General Medical Semiology Guide Part I

Manuela Stoicescu
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GENERAL MEDICAL
SEMIOLOGY GUIDE
PART I

Dr. Manuela Stoicescu

Consultant Internal Medicine
PhD, Assistant Professor
University of Oradea
Faculty of Medicine and Pharmacy
Medical Disciplines Department
Romania
 About the Author
MANUELA STOICESCU

Consultant Internal Medicine doctor, PhD, Assistant Professor at University of Oradea, Faculty of Medicine and
Pharmacy
Medical Disciplines Department,
Romania

Education: Philology-History High School, Oradea, Chemistry e Biology e field High school diploma

University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Faculty of Medicine and Pharmacy
Romania - Physician University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Romania - Residency -
Internal Medicine 5years - Certificate- Internal Medicine Specialist Feb 1996eOct 2001

Pédagogie training department, ClujeNapoca, Romania e Psychopédagogie Certificate.

Certificate of English language proficiency

Residency e Internal Medicine Cluj Napoca e University of Medicine and Pharmacy ”Iuliu Hatieganu”
Cluj-Napoca Romania, Department of Medical Semiology, Medical II Clinic e Cluj Napoca e City Internal Medicine
Department, Medical II Clinic Cluj Napoca City.

Assistant Professor at the University of Oradea e Medical Semiology Department e 2002epresent.

Consultant Internal medicine doctor e 2006

Ph.D. thesis: "Hypertension in the young people - clinical features",

-publication date Jul 28, 2010 publication description Obtained the title of doctor of medicine according to the
Order of the Minister of Education, Research Nr.4542 on 28. 07. 2010. publication description Ph.D. Thesis:
"Hypertension in the young people - clinical features", original work, Obtained the title of doctor of medicine
according to the Order of the Minister of Education, Research, Youth and Sports Nr.4542 on 28. 07. 2010. PhD

Consultant Internal Medicine doctor. PhD, Assistant Professor, University of Oradea, Faculty of Medicine and
Pharmacy, Medical Disciplines Department

Dates Employed: Jan 2001ePresent 2019; Employment Duration: 18 years 8 months; Location: Oradea - Romania

She has been an invited speaker at 56 International Conferences in US and Europe, is Organizing Committee
Member (OCM) in International Conferences in US and Europe, published 20 articles in prestigious journals in US
and is Editorial Board Member in two prestigious ISSN journals in US: Journal of Developing Drugs and Surgery:
Current Research.

ix
 YOU ARE READY?
I AM YOUR LADY
TEACHER

WE WILL DISCUSS
THE PATIENT’S HISTORY
 Introduction

The History of the Patient

The history of the patient represents the first contact and discussion of the physician with the patient and is very
important. Taking a superficial history because of a lack of time is not excusable because it can generate mistakes. A
serious and careful history of the patient will aid in a successful diagnosis. We must always ask a few typical ques-
tions, which are presented next.

Look at me how carefully I am talking

to the patient and take notes!

In the first instance I will ask about personal information: name, age, gender.
xxvi Introduction

1. PERSONAL DATA
What is your name?
How old are you?
I observe if the patient is a man or a woman, because I know that some diseases are more common in women and
other diseases appear more often in men.

2. PLACE OF BIRTH AND HOME (ADDRESS)

Where were you born?
Where do you live?
What is your address? What is your phone number?

3. ALLERGY?

I will ask my patient if he or she is allergic to any drugs.

If the answer is yes, I will ask what drugs have caused allergy in the past and I will mark it with red color in the
personal papers of the patient. Very important! The administration of these drugs must to be avoided to prevent
anaphylactic shock, Quincke edema, or sudden death.
For example, I noticed:
allergy to aspirin
allergy to penicillin

So, I will never give this patient aspirin or penicillin!

