York and the Mississippi valley, which denote
precisely the same state of arts and the same eras of occupancy.
Such are the Minace Alleghanic which occurs alike in the Grave
Creek mound and the simple places of sepulture in Onondaga, the
Nabikoaguna Antique, which has been found at Upper Sandusky and
at Onondaga; and the Medaëka Missouri, from the valley of the
Sciota, in Ohio, and the Kasonda in New-York.

Accurate descriptions of the whole class of our antiquarian remains

could not, if thoroughly executed, but throw much light on, and
introduce precision in, periods of remote history in this State, and
indeed the continent, which are now either involved in obscurity, or
constitute themes of mere conjecture.
 I. HISTORICAL AND ETHNOLOGICAL
MINUTES.
MADE ON TAKING THE CENSUS OF THE IROQUOIS
OF NEW-YORK, IN CONFORMITY WITH AN ACT OF
THE LEGISLATURE, IN 1845.

[a.] A Sketch of the Iroquois Groupe of Aboriginal

Tribes.

On the discovery of North America, the Iroquois tribes, were found

seated chiefly in the wide and fertile territory of western and
northern New-York, reaching west to the sources of the Ohio;10
north, to the banks of Lake Champlain and the St. Lawrence; and
east, to the site of Albany. They had as much nationality of
character, then, as any of the populous tribes, who, in the 4th
century wandered over central and western Europe. They were, in a
high degree, warlike, handling the bow and arrow with the skill and
dexterity of the ancient Thracians and Parthians. They were
confederated in peace and war, and had begun to lay the
foundations of a power, against which, the surrounding nations, in
the Mississippi valley, and along the St. Lawrence, the Hudson, and
the Delaware, could not stand. The French, when they effectually
entered the St. Lawrence in 1608,11 courted their alliance on the
north, and the Dutch did the same in 1609, on the Hudson. Virginia
had been apprised of their power, at an early day, and the other
English colonies, as they arrived, were soon made acquainted with
the existence of this native confederacy in the north. By putting fire-
arms into their hands, they doubled the aboriginal power, and
became themselves, for more than a century, dependant on their
caprice or friendship.

10 They always denominated the Alleghany river by the name of

Ohio. This I found to be the term constantly used for that river
in 1845. They give the vowel i, in this word, the sound of i, in
machine.

11 They actually discovered this river, in 1535.

The word Iroquois, as we are told by Charlevoix, who is a competent

and reliable witness on this point, is founded on an exclamation, or
response, made by the sachems and warriors, on the delivery to
them, of an address. This response, as heard among the Senecas, it
appeared to me, might be written eoh; perhaps, the Mohawks, and
other harsher dialects of this family, threw in an r, between the
vowels. It is recorded in the term Iroquois, on French principles of
annotation, with the substantive inflection in ois, which is
characteristic of French lexicography. It is a term which has been
long, and extensively used, both for the language and the history of
this people; and is preferable, on enlarged considerations, to any
other. The term Five Nations, used by Colden, and in popular use
during the earlier period of the colony, ceased to be appropriate
after the Tuscarora revolt in North Carolina, and the reunion of this
tribe with the parent stock, subsequent to 1712. From that period
they were called the Six Nations,12 and continued to acquire
increased reputation as a confederacy, under this name, until the
termination of the American Revolution in 1783, and the flight of the
Mohawks and Cayugas to Canada, when this partial separation and
breaking up of the confederacy, rendered it no longer applicable.
 12 In 1723, they adopted the Necariages, as a Seventh Nation, as
will be noticed under the appropriate head.

The term New-York Indians, applied to them in modern days, by the

eminence in their position, is liable to be confounded, by the
common reader, with the names of several tribes of the generic
Algonquin family, who formerly occupied the southern part of the
State, down to the Atlantic. Some of these tribes lived in the west,
and owned and occupied lands, among the Iroquois, until within a
few years. And, at any rate, it is too vague and imprecise a term to
be employed in philology or history.

By the people themselves, however, neither the first nor the last of
the foregoing terms appear ever to have been adopted, nor are they
now used. They have no word to signify “New-York” in a sense more
specific, than as the territory possessed by themselves—a claim
which they were certainly justified in making, at the era of the
discovery, when they are admitted, on all hands, to have carried
their conquests to the sea.

The term Ongwe Honwe, or a people surpassing all others, which

Colden was informed they applied proudly to themselves, may be
strictly true, if limited, as they did, to mean a people surpassing all
other red men. This they believed, and this was the sense in which
they boastfully applied it. But it was a term older than the discovery,
and had no reference to European races. The word Honwe, as will
appear by the vocabulary hereto appended, means man. By the
prefixed term Ongwe, it is qualified according to various
interpretations, to mean real, as contradistinguished from sham
men, or cowards; it may also mean strong, wise, or expert men,
and, by ellipsis, men excelling others in manliness. But it was in no
other sense distinctive of them. It was the common term for the red
race of this continent, which they would appear, by the phrase, to
acknowledge as a unity, and is, the word as I found it, used at this
day, as the equivalent for our term “Indian.”
Each tribe had, at some period of their progress, a distinctive
appellation, as Onondaga, Oneida, &c. of which some traditionary
matter will be stated, further on. When they came to confederate,
and form a general council, they took the name of Konoshioni, (or as
the French authors write it, Acquinoshioni), meaning literally, People
of the Long House, and figuratively a United People, a term by which
they still denominate themselves, when speaking in a national sense.
This distinction, it is well to bear in mind, and not confound. This
Long House, to employ their own figure, extended east and west
from the present site of Albany to the foot of the great lakes, a
distance, by modern admeasurement, of 325 miles, which is now
traversed by railroad. An air palace, we may grant them, having
beams and rafters, higher and longer than any pile of regal
magnificence, yet reared by human hands.

