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 Complete OSCE Skills for
Medical and Surgical Finals

K27185_C000.indd 1 22/06/2018 15:19

K27185_C000.indd 2 22/06/2018 15:19
 Complete OSCE Skills for
Medical and Surgical Finals
Second Edition

Edited by

KATE TATHAM BSc (Hons) MBBS PhD MRCP FRCA FFICM

Specialty Registrar in Anaesthetics and Intensive Care,
Imperial School of Anaesthesia;
Clinical Lecturer, Section of Anaesthetics,
Pain Medicine and Intensive Care, Imperial College,
London, UK

KINESH PATEL BA (Hons) MBBS MD MRCP

Consultant Gastroenterologist,
Chelsea and Westminster Hospital NHS Foundation Trust,
London, UK

K27185_C000.indd 3 22/06/2018 15:19

 CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2019 Kate Tatham and Kinesh Patel

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-498-75020-2 (Paperback)

International Standard Book Number-13: 978-1-138-09982-1 (Hardback)

This book contains information obtained from authentic and highly regarded sources. Reasonable
efforts have been made to publish reliable data and information, but the author and publisher cannot
assume responsibility for the validity of all materials or the consequences of their use. The authors and
publishers have attempted to trace the copyright holders of all material reproduced in this publication
and apologize to copyright holders if permission to publish in this form has not been obtained. If any
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Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
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hereafter invented, including photocopying, microfilming, and recording, or in any information stor-
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K27185_C000.indd 4 22/06/2018 15:19

 Contents

Preface ix
List of contributors xi
List of abbreviations xiii

1 History1
Catherine Bennett
2 Examination: Cardiovascular 27
Kate Tatham and Kinesh Patel
3 Examination: Respiratory 43
Kate Tatham and Kinesh Patel
4 Examination: Abdominal 59
Kate Tatham and Kinesh Patel
5 Examination: Neurological 79
Kate Tatham and Kinesh Patel
6 Examination: Musculoskeletal 113
Kate Tatham and Kinesh Patel
7 Examination: Surgical 143
Paolo Sorelli
8 Examination: Endocrine 153
Kate Tatham and Kinesh Patel
9 Examination: Dermatological 165
Kate Tatham and Kinesh Patel
10 Obstetrics and Gynaecology 175
Rebecca Evans-Jones
11 Genitourinary Medicine 205
Catherine Bennett
12 Paediatrics213
Sarita Depani

K27185_C000.indd 5 22/06/2018 15:19

 vi    C o n t e n t s

13 Procedures225
Heidi Artis and James R. Waller
14 Emergencies257
Heidi Artis and James R. Waller
15 Interpretation of Data 269
Lucy Hicks
16 Communication skills 301
Heidi Artis and James R. Waller

Appendix 319
NEWS observation chart
Index 321

K27185_C000.indd 6 22/06/2018 15:19

 To our families

K27185_C000.indd 7 22/06/2018 15:19

K27185_C000.indd 8 22/06/2018 15:19
 Preface

Clinical examinations are a stressful but necessary part of medical school finals. However,
with the appropriate preparation and practice, they can become significantly less daunting
and even an opportunity to prove your clinical skills.
The aim of this book is to help in this process of revision by providing an overview of
common clinical situations encountered in OSCE stations. This quick reference text allows
you and your peers to test each other’s skills both at the bedside and in role play scenarios.
Although this book has not been written as an exhaustive guide, it provides the essential
knowledge necessary to succeed in your exams.
Good luck!
Kate Tatham and Kinesh Patel

K27185_C000.indd 9 22/06/2018 15:19

Visit https://textbookfull.com
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K27185_C000.indd 10 22/06/2018 15:19
 List of Contributors