4. THE REASON FOR HOSPITALIZATION

The reason for hospitalization represents the main symptoms about which the patient came for consultation.
There is always a major symptom; this is the leading symptom. The patient may also present with other symptoms.
These must be put in order per anatomy and system.
 Introduction xxvii

Example No. 1
- Syncope is the leading symptom
- Dyspnea
- Chest pain
- Palpitations

Example No. 2
Hematuria is the leading symptom
- Pollakiuria
- Dysuria
- Chills
- Fever

Example No. 3
- Hemoptysis is the leading symptom
- Dyspnea
- Chills
- Fever

Example No. 4
- Abdominal pain
- Nausea
- Vomiting

5. THE HISTORY OF THE CURRENT DISEASE

In this section we need to describe in detail the history of the current disease of the patient. First, we need to
specify:
How did the disease start?
Was it sudden or insidious?
How long ago did it begin?
What are the symptoms?
What was the patient’s attitude toward the disease?
Has the patient presented him- or herself to a doctor or stayed at home?
Did the patient begin medical treatment on the advice of a physician or did he or she begin treatment alone?
Or did the patient not follow any treatment?
Did he or she start a drug treatment that had an influence on the disease?
Was there improvement, aggravation, or any influence?
Is this the first episode or have there been other similar episodes in the past?
In this section it is necessary to describe in detail the actual history of the patient as regards what he or she is being
hospitalized for, as complete as possible.
If the patient currently has more than one disease, we have to take a history of each one, following the same el-
ements presented before.

6. FAMILY HISTORY

In this section we need to describe what diseases are in the patient’s family. What diseases have the mother, father,
brothers, sisters had? This is because there exists a risk for genetic transmission, for example, arterial hypertension,
diabetes mellitus, cancers at various locations, and genetic diseases with dominant or recessive transmission. These
diseases are important because the patent has a genetic risk for developing these diseases at any point in time.
xxviii Introduction

7. PERSONAL PATHOLOGICAL HISTORY

In this section we need to describe all the diseases that the patient had in the past and also surgical procedures, in
chronological order, except for the current illness.

8. PERSONAL PHYSIOLOGICAL ANTECEDENTS

In this section we need to describe all the physiological antecedents in women regarding menstrual cycles and
pregnancies.
At what age did the first cycle (menarche) occur?
Normal age is between 12 and 14 years.
Have menstrual cycles been regular? Once per month?
Normal cycle is 28 days.
How many days does the flow take?
Normal is between 3 and 5 days.
How do you estimate the amount of blood lost during the menstrual cycle?
Normal is between 300 and 500 mL of blood.
Have you ever had cycles longer than 10 days?
This is called menorrhagia. This is specific for uterine fibroids.
Have you ever had bleeding between menstrual cycles?
This is called metrorrhagia. This is specific for uterine fibroids
Have you had abnormal menstrual cycles with a quantity more than 500 mL?
This is called hypermenorrhea. This is specific for uterine fibroids
Have you had abnormal menstrual cycles with increased quantity and with blood clots and prolonged duration of
more than 5 days?
This is specific for uterine fibroids.
How do you describe the color of the blood?
Normal is fresh red.
Have you ever had a dark bleeding that looks like coffee or coffee grounds?
This is specific for uterine carcinoma.
Have you ever had bleeding like juice in which meat was washed?
This is specific for uterine carcinoma.
Are you in menopause? At what age did menopause begin?
Normal age for menopause is between 45 and 50 years.
Are you in early menopause or artificial menopause after ovariectomy, radiotherapy, or chemotherapy? This is a
risk factor for ischemic heart disease, because the woman has lost the protection of estrogen hormones against
atherosclerosis.
Have you had bleeding in menopause?
This is specific for uterine carcinoma.
Have you been pregnant, and how many times?
Was the delivery at normal time, 9 months, or early or late?
Have you had any abortions, and how many?
Were the abortions spontaneous or induced?
What did your babies weigh after delivery?
Normal weight is between 3 and 4 kg.
A baby bigger than 4 kg is a “big baby” or has macrosomia and represents a risk factor for diabetes mellitus of the
mother in the future.
A baby less than 3 kg is premature.

9. LIFE CONDITIONS

The life conditions of the patient are very important.