Thus much may be said, with certainty, of the name of this

celebrated family of red men, by which they are identified and
distinguished from other stocks of the hunter tribes of North
America. Where they originated, relatively to their position on this
continent, the progress of ethnology does not, at this incipient
period of that science, enable us to determine, nor is it proposed,
save with the merest brevity, now to inquire. Veiling their own origin,
if anciently known, in allegory, or designing by fancy to supply the
utter want of early history, to the intent, perhaps, that they might
put forth an undisputed title to the country they occupied, the
relations of their old sages affirm that they originated in the
territorial area of western New-York. Their tradition on this point, as
put on record by the pen of one of their own people, (see extracts
from Cusic’s historical and traditionary tract, hereto appended,) fixes
the locality of their actual origin at an eminence near the falls of the
Oswego river. To cut short the narration, they assert that their
ancestors were called forth, from the bowels of a mountain, by
Tarenyawagon, the Holder of the Heavens. It represents them as one
people, who moved first towards the east, as far as the sea, and
then fell back, partly on their own tracks, towards the west and
southwest. So far, and so far only, the tale appears credible enough,
and as there is no chronology established by it, although dates are
freely introduced, and consequently nothing to contradict it, their
track of migration and countermigration from the Oswego, may be
deemed as probable.

The diversities of language, and the separation into tribes, are

represented to have taken place, according to known principles of
ethnological inference.

Ondiyaka, an Onondaga sage, and the ruling chief of the

confederacy, who died on an official visit to the Oneidas in 1839, at
the age of ninety, confirmed these general traditions of the
Tuscarora scribe. He informed Le Fort, who was with him in that
journey and at his death, that the Onondagas were created by
Neo,13 in the country where they lived; that he made this island or
continent, “Hawoneo,” for the red race, and meant it for them alone.
He did not allude to or acknowledge any migration from other lands.
This, Le Fort, himself an Onondaga, a chief, and an educated man,
told me during the several interviews I had with him, the present
year, at the Onondaga Castle.

13 The term “Neo,” God, is generally used reverently, with a

syllable prefixed in the different Iroquois dialects, as Yawa-Neo,
in the Tuscarora, Howai-Neo in the Seneca, Hawai-Neo,
Onondaga, Lawai-Neo, Mohawk, &c.

Ondiyaka proceeded to say, as they walked over the ancient ruins in

the valley of the Kasonda,14 that this was the spot where the
Onondagas formerly lived, before they fixed themselves in the
Onondaga valley, and before they had entered into confederation. In
those days they were at enmity with each other; they raised the old
forts to defend themselves. They wandered about a great deal. They
frequently changed their places of residence. They lived in perpetual
fear. They kept fighting, and moving their villages often. This
reduced their numbers, and rendered their condition one of alarms
and trials. Sometimes they abandoned a village, and all their
gardens and clearings, because they had encountered much
sickness, and believed the place to be doomed. They were always
ready to hope for better luck in a new spot. At length they
confederated, and then their fortifications were no longer necessary,
and fell into decay. This, he believed, was the origin of these old
ruins, which were not of foreign construction.15 Before the
confederacy, they had been not only at war among themselves, but
had been driven by other enemies.16 After it, they carried their wars
out of their own country, and began to bring home prisoners. Their
plan was to select for adoption from the prisoners, and captives, and
fragments of tribes whom they conquered. These captives were
equally divided among each of the tribes, were adopted and
incorporated with them, and served to make good their losses. They
used the term, We-Hait-Wat-Sha, in relation to these captives. This
term means a body cut into parts and scattered around. In this
manner, they figuratively scattered their prisoners, and sunk and
destroyed their nationality, and built up their own.

14 Butternut Creek, which runs through parts of the towns of

Pompey, Lafayette and De Witt, Onondaga county.

15 This remark must be considered as applied only to the class of

simple ring forts, so frequent in western New-York. These forts
are proved by antiquarian remains, forest growth, &c. to be the
most ancient of any works, in Onondaga county, in the shape of
forts.

16 Colden represents them as driven by the Algonquins, on the

discovery of Canada.

At what period they confederated, we have no exact means of

deciding. It appears to have been comparatively recent, judging
from traditionary testimony.17 While their advancement in the
economy of living, in arms, in diplomacy and in civil polity, would
lead conjecture to a more remote date. Their own legends, like
those of some other leading stocks of the continent, carry them back
to a period of wars with giants and demons and monsters of the sea,
the land, and the air, and are fraught with strange and grotesque
fancies of wizards and enchanters. But history, guiding the pen of
the French Jesuit, describes them first as pouring in their canoes
through the myriad streams that interlace in western New-York, and
debouching, now on the gulf of the St. Lawrence, now on the
Chesapeake—glancing again over the waves of Michigan, and now
again plying their paddles in the waters of the turbid Mississippi.
Wherever they went, they carried proofs of their energy, courage,
and enterprise.