Dr Heidi Artis BA (Hons) MBBS FRCA

Specialty Registrar in Anaesthetics, University Hospital Southampton, UK
Dr Catherine Bennett BSc (Hons) MBBS MRCGP DFSRH DRCOG
General Practitioner, Wiltshire; Clinical Evidence Fellow, West of England Academic
Health Science Network, UK
Dr Sarita Depani BSc (Hons) MBBS MSc MRCPCH
Cancer Research UK Paediatric Oncology Clinical Trials Fellow, Great Ormond Street
Hospital for Children NHS Foundation Trust, London & Birmingham University Clinical
Trials Unit, UK
Miss Rebecca Evans-Jones BA (Hons) MBBS MSc MRCOG DTM&H
Consultant in Obstetrics and Gynaecology, Gloucestershire Hospitals NHS Foundation
Trust, UK
Dr Lucy Hicks BSc (Hons) MBBS MRCP FHEA
Specialty Registrar in Gastroenterology and General Medicine, Northwest London, UK
Dr Kinesh Patel BA (Hons) MBBS MD MRCP
Consultant Gastroenterologist, Chelsea and Westminster Hospital NHS Foundation Trust,
London, UK
Mr Paolo Sorelli MBBS MSc FRCS
Consultant Colorectal Surgeon, Lewisham and Greenwich NHS Trust, London, UK
Dr Kate Tatham BSc (Hons) MBBS PhD MRCP FRCA FFICM
Specialty Registrar in Anaesthetics and Intensive Care, Imperial School of Anaesthesia;
Clinical Lecturer, Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial
College, London, UK
Dr James R Waller BSc (Hons) MBBS MRCP
Consultant Cardiologist and Physician, Lymington New Forest Hospital, Southern Health
NHS Foundation Trust, Hampshire, UK

K27185_C000.indd 11 22/06/2018 15:19

K27185_C000.indd 12 22/06/2018 15:19
 List of abbreviations

β-hCG β human chorionic gonadotropin

AAA abdominal aortic aneurysm
ABG arterial blood gas
AC air conduction
ACTH adrenocorticotropic hormone
AED automatic external defibrillator
AF atrial fibrillation
AFP α-fetoprotein
ASIS anterior superior iliac spine
BC bone conduction
BCC basal cell carcinoma
BMI body mass index
bpm beats per minute
CABG coronary artery bypass graft
CIN cervical intraepithelial neoplasia
CNS central nervous system
COPD chronic obstructive pulmonary disease
COX-2 cyclo-oxygenase-2
CPR cardiopulmonary resuscitation
CSF cerebrospinal fluid
CT computed tomography
CTG cardiotocograph
DIP distal interphalangeal
DMARD disease-modifying antirheumatic drug
DNACPR do not attempt cardiopulmonary resuscitation
ECG electrocardiogram
ESR erythrocyte sedimentation rate
FBC full blood count
FEV1 forced expiratory volume in 1 second
FiO2 fraction of inspired oxygen
FSH follicle-stimulating hormone
FVC forced vital capacity
GCS Glasgow Coma Scale
GTN glyceryl trinitrate

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 xiv    L i s t o f a b b r e v i a t i o n s

HIV human immunodeficiency virus

HPV human papilloma virus
HRT hormone replacement therapy
HSMN hereditary sensory and motor neuropathy
ICE ideas, concerns and expectations
ICP intracranial pressure
IE infective endocarditis
IPF idiopathic pulmonary fibrosis
IUS intrauterine system
JVP jugular venous pressure
LDH lactate dehydrogenase
LH luteinizing hormone
LMN lower motor neurone
LMP last menstrual period
MCP metacarpophalangeal
MDI metered-dose inhaler
MI myocardial infarction
MMR measles, mumps and rubella
MRI magnetic resonance imaging
NEWS National Early Warning Score
NSAID non-steroidal anti-inflammatory drug
OSA obstructive sleep apnoea
PaCO2  partial pressure of carbon dioxide in arterial blood
PALS Patient Advice and Liaison Service
PaO2  partial pressure of oxygen in arterial blood
PCI percutaneous coronary intervention
PCKD polycystic kidney disease
PCOS polycystic ovary syndrome
PEFR peak expiratory flow rate
PFT pulmonary function test
PID pelvic inflammatory disease
PIP proximal interphalangeal
PND paroxysmal nocturnal dyspnoea
POC products of conception
SCC squamous cell carcinoma
SFH symphysis–fundus height
SFJ saphenofemoral junction
SIADH syndrome of inappropriate antidiuretic hormone secretion
SpO2 peripheral capillary oxygen saturation
STI sexually transmitted infection
U&E urea and electrolytes
UMN upper motor neurone
UTI urinary tract infection

K27185_C000.indd 14 22/06/2018 15:19

 HAPTER
C H A P T E R 1

History
CATHERINE BENNETT

History taking skills 1 Tiredness13

Chest pain 4 Headache15
Shortness of breath 5 Collapse or fall 17
Fever/pyrexia of unknown origin 7 Alcohol misuse 19
Abdominal pain 9 Psychiatric history and risk assessment 21
Change in bowel habit/rectal bleeding 12

HISTORY TAKING SKILLS

Familiarity with the key components of a history is invaluable when taking a history from
any patient.