Especially important are the housing conditions, eating, and toxic consumptions.
 Introduction xxix

A. The housing conditions

The housing conditions are very important because people spend most of their time at home. It is important to
know how many persons live in a room and how many rooms are in the house. The infectious contagious diseases
such as viruses, pneumonia, and tuberculosis are transmitted when the people cohabit.
Another important condition is the cleanliness of the house. Is it a clean house or not? Is it an overcrowded house
or not? Are people living together with cats, dogs, a parrot? Because animals can transmit diseases to the persons
who live with the animals.
Room air conditioning is a risk factor for respiratory tract infections and allergies as well.

B. Eating
A person’s diet is very important. It must be nutritionally balanced in accordance with the physical effort. A
normal diet should be varied and balanced in the content of proteins, carbohydrates, lipids, and vitamins. A unilat-
eral diet excessive in glucoses and carbohydrates represents a risk factor for diabetes mellitus. A unilateral diet
increased in animal lipids represents a risk factor for dyslipidemia, atherosclerosis, ischemic heart diseases, angina
pectoris, and heart attack.
Also, excess calories together with sedentary habits are a risk factor for obesity, high blood pressure, and diabetes
mellitus. Deficiency in diet leads to weight loss.
Failure to eat regular meals is a risk factor for the occurrence of gastritis and gastric or duodenal ulcers.

C. Toxic consumptions
In this section, the patient should be asked about the toxic consumption of alcohol, smoking, coffee, and drugs.

Alcohol consumption
In terms of alcohol consumption the patient should be asked how often he or she consumes alcohol: every day or
occasionally? The truth is that alcohol is often not recognized by the person concerned; usually the family is the one
who informs the doctor about alcohol consumption.
It is important to know the amount consumed and what kind of alcoholic beverages are consumed, hard alcohol
or light alcohol, like beer or wine?
Persons with chronic alcohol consumption have risks for many diseases, such as chronic alcoholic hepatitis, liver
cirrhosis, gastric or duodenal ulcers, mental illnesses such as alcoholic dementia, and others.

Smoking
Smoking is another risk factor for many diseases. It is really important to ask the patient at what age he or she
began smoking (how long?). What type of cigarette, with filter or without filter? How often? Daily? How many cig-
arettes per day? Pipe smokers are at risk for lip cancer.
Smoking is an important risk factor for cardiovascular diseases such as ischemic heart disease, angina pectoris,
acute myocardial infarction, cardiac arrhythmias, and sudden death; respiratory diseases such as chronic tobacco
bronchitis, COPD, and bronchusepulmonary cancer; and digestive diseases such as gastric ulcer or duodenal ulcer.
We must consider the state of the passive smoker. This is represented by peopledinnocent victimsdwho
passively inhale cigarette smoke because they are around a person who smokes. The most innocent victims are chil-
dren. Passive smokers are at risk for the aforementioned diseases in a percentage almost as great as active smokers!
The younger the age at which smoking started, and the higher the number of cigarettes a day, the higher is the risk
for the diseases mentioned.

Coffee
Coffee consumption has been known from the earliest times. This small daily vice is practiced around the world.
Abuse of coffee consumption can cause palpitations, tachycardia, irritability, nervousness, and insomnia. It is also a
risk factor for the occurrence of high blood pressure and dangerous arrhythmias.

Drugs
Drug consumption represents a risk factor for dangerous arrhythmias, myocardial infarction at a young age, and
sudden death. Bacterial endocarditis represents another risk after drug consumption. Drug consumption must to be
stopped, especially because many victims are young people.
xxx Introduction

10. WORKING CONDITIONS

Working conditions represent another important part of the history of the patient. Many risk factors are present at
the workplace. For this reason it is very important to ask and to know the profession of the patient. How many hours
are worked per day? Risk factors from work include dust, humidity, and noise. Does the patient work during the
night? Work supplementary hours? How are his or her relationships with colleagues? Relationship with the boss?
Everything is important!

11. GENERAL MANIFESTATIONS

The history of the patient finishes with a few important questions regarding general manifestations such as:
Appetite
The weight curve
- increasing?
- decreasing?
- stationary?
The stool
The urine
Frequency of urination in 24 h?
Diuresis?
Sleep
Do you sleep during the night?
Do you have insomnia?
The history of the patient is finished with these general manifestation questions.

I'm really happy!