17 Vide Pyrlaus.

At one period we hear the sound of their war cry, along the straits of
the St. Mary’s and at the foot of Lake Superior. At another under the
walls of Quebec, where they finally defeated the Hurons under the
eyes of the French. They put out the fires of the Gahkwas and Eries.
They eradicated the Susquehannocks. They placed the Lenapees,
the Nanticokes, and the Munsees under the yoke of subjection. They
put the Metoacks and the Manhattans under tribute. They spread
the terror of their arms over all New-England.

They traversed the whole length of the Appalachian chain, and

descended like the enraged Gish and Megalonyx, on the Cherokees
and the Catawbas. Smith encountered their warriors, in the
settlement of Virginia, and La Salle on the discovery of the Illinois.
Nations trembled when they heard the name of the Konoshioni.

They possessed a fine physical structure—they lived in a climate

which imparted energy to their motions. They used a sonorous and
commanding language, which had its dual number, and its neuter,
masculine, and feminine genders. They were excellent natural
orators, and expert diplomatists. They began early to cherish a
national pride, which grew with their conquests. They had, like the
Algonquins, in the organization of the several clans, or families,
which composed each tribe, a curious heraldic tie, founded on
original relationship, which exercised a strong influence, but which
has never been satisfactorily explained. They were governed by
hereditary chieftaincies, like others of the aboriginal stocks, but
contrary to the usage of these other stocks, the claims of their
chiefs, were subjected to the decision of a national council. The
aristocratic and democratic principles, were thus both brought into
requisition, in candidates for office. But in all that constituted
national action, they were a pure Republic. So far was this carried,
that it is believed the veto of any one chief, to a public measure, was
sufficient to arrest its adoption by the Council.

In the development of their nationality, they have produced several

men of energy and ability, who were equal, in natural force of
character, to some of the most shining warriors and orators of
antiquity. Few war captains have exceeded Hendrick, Brant or
Skenandoah. The eloquence and force of Garangula, Logan and Red
Jacket, in their public speeches, have commanded universal
admiration. Mr. Jefferson considered the appeal of Logan to the
white race, after the extirpation of his family, as without a parallel;
and it has been imitated in vain, by distinguished poets and orators.

Such were the aboriginal people who occupied western New-York,

and their memory will forever live in the significant names which
they have bestowed upon Niagara and Ontario, and a thousand
lesser waters, which beautify and adorn the land. Viewed as one of
the Indo-American stocks, they possessed some very striking traits.

Few barbarous nations have ever existed on the globe, who have
shown more native energy, and distinctiveness of character. Still
fewer who have evinced so firm a devotion to the spirit of
independence. Yet all their native manliness and energy of character
and action, would have failed, or become inoperative, had they not
abandoned the fatal Indian principle of tribal supremacy, or
independent chieftainships, and made common cause in a national
confederacy. The moment this was done, and each of the
component clans or tribes, had surrendered the power of
sovereignty to a general council of the whole, the foundation for
their rise was laid, and they soon became the most powerful political
body among the native tribes of North America, this side of the
palace of Montezuma.

In visiting the descendants of such a people, after a lapse of more

than two centuries and a quarter from the discovery, it was the
impulse of the commonest interest, to make some inquiries into their
former history, and antiquities. These have been pursued under
favorable circumstances, for the most part, at all points of my
journey, and have been resumed, when broken off, whenever
practical. The only method pursued, was to obtain all the facts
possible, from red or white men, of reliable testimony. There was no
time and no intention, to digest them, into a connected history. They
were collected in the pauses which intervened, in the obtaining of
the statistics of the census, and they are contributed herewith, in the
simple garb and freshness of the original minutes. Those who
related the traditions, did not suppose themselves to be delivering
the important lore of their history. They were related, along the
road, or seated around the evening circle, as the current belief of
the people. Sometimes the fields or hills, disclosing the localities of
old forts, were the scene of the narrations; sometimes the Indian
burial ground; sometimes more formal interviews. He who gleans
popular traditions among this race, must have his ear ever open, his
memory under notice “to retain,” and his pen or pencil ever ready.

Historical and biographical notices, names of places, and sketches of

antiquarian remains, were thus entered on or dropped, as time or
occasion prompted. To make minutes of what occurred, was all that
time permitted me; but it was a rule, to make them promptly and on
the spot. This much seemed necessary in despatching this portion of
my report, with the miscellaneous details accompanying it; and
having accomplished this object, my present task is terminated.
 [b.] Ethnological Suggestions.