INTRODUCTION
⦁ Introduce yourself
⦁ Ensure the patient is sitting comfortably, alongside, and not behind, a desk
⦁ Confirm the reason for the attendance

PATIENT DETAILS
⦁ Confirm the patient’s details:
• Full name
• Age and date of birth

PRESENTING COMPLAINT
⦁ Ask the patient to describe their problem by using open questions (see Box 1.1)
⦁ The presenting complaint should be expressed in their own words, e.g. ‘heaviness in
the chest’

BOX 1.1 EXAMPLES OF OPEN QUESTIONS

⦁⦁ How can I help today?

⦁⦁ What can I do for you today?
⦁⦁ Why have you come to see me today?
⦁⦁ What seems to be the problem?
⦁⦁ What kind of problems have you been having recently?
⦁⦁ Can you tell me a bit more about that?

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 2    H i s t o r y

⦁ Do not interrupt their first few sentences. Pausing after the patient’s first few sentences
before asking questions can sometimes elicit more information
⦁ Try to draw out their ideas, concerns and expectations (‘ICE’), e.g. ‘Was there anything
that you thought might be causing this or anything in particular you were worried
about?’ or ‘What were you hoping for today?’
• Use active listening techniques, e.g. nodding
• Reflect back patients’ own words/feelings to show you have heard them, e.g. ‘I can
see that you are upset by that,’ or ‘You mentioned you had felt…’

HISTORY OF PRESENTING COMPLAINT

⦁ Interrogate the patient further about the presenting complaint
⦁ A useful guide, e.g. for pain, is the mnemonic ‘SOCRATES’:
• Site
• Onset
• Character
• Radiation
• Alleviating factors
• Timing
• Exacerbating factors
• Severity (scale 1–10)
• And associated Symptoms

PAST MEDICAL HISTORY

⦁ Enquire about diseases relating to the presenting complaint. For example, for chest
pain:
• Coronary heart disease/angina/myocardial infarction (MI)
• Indigestion/reflux/hiatus hernia
• Asthma/chronic obstructive pulmonary disease (COPD)/pulmonary fibrosis
• Deep vein thrombosis/pulmonary embolism/hypercoagulability
⦁ Ask all patients if they have a history of important diseases (mnemonic ‘JAM
THREADS Ca’):
• Jaundice
• Anaemia and other haematological conditions
• Myocardial infarction
• Tuberculosis
• Hypertension and heart disease
• Rheumatic fever
• Epilepsy
• Asthma and chronic obstructive pulmonary disease (COPD)
• Diabetes
• Stroke
• Cancer

DRUG HISTORY
⦁ Enquire about all medications including creams, drops, the oral contraceptive and
herbal/vitamin preparations

K27185_C001.indd 2 18/06/2018 09:42

 H i s t o r y t a k i n g s k i l l s     3

⦁ Specify:
• Route
• Dose
• Frequency
• Compliance
⦁ Take a detailed allergy history, e.g. which medications/foods and the symptoms

FAMILY HISTORY
⦁ Ask the patient about any relevant family diseases, e.g. coronary heart disease, diabetes
⦁ Enquire about the patient’s parents, and the cause and age at death if deceased
⦁ Sketch a short family tree, including any offspring (see Fig. 1.1)

Key:

Male

Female

Deceased

Disease sufferer
e.g. haemophilia

Married

Offspring

Figure 1.1 Example family tree

SOCIAL (AND PSYCHIATRIC) HISTORY

⦁ Assess any alcohol use in approximate units/week
⦁ Ask about tobacco use – quantify with ‘pack years’ (number of packets of 20 cigarettes
smoked per day multiplied by number of years smoking)
⦁ Employment history, current and past, including exposure to pathogens, e.g. asbestos
⦁ Enquire about home situation, including any pets
⦁ Enquire about any history of psychiatric disease

SYSTEMS REVIEW
⦁ Run through a comprehensive list of symptoms from all systems:
• Cardiovascular, e.g. chest pain, palpitations
• Respiratory, e.g. cough, dyspnoea
• Gastrointestinal, e.g. abdominal pain, diarrhoea
• Genitourinary, e.g. dysuria, discharge
• Neurological, e.g. numbness, weakness
• Musculoskeletal, e.g. aches, pains
• Psychiatric, e.g. depression, anxiety

SUMMARY
⦁ Provide a short summary of the history including:

K27185_C001.indd 3 18/06/2018 09:42

 4    H i s t o r y

• Name and age of patient

• Presenting complaint
• Relevant medical history
⦁ Give a differential diagnosis (e.g. ‘This could be a myocardial infarction or
oesophageal spasm’)
⦁ Formulate a short investigation and treatment plan