We're done with patient history!
 Motto

“Each patient is unique.We have to practice a personalized medicine”

“Semiology is a window that opens to the universe of internal medicine”

 YOU ARE READY?

WE WILL DISCUSS
THE GENERAL MEDICAL
SEMIOLOGY GUIDE I
 C H A P T E R

1
The Objective Examination
O U T L I N E

1.1 Inspection 3 Hyperresonance 15

1.2 Palpation 4 Dullness 15
Palpation of the Precordial AreadThrill 6 Percussion of the Spleen 15
Palpation of the Thorax Tactile Fremitus 7 Timpani 15
Palpation of the Spleen 8 Percussion of the Abdomen 16
Palpation of the Abdomen 9
1.4 Auscultation 16
Abdominal Skin Fold 10
Gripping the Skin between Two Fingers 10 Auscultation of the Lung 16
Abdominal Skin Fold 10 Auscultation of the Lung 17
The Persistence of the Skin FolddSign of The Method of Auscultation is Comparative and
Dehydration 11 Symmetric 18
Semiological Analysis of a Palpable Formation 11 Auscultation of the HeartdMitral Area 18
1.3 Percussion 13 Aortic Area 19
Percussion of Thorax Resonance 13 Pulmonary Area 19
Comparative and Symmetric 14 Tricuspid Area 20
Percussion of the Thorax 14 Auscultation of the AbdomendBowel Sounds 20

General Medical Semiology Guide Part I

https://doi.org/10.1016/B978-0-12-819637-3.00001-2 2 © 2020 Elsevier Inc. All rights reserved.
 1.1 Inspection 3
Objective examination of the patient is very important. The correlation between symptoms after patient history is
taken and the signs from the objective examination performed helped the doctor to establish the clinical diagnosis of
the patient.
To perform the objective examination, the doctor uses four important methods that we shall discuss: inspection,
palpation, percussion, and auscultation.
In each chapter, these four methods will be used to study the respiratory, renal, cardiovascular, digestive, and
blood systems as well as the medical semiology.

1.1 Inspection

Inspection is the method by which the doctor observes the patient using only his eyes, without touching the pa-
tient, and he is careful if he discovers important signs. The correct inspection of the body must to be generalized by
stripping the clothes off the patient and should be conducted in natural light. For example, in the image below, what
do you observe at simple inspection?
4 1. The Objective Examination

We can see a swelling in the left inguinal area. There is an enlarged lymph node in the inguinal area that occurred
in the context of a venereal disease.
What do you observe at inspection in the image below?

A swelling is observed behind the right ear. There is an enlarged lymph node in this patient with acute tonsillitis.
In the previous images, you must consider the example of patients who have a swelling area in different regions,
where enlarged lymph nodes appeared in the context of different diseases. So an example is the discovery of
enlarged lymph nodes at patient inspection, as shown, but of course we can also observe many other different
and various signs at the inspection of the skin, eyes, oral cavity, anal area, and so on.
It is quite important not to ignore hidden areas such as the oral cavity or genital areas as the vulva, vagina, and
anal areas. Though some patients may be unduly modest about such observations, they must be informed that in
these hidden areas there can be very important signs that can be discovered at simple inspection and possibly
save their lives.

1.2 Palpation

Palpation is the second important method in objective examination. In this moment, the doctor uses his hand to
palpate and feel the formation or area to palpate. For example, the doctor can use two fingers to palpate; in the image
below, we can see how the doctor palpates the lymph nodes in the left inguinal area of the previous patient who has
venereal disease.
 1.2 Palpation 5

Palpation of left inguinal lymph nodes

After palpation, the doctor can appreciate the consistence of the lymph nodes: soft or hard. This is very important
because soft lymph nodes suggest inflammatory etiology, whereas lymph nodes that are hard like a stone suggest
malignant etiology.
In addition, it is possible to feel the contour, whether the area is regular or irregular, sensibility, temperature of the
skin, and many other important signs.
In the image below, the doctor palpates with two fingers under the mandible on the right side, where he tries to
feel and palpate the lymph nodes. This method uses two fingers, and the doctor performs an easy movement of
rotation.