Where we have nothing else to rely upon, we may receive the rudest
traditions of an Indian nation, although they be regarded as mere
historical phenomena, or materials to be considered. Whether such
materials are to be credited or disbelieved wholly, or in part, is quite
another thing. Our Indians, like some of the ancient nations of Asia,
whom they resemble in many points of character, were prone to
refer their origin to myths and legends, under which they doubtless,
sometimes meant to represent truths, or at least, to express
opinions. The Indian tribes, very much like their ancient prototypes
of the old world, seemed to have felt a necessity for inventing some
story of their origin, where it is sometimes probable there was little
or nothing of actual tradition to build it upon. They were manifestly
under a kind of self-reproach, to reflect that they had indeed no
history; nothing to connect their descent from prior races; and if
they have not proved themselves men of much judgment in their
attempts to supply the deficiency in their fabrications and allegories,
they must often come in, it must be confessed, for no little share of
imagination.

There appears, throughout the whole race, to be the vestiges of a

tradition of the creation and the deluge, two great and striking
points in the history of man, which, however he wandered, he would
be most likely to remember. They uniformly attribute their origin to a
superior and divine power. They do not suppose that they came into
existence without the act of this pre-existing almighty power, who is
called NEO, or OWANEO. This is the third great and leading point in
their traditions. And these three primary vestiges of the original
history of the race are to be found among the rudest tribes, between
the straits of Terra del Fuego and the Arctic Ocean, notwithstanding
the amount of grotesque and puerile matter which serves as the
vehicle of the traditions.
Between the creation and the deluge and the present era of the
world, there is nearly an entire blank. Ages have dropped out of
their memory, with all their stirring incidents of wars and migrations,
and the first reliable truth we hear is, that at such a time they lived
on the banks of the Mississippi, the Ohio, the Lakes, or the St.
Lawrence, &c. Nothing but this kind of proximate origin could indeed
be expected to be retained. They acknowledge relationship to no
prior race of man. We see that they are sui generis with, and much
resemble some of the eastern nations in color and features.
Physiologists have never been able to detect a bone or muscle, more
or less, than the Caucasian race possess. Philologists listen to their
speech and admit that in one tribe or another they possess all the
powers of articulate utterance known to that race. We know by this
kind of evidence, physical and moral, that they are a branch of the
original Adamic stock, without reference to the pages of revelation,
where we learn the same truth, and are told in so many words, that
“God out of one flesh, formed all men.” And we must perforce infer,
that the Indian race is of foreign origin, and must have crossed an
ocean to reach the continent.

Ask not the red sage to tell you how? or when? or where? He knows
it not, and if he should pretend to the knowledge, it would be the
surest possible evidence, philosophically considered, that his
responses were fabulous. Three hundred and fifty-three years only
has America been known to Europe, and yet should we strike our
history out of existence, what should we know of the leading facts of
the discovery and the discoverer from Indian tradition? Still the
inquisitive spirit of research leads us to ask, where were this race
eighteen hundred and forty-five years ago? or at the invasion of
Britain by Julius Cæsar? or at the outpouring of the Gothic hordes
under Alaric or Brennus? Scandinavian research tells us they were
here in the 10th century. The Mexican picture writings inform us that
some of them reached the valley of Mexico in the 11th century.
Welsh history claims to have sent one of her princes among them in
the 12th century. The mounds of the Mississippi valley do not appear
to have had an origin much earlier. The whole range of even
historical conjecture is absolutely limited within eight or nine
hundred years. Nothing older, of their presence here certainly, is
known, than about the time of the crowning of Charlemagne, A. D.
800, unless we take the Grecian tradition of Atlantis.

That we have nothing in the way of tradition older than the dates
referred to, is no positive proof that the tribes were not upon the
continent long prior. There are some considerations, in the very
nature of the case, which argue a remote continental antiquity for
these tribes. It is hardly to be supposed that large numbers of the
primitive adventurers landed at any one time or place; nor is it more
probable that the epochs of these early adventurers were very
numerous. The absolute conformity of physical features renders this
improbable. The early migrations must have been necessarily
confined to portions of the old world peopled by the Red Race—by a
race, not only of red skins, black hair and eyes, and high cheek
bones, who would reproduce these fixed characteristics, ad
infinitum, but whose whole mental as well as physiological
development assimilates it, as a distinct unity of the species. While
physiology, however, asserts this unity, in the course of the
dispersion and multiplication of tribes, their languages, granting all
that can be asked for on the score of original diversity, became
divided into an infinite number of dialects and tongues. Between
these dialects, however, where they are even the most diverse, there
is a singular coincidence in many of the leading principles of concord
and regimen, and polysynthetic arrangement. Such diversities in
sound, amounting, as they do in many cases, for instance, in the
stocks of the Algonquin and Iroquois, to an almost total difference,
must have required many ages for their production. And this fact
alone affords a proof of the continental antiquity of the American
race.

[c.] Indian Cosmogony.

 Origin of the Continent, of the Animal Creation, and of the Indian
Race: The Introduction of the Two Principles of Good and
Evil Into The Government of the World.