CHEST PAIN
INTRODUCTION
⦁ Introduce yourself
⦁ Confirm the patient’s name
⦁ Confirm the reason for meeting
⦁ Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

The mnemonic ‘SOCRATES’ is useful for assessing chest pain (see p. 2). Enquire about:
⦁ Site – central or left chest, retrosternal, epigastric
⦁ Onset – sudden, gradual, related to trauma/exertion
⦁ Character – crushing, heavy, tight band, pleuritic, burning
⦁ Radiation – radiating to left arm, neck, jaw or back
⦁ Alleviation – rest, glyceryl trinitrate (GTN) spray, sitting forward (pericarditis)
⦁ Timing – related to exertion or occurring at rest
⦁ Exacerbating factors – effort, emotion, movement, food, respiration, cold weather
⦁ Severity (scale 1–10)
⦁ And associated Symptoms:
• Dyspnoea, palpitations
• Syncope/collapse
• Sweating, burping, nausea/vomiting
• Ankle swelling
• Calf swelling
• Paroxysmal nocturnal dyspnoea (PND) or orthopnoea
• Cough, haemoptysis, sputum
• Fever, constitutional upset, coryza
• Panic attacks, anxiety

PAST MEDICAL HISTORY

⦁ Vascular disease:
• Angina, previous MI, previous angioplasty or coronary artery bypass graft
(CABG) surgery
• Claudication
• Cerebrovascular disease, transient ischaemic attacks
• Risk factors:
♦ Hypertension
♦ Hyperlipidaemia

K27185_C001.indd 4 18/06/2018 09:42

 S h o r t n e s s o f b r e a t h     5

♦ Diabetes
♦ Smoking
♦ Family history (MI <60 years of age, hyperlipidaemia)
⦁ Thromboembolic disease:
• Recent surgery, cancer, immobility
• Inherited hypercoagulable state, e.g. protein S or C deficiency
• Oral contraceptive/hormone replacement therapy
• Smoking
⦁ Pneumothorax:
• Tall, thin man
• Connective tissue disease (e.g. Marfan’s)

DRUG HISTORY
⦁ Cardiac medications: β-blockers, diuretics, antiplatelet agents, GTN spray
⦁ Recreational drug use, e.g. cocaine (coronary artery spasm)
⦁ Chronic non-steroidal anti-inflammatory drug (NSAID) use causing gastritis/
oesophagitis/reflux

SOCIAL HISTORY
⦁ Smoking
⦁ Alcohol intake
⦁ Diet (fatty food, salt intake)
⦁ Lifestyle, exercise
⦁ Recent immobility/major surgery/long-haul travel

BOX 1.2 DIFFERENTIAL DIAGNOSIS: CHEST PAIN

Cardiovascular: Respiratory:
⦁⦁ MI ⦁⦁ Pulmonary embolism
⦁⦁ Acute coronary syndrome (non-ST ⦁⦁ Pneumonia
elevation MI, unstable angina) ⦁⦁ Pneumothorax
⦁⦁ Angina (induced by effort and Musculoskeletal:
relieved by rest) ⦁⦁ Costochondritis (Tietze’s syndrome)
⦁⦁ Acute aortic dissection ⦁⦁ Chest wall injuries
⦁⦁ Pericarditis
Psychosomatic:
Gastrointestinal: ⦁⦁ Anxiety/depression
⦁⦁ Reflux oesophagitis
⦁⦁ Oesophageal spasm
⦁⦁ Peptic ulcer disease

SHORTNESS OF BREATH
INTRODUCTION
⦁ Introduce yourself
⦁ Confirm the patient’s name

K27185_C001.indd 5 18/06/2018 09:42

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 6    H i s t o r y

⦁ Confirm the reason for meeting

⦁ Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
⦁ Onset and duration – acute, chronic, constant, intermittent
⦁ Exacerbating factors – effort, emotion, movement, cold weather
⦁ Alleviation – rest, inhalers
⦁ Timing – related to exertion
⦁ Associated symptoms:
• Wheeze
• Stridor
• Cough – productive or dry, colour/viscosity of sputum
• Fever, night sweats or weight loss
• Haemoptysis – how much: teaspoon, cup-full
• Chest pain – pleuritic, cardiac
• Palpitations
• Nausea and vomiting, sweating, dizziness
• Ankle swelling
• PND
• Orthopnoea – number of pillows
• Exercise tolerance – quantify, e.g. number of stairs, distance on the flat