Palpation of lymph nodes under the mandible on the right side

6 1. The Objective Examination

In this case, the patient in the previous picture had acute tonsillitis with secondary pus appearing at inflammatory
lymph nodes under the mandible. For this reason, in the image above the doctor palpates the enlarged lymph nodes
under the mandible, with dimensions 2 x 1.5 cm, with regular borders, round, soft consistency, mobility, and sensi-
bility at palpation. These represent the typical features of inflammatory lymph nodes.
The correct method of palpation of enlarged lymph nodes is presented in the image above, with two fingers and
the doctor effecting simple, easy rotator movements to feel all the features mentioned earlier: shape, dimensions,
contour, consistence, mobility, and sensibility. It is important to know all these characteristics because these help
us to establish the etiology of enlarged lymph nodes.

Palpation of the Precordial AreadThrill

Heart fremitus (thrill) is felt by palpation with the whole palm on the precordial area and the chest. In the image
above, we see the method of palpation of the precordial area with the whole palm on the chest of the patient, where
the doctor tries to feel thrilldthis is the palpation of vibrations of increased intensity of heart murmur, V or VId
typical in aortic stenosisdbecause in this valve, disease appears to increase the intensity of heart murmur from
the cardiovascular pathology.
Another important element of the palpation method is when the doctor feels thrilldthe palpation of vibrations of
increased intensity of heart murmur as in aortic stenosis. The method of palpation of the precordial area for thrill is
shown in the image above.
In the next images, we will see the method of palpation of the posterior thorax, where the patient is asked to say
“99” or “33” while the doctor feels, under the palms, the vocal cord vibrations transmitted to the chest wall of the
thorax. This is tactile fremitus.
 1.2 Palpation 7
Palpation of the Thorax Tactile Fremitus

Palpation of deep abdominal organs is another advantage of the palpation method. In the image below, we see the
method of palpation of the spleen, for example:
8 1. The Objective Examination