Iroquois tradition opens with the notion that there were originally
two worlds, or regions of space, namely, an upper and lower world.
The upper was inhabited by beings similar to the human race; the
lower by monsters, moving in the waters. When the human species
were transferred below, and the lower sphere was about to be
rendered fit for their residence, the act of their transference or
reproduction is concentrated in the idea of a female, who began to
descend into the lower world, which is depicted as a region of
darkness, waters and monsters. She was received on the back of a
tortoise, where she gave birth to male twins, and expired. The shell
of this tortoise expanded into the continent, which, in their
phraseology, is called an “island;” and is named by the Onondagas,
AONAO. One of the infants was called Inigorio, or the Good Mind;
the other, Inigohatea, or the Bad Mind. These two antagonistical
principles, which are such perfect counterparts of the Ormuzd and
Ahriman of the Zoroaster, were at perpetual variance, it being the
law of one to counteract whatever the other did. They were not,
however, men, but gods, or existences, through whom the “Great
Spirit,” or “Holder of the Heavens,” carried out his purposes. The first
labor of Inigorio was to create the sun out of the head of his dead
mother, and the moon and the stars out of other parts of the body.
The light these gave, drove the monsters into deep water, to hide
themselves. He then prepared the surface of the continent, and
fitted it for human habitation, by diversifying it with creeks, rivers,
lakes and plains, and by filling these with the various species of the
animal and vegetable kingdoms. He then formed a man and woman
out of earth, gave them life, and called them “Ea-gwe-ho-we,” or, as
it is more generally known to Indian archæologists, Ong-we-Hon-we;
that is to say, a real people. [D.]

Meanwhile the Bad Mind created mountains, waterfalls, and steeps

and morasses, reptiles, serpents, apes, and other objects supposed
to be injurious to, or in mockery of mankind. He made attempts also
to conceal the land animals in the ground, so as to deprive man of
the means of subsistence. This continued opposition to the wishes of
the Good Mind, who was perpetually busied in restoring the effects
of the displacements and wicked devices of the other, at length led
to a personal combat, of which the time and instruments of battle
were agreed on. They fought for two days, the one using deer’s
horns, and the other flag roots, as arms.18 Inigorio, who had chosen
horns, finally prevailed; his antagonist sunk down to a region of
darkness, and became the Evil Spirit, or Kluneolux,19 of the world of
despair. Inigorio, having obtained this triumph, retired from the
earth.

18 By reference to the Algonquin story of the combat between

Manabozho and his father, the West Wind, as given in Algic
Researches, vol. 1, p. 134, it will be seen that the weapons
chosen by the parties were the same as those employed by
Inigorio and Inigohatea, namely, deer’s horns and flag roots.

19 Oneida.

This piece of ingenuity, or philosophy of the Indian mind, much of

which is pure allegory, under which truths are hid, stands in the
remote vista of Iroquois tradition, and it seemed necessary to notice
it, in preparing to take up their more sober traditions. It is picked out
of a mass of incongruous details, published by a native, [see App.
D.] which only serve, peradventure, to denote its genuineness, for
divested of absurdity, in the original, we should not ascribe much
antiquity to it, or be prone to attribute it to an ignorant,
superstitious, pagan people, living in all their earlier times without
arts, letters or civilization. Futile as it is, it will be found veritable
philosophy, compared with most of the earlier theories of the
renowned nations of antiquity. Take, as an instance, the account
Sanconeathus gives of the theology of the Phœnicians.20

20 Gowan’s Ancient Fragments, 1 vol. 8vo., N. Y., 1835.

 [d.] Gleams of their General Ancient History.

Items: Indians claim to be the offspring of an independent act of

creation. The Iroquois name themselves in proud allusion
to their supposed supremacy. Tribes on the St. Lawrence
and the lakes live in disputes. War with a race of giants
called Ronongweca: the fiend Shotrowea,—contests with
the great Kwiss Kwiss, or Mastodon,—the Big Elk,—and
the Horned Serpent. A meteor falls in the camp. Northern
tribes confederate; send an unfortunate embassage to a
great chief south,—war with him,—war with each other,
and the country thereby depopulated and left to its
original desolation.

When we come to draw the minds of the sages and chroniclers of

the Iroquois cantons, to the facts of their early history and origin,
they treat us with legendary fables, and myths of gods and men,
and changes and freaks in elementary matter, which indicate that
such ideas, were common to their progenitors, whatever part of the
world they occupied. We have adverted to their notions on this
head, in the preceding remarks on their cosmogony, tinctured, as it
strongly is, with the old Persian philosophy.

They deny, as do all the tribes, a foreign origin. They assert, that
America, or AONAO, was the place of their origin. They begin by
laying down the theory, that they were the peculiar care of the
Supernal Power who created all things, and who, as a proof of his
care and benevolence of a race whom he had marked by a distinct
color, created the continent for their especial use, and placed them
upon it. None of the tribes pretend to establish dates, nor have they
any astronomical data, to fix them. But they all give to the story of
their origin, or creation, a locality, which is generally fixed to some
prominent geographical feature near to their present respective
place of abode, or at least, a spot well known. This spot, among the
Iroquois cantons, is located in the northern hemisphere.

The term, Ongwe Honwe, is used by these tribes, very much in the
manner in which the ancient Teutons called themselves, Allamanna,
or Ghermanna, from which we have the modern terms, Allemand
and German. If they did not literally call themselves “all-men,” as did
these proud tribes, they implied as much, in a term which is
interpreted to mean, real men, or a people surpassing all others. It
is the common term for the red race, as contradistinguished from all
other races, and the true equivalent of the phrase, “Indian.”