PAST MEDICAL HISTORY

⦁ Asthma: frequency of attacks, admissions to hospital or intensive care unit
⦁ COPD: frequency of exacerbations, admissions (as for asthma), use of home oxygen
(number of hours) and home nebulizers
⦁ Recurrent lower respiratory tract infections
⦁ Cardiac failure or structural disease
⦁ Arrhythmias
⦁ Deep vein thrombosis, procoagulant states (e.g. pregnancy, cancer, surgery)

DRUG HISTORY
⦁ Nebulizers
⦁ Cardiac medications
⦁ Diuretics, e.g. furosemide
⦁ Angiotensin-converting enzyme inhibitors

FAMILY HISTORY
⦁ History of atopy – asthma, eczema, hay fever
⦁ Tuberculosis

SOCIAL HISTORY
⦁ Smoking history (active and passive)
⦁ Occupation and exposure to coal, dust, asbestos

K27185_C001.indd 6 18/06/2018 09:42

 Fe v e r / p y r e x i a o f u n k n o w n o r i g i n     7

⦁ Animal exposure (pets, farming)

⦁ Tuberculosis exposure
⦁ Limitation of daily activities by shortness of breath

BOX 1.3 DIFFERENTIAL DIAGNOSIS

Acute: Chronic:
⦁⦁ Asthma ⦁⦁ COPD
⦁⦁ Acute exacerbation of COPD ⦁⦁ Cardiac failure
⦁⦁ Lower respiratory tract infection ⦁⦁ Pulmonary fibrosis
⦁⦁ Pulmonary oedema ⦁⦁ Anaemia
⦁⦁ Pulmonary embolism ⦁⦁ Arrhythmias
⦁⦁ Pneumothorax ⦁⦁ Cystic fibrosis
⦁⦁ Pleural effusion ⦁⦁ Pulmonary hypertension
⦁⦁ Lung cancer
⦁⦁ Anxiety/panic attack
⦁⦁ Metabolic acidosis

FEVER/PYREXIA OF UNKNOWN ORIGIN

INTRODUCTION
⦁ Introduce yourself
⦁ Confirm the patient’s name
⦁ Confirm the reason for meeting
⦁ Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

⦁ Onset – sudden, gradual
⦁ Character – constant, intermittent
⦁ Frequency of peaks in temperature
• Has the temperature been recorded?
⦁ Alleviation – rest, paracetamol
⦁ Timing – related to exertion
⦁ Exacerbating factors – climate/weather, time of day
⦁ Associated symptoms/signs:
• Rigors or shivering
• Sweating (especially at night)
• Weight loss
• Anorexia
• Feeling faint or dizziness, syncopal episodes
• Fatigue
• Lumps, tender lymph nodes
• Pain
• Cough and sputum (lower respiratory tract infection)
• Diarrhoea and vomiting, abdominal pain (gastroenteritis)

K27185_C001.indd 7 18/06/2018 09:42

 8    H i s t o r y

• Urinary frequency, dysuria, haematuria (urinary tract infection [UTI])

• Rashes or skin changes, areas of erythema (viral illnesses, cellulitis)
• Headache, neck stiffness, photophobia (meningitis)
• Heart failure, track marks, lethargy, rash, new murmur (infective endocarditis)

PAST MEDICAL HISTORY

⦁ Recent surgery
⦁ Recent illness, e.g. upper respiratory tract infection
⦁ Blood transfusions

DRUG HISTORY
⦁ Intravenous drug use
⦁ Appropriate malaria prophylaxis when travelling and compliance
⦁ Immunizations up to date

FAMILY HISTORY
⦁ Any family members with contagious disease
⦁ Animal – contact, bites

SEXUAL HISTORY
⦁ Sexual history – recent sexual practices (see p. 205)

TRAVEL HISTORY
⦁ Travel history – location, appropriate vaccinations, diet, food hygiene, swimming

SOCIAL HISTORY
⦁ Tattoos
⦁ Piercings
⦁ Occupational exposure, e.g. to animals

BOX 1.4 COMMON DIFFERENTIAL DIAGNOSES OF PYREXIA OF UNKNOWN ORIGIN

Infective:
⦁⦁ Bacterial: e.g. pneumonia, UTI, meningitis, endocarditis, abdominal/pelvic
abscess
⦁⦁ Viral: e.g. gastroenteritis, hepatitis, human immunodeficiency virus (HIV)
seroconversion
⦁⦁ Parasitic: e.g. malaria, schistosomiasis
Inflammatory: e.g. systemic lupus erythematosus, rheumatoid arthritis, Crohn’s
disease
Malignancy: e.g. lymphoma, leukaemia, hepatocellular carcinoma
Others: e.g. pulmonary embolus, factitious, recent vaccination, thyrotoxicosis