Palpation of the Spleen

 1.2 Palpation 9
Palpation of the Abdomen
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old woman made more mischief, told her Sir Geoffrey would never
forgive her, and all that. So the little woman went off her head very
nearly. And goodness knows what would have happened if we hadn’t
gone after her so soon.”
Mabin wrenched herself away from Rudolph, who had held one
arm round her while he spoke.
“Then that wicked old woman has been cheating her into thinking
she killed him, while all the while he was alive and well?” she cried,
only now awakening to the full sense of the situation.
“Yes.”
“And poor Mrs. Dale has been allowed to torture herself for
nothing?”
“Well, it wasn’t exactly nothing. She might have killed him. Indeed
she meant——”
But Mabin would not let him finish.
“Nonsense,” she said sharply. “I’m going in by the kitchen-garden.
Good-night.”
And she fled so precipitately that Rudolph had no time for another
word.
In the long drawing-room, no longer a dreary and desolate place,
husband and wife were sitting together. Almost without a word she
had led him into the house, and, shuddering in the midst of her
thankfulness at the sight of the open door of the dining-room, where
old Lady Mallyan had shown her so little mercy as to drive her to
despair, she had thrown open the door of the drawing-room, where a
lamp had been placed upon the table, making a tiny oasis of light in
a great wilderness of shadow.
Very gently, very humbly, with eyes still wet, hands still tremulous,
she led him to a chair and took her own seat modestly on a footstool
near his feet.
“And now tell me,” she began in a low voice, as soon as he was
seated, “why did you let me think I—I——”
She could not go on.
“My dear child,” said Sir Geoffrey tenderly, as he drew her half-
reluctant hands into his, and stroked her bright hair, “we have all
made mistakes in this unhappy business, and that was the first, the
greatest of all.”
 “It was not your doing, I am sure of that,” said Dorothy quickly.
“You would not have thought of doing anything so cruel, of your own
accord.”
He frowned. It had already become clear to him that, in yielding so
much as he had done to the advice of his mother, he had not only
imperilled his own happiness, but had caused his young wife
suffering more bitter than he had imagined possible.
“I was wrong too. I should have known; I should have trusted you
more,” said he in a remorseful voice. “But you were such a child, you
seemed such a feather-headed little thing, I could only believe my
mother’s judgment when she gave me advice about you.”
“But you should not have mistrusted me, however much she said.
You should have watched me yourself if you thought I wanted
watching.”
“I know—I know. I am sorry, child.”
“Then why, when I had done the dreadful thing—” and suddenly
the fair head bent down in humility and shame—“why didn’t you see
me? Why didn’t you let me see you? And why, oh, why did you let
them tell me I had k-killed you? Think of it! Think of it! The horror of
that thought is something you can never imagine, never understand.”
“When my mother first told you that,” answered Sir Geoffrey
gravely, “she thought it was true. I was very ill, you know, long after
they had extracted the bullet. I was too ill to see you, even if she had
let me. And when you had been sent away, I suppose my mother
meant to punish you by letting you think as she did.”
“Ah, but it was brutal to let me believe it so long!”
“I am afraid it was!”
“But you—when you knew—when at last she told you what I had
been taught—didn’t you see yourself how cruel it was?”
Sir Geoffrey was silent. He did not wish to own to Dorothy, what he
was forced to acknowledge to himself, that his mother had deceived
him as egregiously as she had his wife; that, in pursuing her own
revengeful and selfish ends, she had gone near to wrecking both
their lives. But something, some part of her work was bound to
become known; and he had reluctantly to see that the intercourse
between his wife and his mother could never be anything but
strained.
 “I had been led to believe,” admitted he, “that your hatred of me
was so great, your fear of me too, that even the idea that I had died
would not affect you long.”
She shuddered, and abruptly withdrew her hand from his.
“Dorothy, forgive me. I never meant that you should bear the burden
so long. When you rebelled, and insisted on going away from the
place where my mother had put you, I had been sent abroad for my
health. When I came back, you were gone, and my mother told me
you were travelling abroad. But I was already hungering for a sight of
you, anxious to see you, to find out whether there was really no
prospect of reconciliation for us. And as I found my mother unwilling
to help me, I went away, but not abroad as she thought. I had found
out where you were, and I determined to settle down near you, and
to keep watch for an opportunity of approaching you, and finding out
that one thing which was more important than anything else in life to
me—whether my young wife was ready to forgive her old husband,
and to welcome him back to life.”
At these words he paused. Dorothy, her face glowing with deep
feeling, went down on her knees and lifted her swimming eyes to his.
“If you could have known—If you could have looked into my heart!”
she whispered.
“Ah! my darling, how could I know? I used to watch you from the
lane, waiting for hours for what glimpse I could catch of your face
through the trees. Then one night, when I was prowling about the
place, thinking of you, it came into my head that if I could look on
your face while you slept, and call to you, I might speak to you while
you were half awake, and tell you what was in my heart and prepare
you for finding out that I was alive. So I climbed up to your window,
and looked in.”
“Ah! That was what I thought was a dream! I saw you!”