By their earliest traditions, we are told that a body of the Ongwe

Honwe, encamped on the banks of the St. Lawrence, where they
were invaded by a nation few in number, but of giant stature, called
Ronongweca.21 After a war, brought on by personal encounters and
incidents, and carried on with perfidy and cruelty, they were
delivered at length, by the skill and courage of Yatontea,21 who,
after retreating before them, raised a large body of men and
defeated them, after which they were supposed to be extinct. They
next suffered from the malice, perfidy, and lust of an extraordinary
person called Shotrowea,21 who was finally driven across the St.
Lawrence, and came to a town south of the shores of lake Ontario,
where, however, he only disguised his intentions, to repeat his cruel
and perfidious deeds. This person, who assassinated many persons,
and violated six virgins, they point to as a fiend in human shape.

21 I abbreviate these words from the originals, for the sole

purpose of making them readable to the ordinary reader.

At this time the Big Quisquis22 invaded the country, who pushed
down the houses of the people, and created great consternation and
disturbance. After making ineffectual resistance, they fled, but were
at length relieved by a brave chief, who raised a body of men to
battle him, but the animal himself retired. In this age of monsters,
their country was invaded by another monster called the “Big Elk,”
who was furious against men,23 and destroyed the lives of many
persons, but he was at length killed after a severe contest.

22 Kwis Kwis is the name of a hog in modern Iroquois.

23 Carnivorous—but this is not a characteristic of the Elk.

A great horned serpent next appeared on Lake Ontario, who, by

means of his poisonous breath, produced diseases, and caused the
death of many, but he was at last compelled to retire by
thunderbolts. This fourth calamity was not forgotten, when a fifth
happened. A blazing star fell into a fort situated on the banks of the
St. Lawrence, and destroyed the people. Such a phenomenon
caused great panic and dread, and they regarded it as ominous of
their entire destruction. Prior to this, a confederation had taken
place among these northern tribes, situated north of and along the
banks of the great lakes, and they had a ruling chief over all. This
ruler repaired to the south to visit a ruler of great fame and
authority, who resided at a great town in A Lodge of Gold. But it only
proved to be an embassy of folly, for this great ruler, exercising an
imperial sway, availing himself of the information thus derived, of a
great country full of resources, built many forts throughout the
country, and almost penetrated to the banks of Lake Erie. The
people who had confederated on the North resisted. A long war of a
hundred years standing ensued, but the northern people were better
skilled in the use of the bow and arrow, and were more expert
woodsmen and warriors. They at length prevailed, and taking all
these towns and forts, left them a heap of ruins.

But the prediction of the blazing star was now verified. The tribes
who were held together by feeble bands, fell into disputes, and wars
among themselves, which were pursued through a long period, until
they utterly destroyed each other, and so reduced their numbers,
that the land was again overrun by wild beasts. [D.]
 II. ORIGIN AND HISTORY OF THE
IROQUOIS, AS A DISTINCT PEOPLE.

The first period of Indian history having thus terminated in discords,

wars, and the mutual destruction of each other, tradition does not
denote how long the depopulation of the country continued. It
begins a second period by recollections of the Konoshioni, or
Iroquois. They do not indicate what relation they bear to the
ancient, broken down confederacy glanced at, in the preceding
paper; but leave us to suppose that they may have been
fragmentary descendants of it. That such a conclusion should not be
formed, however, and in order to prove themselves an original
people in the land, they frame a new myth, to begin their national
existence. They boldly assert, that they were, through some means,
confined in a mountain, from whose subterraneous bowels they
were extricated by Taryenyawagon, the Holder of the Heavens. They
point to a place at or near the falls of the Oswego river, where this
deliverance happened, and they look to this divine messenger, who
could assume various shapes, as the friend and patron of their
nation.24

24 Where the Indians dwelt for a long time, it is customary for

them to affirm in their metaphorical language, that they
originated, or were created. When they date from such a spot,
we find they frame a story, saying that they came out of a hill,
&c. at that spot. In 1791, an extensive work, consisting of
ditches, &c. was found about 40 miles south of Oswego, which
is not remote from the probable place of origin their traditions
 refer to; and it may be worthy of examination with this
particular view. Some account of this old fort appeared in the N.
Y. Mag. 1792.

As soon as they were released, he gave them instructions respecting

the mode of hunting, matrimony, worship, and other points. He
warned them against the Evil Spirit, and gave them corn, beans,
squashes, potatoes and tobacco, and dogs to hunt their game. He
bid them go towards the east, and personally guided them, until
they entered a valley called Tenonanatchi, or the Mohawk. They
followed this stream to its entrance into the Sanatatea, or, as called
by the Mohawks, Kohatatea, which they pursued to the sea.

From this point they retraced their steps towards the west,
originating as they went, in their order and position, the Mohawks,
the Oneidas, the Onondagas, the Cayugas, and the Senecas. They
do not omit the Tuscaroras, whom they acknowledged, after a long
period of wandering and a considerable change of language, and
admitted as the Sixth tribe of the confederacy.