K27185_C001.indd 8 18/06/2018 09:42

 A b d o m i n a l p a i n     9

INVESTIGATIONS
There are numerous investigations, depending on the history, including:
⦁ Full blood count, urea and electrolytes, liver function tests, C-reactive protein,
erythrocyte sedimentation rate, thyroid function tests
⦁ Viral screen, e.g. Epstein–Barr virus, cytomegalovirus, HIV
⦁ Autoimmune screen, e.g. antinuclear antibody, antineutrophil cytoplasmic antibody
⦁ Blood cultures
⦁ Blood film to exclude malaria and haematological disorders
⦁ Sputum culture
⦁ Mid-stream urinalysis
⦁ Stool culture
⦁ Chest X-ray
⦁ Electrocardiogram
For difficult cases, echocardiography (endocarditis), computed tomography and positron
emission tomography can help localize abnormalities giving rise to the fever. Referral to a
genitourinary medicine clinic or a tropical disease specialist may be warranted if indicated
by the history.

ABDOMINAL PAIN
INTRODUCTION
⦁ Introduce yourself
⦁ Confirm the patient’s name
⦁ Confirm the reason for meeting
⦁ Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
⦁ Site – where did it start and has it moved?
⦁ Onset – sudden, gradual
⦁ Character – crampy, colicky, sharp, burning
⦁ Radiation – e.g. loin to groin (renal colic)
⦁ Alleviation – relieved by opening bowels or vomiting?
⦁ Timing – related to eating/bowels/micturition/menstruation/movement?
⦁ Exacerbating factors
⦁ Severity (scale 1–10), does it wake you?
⦁ And associated Symptoms:
• Nausea and vomiting – haematemesis, ‘coffee-ground’ vomit, bile-stained or
feculent?
• Dysphagia
• Dyspepsia
• Change in bowel habit – e.g. diarrhoea/constipation, altered frequency, colour,
consistency, pale, offensive smell, frothy, hard to flush away (steatorrhoea), blood

K27185_C001.indd 9 18/06/2018 09:42

 10    H i s t o r y

or mucus present
• Rectal bleeding
• Bloating, flatulence
• Weight gain/loss
• Appetite change
• Jaundice, pruritus, dark urine, pale stools
• Rigors/fever

Right Epigastric Left Right Left

hypochondrium region hypochondrium upper upper
quadrant quadrant
Right Umbilical Left
lumbar region region lumbar region
Right Left
lower lower
Right Supra- Left
quadrant quadrant
iliac fossa pubic iliac fossa
region

(a) (b)

• Haematuria, dysuria, vaginal discharge or bleeding

Figure 1.2 Areas of the abdomen: (a) ninths or (b) quadrants

PAST MEDICAL HISTORY

⦁ Inflammatory bowel disease – Crohn’s disease, ulcerative colitis
⦁ Diverticular disease
⦁ Previous abdominal/pelvic surgery (adhesions causing bowel obstruction)
⦁ Recent trauma or injury (e.g. splenic rupture)
⦁ Menstruation (pregnant/ectopic) and sexual history (pelvic inflammatory disease)
⦁ Other common diseases: MJ THREADS Ca (see p. 2)