“Yes. You were not asleep. You looked at me with such a stare of
horror and alarm, that I was afraid of the effect of my own act, and I
dropped down to the ground. But some one looked out from an
upper window—it was your housemaid, Annie; the next day I met
her, and, seeing that she recognized me as the person she had seen
the night before, I told her who I was. Fortunately, she had seen my
portrait hanging in a room of the house, a locked room, she told me;
so that she was ready to believe me.”
“Ah!” cried Dorothy.
“And this knowledge that you kept my portrait gave me hope. The
girl promised to get me the key of the room in which it was hung, and
to leave a window open by which I could get into the house that
night.”
Dorothy looked up with rather wide eyes.
“These sentimental girls!” exclaimed she. “Supposing you had not
been my husband!”
Sir Geoffrey smiled.
“We need not trouble our heads about that now,” said he. “I got in
that night, but you had played a trick upon me, for in your room there
was another lady!”
Dorothy stared.
“Did she see you? Did Mabin see you?” she asked breathlessly.
“She not only saw me. She gave chase, and nearly caught me! I
was covered with confusion. But since then the young lady, who is a
very charming one, and I have come to an explanation.”
“Mabin! And she never told me! Oh, yes she did—I remember. She
told me you had promised never to see me again.”
And Dorothy, with a little shiver, drew nearer to her husband, and
let his sheltering arms close round her.
Rudolph was hanging about the place at an early hour next
morning. He sprang upon Mabin as soon as she stepped into the
garden, with a particularly happy look on her young face.
“I’ve come to ask for an explanation,” said he, standing very erect,
and speaking in a solemn tone, tempered by fierceness.
“An explanation? Of what?”
“Various points in your conduct.”
“Oh!” cried Mabin, turning quickly to face her accuser, and
evidently ready with counter accusations.
“In the first place, why have you been so cool to me lately?”
“Because—because—was I cool?”
“Were you cool! Yes, you were, and I know why. You were
jealous.”
Mabin said nothing.
 “And now I expect an apology, and an acknowledgment that you
are heartily ashamed of yourself.”
“Do you expect that, really?”
“Well, I’ll alter the form of words, and say that I ought to get it.”
“Well, you won’t.”
“I thought as much. But I am willing to compound for a promise
that you will never be so foolish again. There! That’s downright
magnanimous, isn’t it?”
Mabin shook her head.
“I won’t promise,” said she. “It’s too risky.”
“You haven’t much faith in me then?”
“I haven’t much faith in—myself. If I were to see you again
apparently absorbed in a very beautiful woman and her misfortunes,
I should feel the same again. Especially a widow!”
“But Mrs. Dale was not a widow!”
“Well, a married woman. They are more dangerous than the
unmarried ones.”
“Well, then if you become a married woman yourself, you will be
able to meet them on their own ground. There’s something in that,
isn’t there?”
And although Mabin was astonished and rather alarmed by the
suggestion, he argued her into consent to his proposal that he
should write to Mr. Rose that very day.
It was astonishing how quickly the neighbors got over their
prejudices against the color of “Mrs. Dale’s” hair when they
discovered that the lady in black was the wife of Sir Geoffrey
Mallyan. And although odd stories got whispered about as to the
reason for her stay in Stone under an assumed name, it was in the
nature of things as they go in the country, where each head weaves
its own fancy, that the truth never got known there.
Before the newly united couple left “The Towers,” they were both
present at the wedding of Rudolph and Mabin, who were married by
the Vicar, under the offended eyes of Mrs. Bonnington. Indeed it is
doubtful whether she would ever have consented to the marriage, if
the accident to Mabin’s ankle, although it left no worse effects, had
not made it impossible for her ever to ride a bicycle again.
 And then, very quietly, and without warning Sir Geoffrey and his
wife Dorothy went away, telling nobody where they were going.
There was a breach now between them and old Lady Mallyan which
could never be entirely healed. But in order that they might have a
little time to themselves before they even pretended to forgive her,
husband and wife went off to Wales together. And under the tender
care of his wife, Sir Geoffrey began quickly to recover the health, the
loss of which Dorothy remorsefully traced to the mad act of which
she had so bitterly repented.

THE END.
 TRANSCRIBER’S NOTES.
Florence Warden was the pseudonym of Florence Alice (Price)
James.
The F. V. White & Co. edition (London, 1896) was referenced for
most of the changes listed below and provided the cover image.
Minor spelling inconsistencies (e.g. lime-trees/lime trees,
stepmother/step-mother, etc.) have been preserved.

Alterations to the text:

Punctuation: missing periods, quotation mark pairings/nestings,
etc.
[Chapter I]
Change (“That’s what I aways say. Especially a widow.) to always.
[Chapter III]
“the little scene, was looking out of window.” add the after of.
[Chapter IV]
“not comfortable with her, the fault was her’s and her father’s” to
hers.
“slight objection I had to your going to the ‘The Towers’ has” delete
the first the.
(Don’t you think that a little dog always looks rather, rather odd?)
change the comma and space after the first rather to an m-dash.
[Chapter V]
“athough she had forgotten that it was from the lips of” to although.
(It led to awful consequnces in my case,” added Mrs. Dale) to
consequences.
[Chapter VIII]
“Mrs. Dale lay down on the couch beween the windows” to
between.
[Chapter XIV]
“If anyting has happened to her, it is the fault of” to anything.
[End of text]
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