The Tuscaroras affirm, that, after reaching the lake waters, they
turned southwest, to the Mississippi river, where a part of them
crossed on a grape vine, but it broke, leaving the remainder east.
Those who went west, have been lost and forgotten from their
memory. The remainder, or eastern Tuscaroras, continued their
wanderings, hunting, and wars, until they had crossed the
Alleghanies and reached the sea again, at the mouth of the Cautoh,
or Neuse river, in North Carolina.

Each tribe was independent of the others. They increased in

numbers, valor and skill, and in all sorts of knowledge necessary in
the forest. But they began to fight and quarrel among themselves,
and thus wasted and destroyed each other. They lived a life of
perpetual fear and built forts to defend themselves, or to protect
their women and children. Besides this, the country was wide and
covered with large forests and lakes, and it gave shelter to many
fierce wild animals and monsters, who beset their paths and kept
them in dread. The evil spirit also plagued them with monstrous
visitations. They were often induced to change their villages,
sometimes from the fear of such enemies, and sometimes from
sickness or bad luck. In this manner, and owing to their perpetual
hostility, their population was often reduced. How long they
wandered and warred, they do not know. At length it was proposed
by some wise man that they should no longer fight against each
other, but unite their strength against their enemies, the Alleghans,
the Adirondacks, the Eries, and other ancient and once powerful
tribes, who figure in the foreground of their early history, and who, if
accounts be true, once greatly excelled them both in war and arts,
the skill of making implements, canoes and utensils, &c.

To this league, which was formed on the banks of Onondaga lake,

they in time, gave the name of the Long House, using the term
symbolically, to denote that they were tied and braced together by
blood and lineage, as well as political bonds. This house, agreeably
to the allusion so often made by their speakers, during our colonial
history, reached from the banks of the Hudson to the Lakes. At its
eastern door stood the Mohawks, at the west the Senecas, who
guarded it with vigilance.

[a.] The Mohawks.

The Mohawks are supposed to be the eldest brother, in the

symbolical chain of the Six Nations. Their own tradition assigns them
this rank, and it appears to be consonant to other traditions.

When Tarenyawagon, their liberator from their subterranean

confinement, bid them travel east, he gave them his personal
conduct and care until they had entered the Mohawk valley. Some of
their western brethren call this stream Tenonanatche, or a river
flowing through a mountain. In due time, they went on into the
valley of the Hudson, and thence, if we credit their annals, to the
sea. The seat of their power and growth was, however, in the genial
valley where they had at first located. Here they lived when the
country was discovered, and here they continued to live and flourish
until the events of the American revolution, and the determined
cruelty which they exercised, under the authority and influence of
the British crown, drove them out of it, and lost them the
inheritance.

It does not appear, from any thing history or tradition tells us, or
from any monumental remains in the valley or its immediate vicinity,
that it had before been occupied by other nations. They do not
speak of having driven out or conquered any other tribe. There are
no old forts or earthen walls, or other traces of military or defensive
occupancy, of which we have heard. Their ramparts were rather their
own brawny arms, stout bodies and brave hearts. From the earliest
notices of them, they were renowned for wielding the war club and
arrow with great dexterity. They raised corn on the rich intervales,
and pursued the deer, bear and elk in the subjacent forests. Their
dominion extended from the head waters of the Susquehanna and
Delaware to Lake Champlain. They had pursued their forays into the
territorial area of New-England, as far, at least, as the central
portions of the Connecticut, and had made their power felt, as
temporary invaders, among the small independent tribes who lived
about the region of the present city and harbor of New-York.
Wherever they went, they carried terror. Their very name, as we
learn from Colden, was a synonyme for cruelty and dread.25 No
tribe, perhaps, on the continent, produced better warriors, or have
ever more fully realized, as a nation, the highest measure of heroism
and military glory to which hunter nations can reach.

25 The word Mohawk itself, is not a term of Mohawk origin, but

one imposed upon them, as is believed, by the Mohegan race,
who inhabited the borders of the sea. Among this race the
Dutch and English landed, and they would naturally adopt the
 term most in vogue for so celebrated a tribe. The Dutch, indeed,
modified it to Maaquas—a modification which helps us to
decypher its probable origin, in Mauqua (by kindred tribes,
Mukwa, &c.) a bear. By others, it may be traced to mok, wa, a
wolf, and awki, a country.

In passing over the country which they once occupied, there is little
to stimulate historical interest, beyond the general idea of their
power and military renown. Their history is connected with the rise
and influence of one of our most distinguished anti-revolutionary
citizens, Sir William Johnson. The influence he obtained over them
was never exceeded, if equalled by that of any other man of
European lineage. He moulded them to his purposes in peace and
war. They followed him in his most perilous expeditions, and
sustained him manfully, as we know, in the two great contests to
whose successful issue he owed his laurels, namely, Lake George
and Niagara. So completely identified were they in feeling and policy
with this politic and brave man, that after his death, which happened
at the crisis of ’76, they transferred their attachment to his family,
and staking their all on the issue, abandoned their beloved valley
and the bones of their fathers, and fled to the less hospitable
latitudes of Canada, from which they have never permanently
returned.