DRUG HISTORY
⦁ NSAIDs
⦁ Laxatives
⦁ Opiates
⦁ Antibiotics, e.g. erythromycin

K27185_C001.indd 10 18/06/2018 09:42

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Stamford, 1470. The ninth lord was William, who was descended
from a younger son of the fifth Baron Willoughby, since Richard
Hastings, whom Joan, the sister and heiress of the eighth Lord
Welles, had married, left no issue. There is a monument in Ashby
church near Spilsby, though in a very fragmentary condition, to
William and also to Joan and Richard Hastings. William married
Katherine of Aragon’s maid-of-honour, Lady Mary Salines, for his
second wife, and by a will, dated Eresby 1526, desired to be buried
and have a monument erected to himself and his wife at Spilsby, but
this was never done. The stone screen with its supporting figures of
a hermit, a crowned Saracen, and a wild man, erect, set up in 1580,
is in memory of his daughter and heiress, Katherine Duchess of
Suffolk, and her second husband, Richard Bertie, her first husband
being that Charles Brandon who obtained so huge a share of the
estates confiscated by Henry VIII. in Lincolnshire. They lived at
Grimsthorpe, on the west side of the county, which the king had
given to Katherine’s parents; and thenceforth that became the chief
seat of the Willoughby family, and the series of monuments is
continued in Edenham church. But there is one more monument, in
what is now called the Willoughby chapel at Spilsby. This is to a son
of the duchess, Peregrine Bertie, tenth Baron Willoughby; he died at
Berwick in 1601, and was buried at Spilsby as directed in his will; his
daughter, Lady Watson, died in 1610, and, as she wished to be
buried near her father, Sir Lewis Watson of Rockingham erected a
monument to both father and daughter, the latter reclining on her
elbow, with the baby, which caused her death, in a little square cot
at her feet. Peregrine was so named because he was born abroad,
his parents having fled from the Marian persecutions. His wife was
the Lady Mary Vere who brought the office of chamberlain into the
Willoughby family. It was claimed by her son Robert, the eleventh
baron, who in 1630 was made Earl of Lindsey, and thus the barony
became merged in the earldom, the fourth earl being subsequently
created Duke of Ancaster.
Eresby Manor was burnt down in 1769, and only the moat and
garden wall and, at the end of the avenue, one tall brick-and-stone
gate-pillar surmounted by a stone vase remain. At the suppression
of the college and chantries the Grammar School was founded on
the site of the college, just to the north of the church, Robert
Latham being the first master, in 1550.
At the south-west end of the church are three tablets to three
remarkable brothers born in Spilsby towards the end of the
eighteenth century.
Major James Franklin, who made the first military THE FRANKLINS
survey of India, and contributed a paper to the
Geological Society in 1828, died in 1834. Sir Willingham Franklin
who, after a distinguished career at Westminster and Oxford, died,
with wife and daughter, of cholera, 1824, at Madras, where he was
judge of the Supreme Court. And Sir John Franklin, the famous
Arctic navigator, who fought at Trafalgar and Copenhagen, and died
in the Arctic regions on June 11, 1847, before the historic disaster
had overtaken the crews of the Erebus and Terror. His statue stands
in his native town, and also in Hobart Town, where he lived for a
time as Governor of Tasmania, and is one of the two statues in
London which were set up by the nation. On his monument in
Westminster Abbey are the beautiful lines by his friend and
neighbour, and relative by marriage, Alfred Tennyson.

Not here! the white North has thy bones; and thou,
Heroic sailor-soul,
Art passing on thy happier Voyage now
Towards no earthly pole.