Some twenty or more persons of this tribe are mingled as residents

of the villages of their brethren, the Senecas, Tuscaroras, and
Oneidas. A much greater number exist with intermixture of other
kindred tribes, in the St. Regis canton of St. Lawrence county; but
the greater number of the parent tribe reside on lands appropriated
for their use by the British government, at Brantford, on the Grand
river of Canada West. To this place at the close of the war, they
followed their distinguished leader, Thayendanegea, the Jephtha of
his tribe, who, against the custom of birth and descent, and every
other obstacle, after the failure of the line of wise and brave chiefs
to lead them to battle, was made their Tekarahogea and leader, and
displayed a degree of energy and firmness of purpose, which few of
the aboriginal race in America have ever equalled.

What light the examination of the old places of burial of this tribe in
the valley would throw on their ancient history or arts, by entombed
articles, cannot be told without examinations which have not been
made. Probably the old places of Indian interment about
Canajoharie, Dionderoga, and Schenectady, would reveal something
on this head, conforming at least, in age and style of art, with the
stone pipes, tomahawks and amulets of the Onondaga and Genesee
countries. The valley of the Schoharie and that of the Tawasentha,
or Norman’s kill, near Albany, might also be expected to reward this
species of research. [Vide B.] A human head, rudely carved in stone,
apparently aboriginal, was sent to the New-York Historical Society
early in 1845, which was represented to have been found in
excavating a bank at Schenectady. If this piece of sculpture, which
denoted more labor than art, be regarded as of Mohawk origin, it
would evince no higher degree of art, in this respect, than was
evinced by similar outlines cut in the rock, but not detached, by
some of the New-England tribes.26

26 Rude carvings of this kind are represented to exist on the

banks of the Connecticut, at Bellows’ Falls, &c.

[b.] Origin and History of the Oneidas.

This canton of the Iroquois nation, deduces its origin in a remote

age, from the Onondagas, with the language of which, the Oneida
has the closest affinity. According to a tradition which was related to
me, and which is believed to be entitled to respect, they are
descended from two persons, who, in their obscure ages, and before
a confederation had been thought of, went out from the people at
Onondaga, and first dwelt at the head of the Oneida river. After
increasing in numbers, they removed to the outlet of the Oneida
creek, which flows into Oneida lake. Here they fortified themselves,
and farther increased in numbers and power. Remains of this
fortification are said still to exist. Their next removal was up the
Oneida creek valley, to the storied locality of the Oneida stone, from
which, by a figure of speech, they represent themselves to have
sprung. This stone is in the town of Stockbridge, Madison county. It
lies on a very commanding eminence, from which the entire valley,
as far as the Oneida lake, can be seen in a clear atmosphere. The
day of my visit being hazy at a distance, the lake could not be seen,
although the view down the valley, was both magnificent and
picturesque. This eminence was formerly covered with a butternut
grove. Old, and partly decayed trees of this species, still remain in a
few places. The ancient town extended in a transverse valley, south
of this ridge of land, covered as it was, with nut wood trees, and
was completely sheltered by it, from the north winds. A copious and
clear spring of water issued at the spot selected for their wigwams.
Here in seclusion from their enemies, the tribe expanded and grew
in numbers. When it was necessary to light their pipes, and
assemble to discuss their national affairs, they had only to ascend
the hill, through its richly wooded grove, to its extreme summit, at
the site of the Oneida stone. This stone, represented on the
succeeding page, became the national altar.

Standing at its side, at a probable elevation of 400 or 500 feet above

the Stanwix summit, they could survey the whole valley of the
Oneida; and a beacon fire lighted here, was the signal for
assembling their warriors, from all the surrounding lateral plains and
vallies. Time and usage rendered the object sacred, and as they
expanded into nationality and power, while located around it, their
sages asserted with metaphorical truth, that they sprang from this
rock. Stone in this language is Onia. They called themselves, Oniota-
aug, people of, or who sprung from the stone. There is some variety
in the pronunciation. The Mohawks call them Onéota. The French
wrote it Aneyoute, the English and Dutch, Oneida, which latter has
prevailed. Neither retained the plural inflection in aug, which carries
the idea of people.

With a knowledge of these traditions, I approached the spot with

deep interest. It occupies the extreme summit, as shown in the
print. The first feeling, on approaching it, was one of disappointment
at its size, but this feeling soon subsided in the interest of its
antiquity and national associations. It is a large, but not enormous
boulder of syenite,27 of the erratic block groupe, and, consequently,
geologically foreign to the location. There are no rocks of this
species in situ, I believe, nearer to it, in a northerly or easterly
direction, than the Kayaderosseras or the Adirondack mountains.28
The summit upon which, partly embedded, it reposes, is now a
cleared field, in grass. A few primitive and secondary boulders, all of
lesser size, are strown about the ridge, and several of weight and
magnitude rest upon its flanks, and in the vallies at its base. One of
the largest of these is the White Stone at the spring, which has been
spoken of, I think, in some early notices of the Oneidas, as the true
Oneida Stone; but this opinion is erroneous, by the concurrent
testimony of red and white men, cognizant of the facts, whom I
consulted. This white stone, figured below, has been removed, by
the proprietor of the land,29 from its ancient position near the
spring, to constitute part of a stone fence; it is a carbonate of lime.
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