The other brother, Thomas Adams Franklin, raised the Spilsby and
Burgh battalion of volunteer infantry in 1801. Major Booth followed
his good example and raised a company at Wainfleet to resist the
invasion by Napoleon, and the men of the companies presented
each of them with a handsome silver cup. Five Franklin sisters
married and settled in the neighbourhood; and Catharine, the
daughter of Sir Willingham, married Drummond, the son of the Rev.
T. H. Rawnsley, vicar of Spilsby. Thus quite a clan was created,
insomuch that forty cousins have been counted at one Spilsby ball.
Drummond succeeded his father as rector of Halton, and very
appropriately preached the last sermon in the old church at Spilsby
at the closing service previous to its restoration, speaking from the
pulpit which his father had occupied from 1813 to 1825. His sermon,
a very fine one, called “The Last Time,” was from 1 St. John ii. 18,
and was delivered on Trinity Sunday, 1878.
The time to visit Spilsby is on market day, when, LINCOLNSHIRE
round the butter cross, besides eggs, butter and STORIES
poultry, pottery is displayed “on the stones,” stalls
are set up where one may buy plants and clothes, and things hard
to digest like “bull’s eyes,” as well as boots and braces, and near
“the Statue” at the other end, are farm requisites, sacks, tools, and
the delightful-smelling tarred twine, as well as all sorts of old iron,
chains, bolts, hinges, etc., which it seems to be worth someone’s
while to carry from market to market. It is here that the humours of
the petty auctioneer are to be heard, and the broad Doric of the
Lincolnshire peasant. In the pig market below the church hill you
may hear a man trying to sell some pigs, and to the objection that
they are “Stränge an’ small,” he replies, “Mebbe just now; but I tell
ye them pigs ’ull be greät ’uns,” then, in a pause, comes the voice
from a little old woman who is looking on without the least idea of
buying, “It ’ull be a straänge long while fust,” and in a burst of
laughter the chance of selling that lot is snuffed out, or, as they say
at the Westmorland dog trials, “blown off.”
There is an unconscious humour about the older MORE STORIES
Lincolnshire peasants which makes it very amusing
to be about among them, whether in market, field or home. My
father never returned from visiting his parish without some rich
instance of dialect or some humorous speech that he had heard.
Finding a woman flushed with anger outside her cottage once, and
asking her what was amiss, he was told “It’s them Hell-cats.” “Who
do you call by such a name?” “Them Johnsons yonder.” “Why? What
have they been doing?” “They’ve been calling me.” “That’s very
wrong; what have they been calling you?” “They’ve bin calling me
Skinny.” At another time a woman, in the most cutting tones,
alluding to her next-door neighbours who had an afflicted child, said,
“We may-be poor, and Wanty [her husband] says we are poor,
destitutely poor, and there’s no disgraäce in being poor, but our
Mary-Ann doant hev fits.” Another time, when my sister was
recommending a book from the lending library describing a voyage
round the world, and called “Chasing the Sun,” a little old woman
looked at the title and said, “Naäy, I weänt ha’ that: I doänt howd wi
sich doings. Chaäsing the Sun indeed; the A’mighty will soon let ’em
know if they gets a chevying him.” In the same village I got into
conversation one autumn day with a small freeholder whose cow
had been ill, and asked him how he had cured her, he said, “I got
haafe a pound o’ sulphur and mixed it wi’ warm watter and bottled it
into her. Eh! it’s a fine thing I reckon is sulphur for owt that’s badly,
cow or pig or the missis or anythink.” Then, with a serious look he
went on, “There’s a straänge thing happened wi’ beans, Mr.
Rownsley.” “What’s that?” “Why, the beans is turned i’ the swad” (=
pod). “No!” “Yees they hev.” “How do you mean?” “Why they used to
be black ends uppermost and now they’r ’tother waay on.” “Well,
that’s just how they always have been.” “Naay they warn’t. It was
’81 they turned.” They do lie with the attachment of each bean to
the pod, just the way you would not expect, and having noticed this
he was convinced that up to then they had really lain the way he
had always supposed they did, so difficult is it to separate fact from
imagination. The similes used by a Lincolnshire native are often
quite Homeric, as when an old fellow, who was cutting his crop of
beans, the haulm of which is notoriously tough, resting on his scythe
said, “I’d rayther plow wi two dogs nor haulm beans.” Then they
have often a quiet, slow way of saying things, which is in itself
humorous. I remember a labourer who was very deaf, but he had
been much annoyed by the mother of a man whose place he had
succeeded to. He was working alongside of his master and apropos
of nothing but his own thoughts, he said, “Scriptur saäys we should
forgive one another; but I doänt knoä. If yon owd ’ooman fell i’ the
dyke I doänt think I should pull her out. I mowt tell some ’un on her,
but I doänt think I should pull her out howiver.” There is some
kindliness in that, though in quantity it is rather like the Irishman’s
news: “I’ve come to tell you that I have nothing to tell you, and
there’s some news in that.” But the Lincolnshire native is a trifle
stern; even the mother’s hand is more apt to be punitive than
caressing. “I’ll leather you well when I gets you home, my lad,” I
have heard a mother say to a very small boy, and I have heard tell
of a mother who, when informed that her little girl had fallen down
the well, angrily exclaimed, “Drat the children, they’re allus i’
mischief; and now she’s bin and drownded hersen I suppose.”
In Westmorland it is the husband who will take too much at
market on whom the vials of the wrath of the missis are outpoured,
and they generally know how to “sarve” him. One good lady, on
being asked “However did you get him ower t’wall, Betty?” replied “I
didna get him ower at a’—I just threshed him through th’ hog-hole”
(the hole in the wall for the sheep, or hoggetts, to pass through).
Speaking of tippling, there is no more delightful story than this
from Westmorland, of a mouse which had fallen into a beer vat and
was swimming round in despair, when a cat looked over, and the
mouse cried out, “If ye’ll git me oot o’ this ye may hev me.” The cat
let down her tail and the mouse climbed up, and shaking herself on
the edge of the vat, jumped off and went down her hole, and on
being reproached by the cat as not being a mouse of her word,
answered, “Eh! but ivry body knaws folks will say owt when they’re i’
drink.”
There are several pretty little bits of country near OLD
Spilsby, but the most interesting of the by-ways BOLINGBROKE
leads off from the Horncastle road at Mavis
Enderby, and, going down a steep hill, brings us to Old Bolingbroke,
a picturesque village with a labyrinth of lanes circling about the
mounded ruins of the castle, where, in 1366, Henry IV. “of
Bolingbroke” was born. It was built in 1140 by William de Romara,
first Earl of Lincoln, and was, till 1643, when Winceby battle took
place, a moated square of embattled walls, with a round tower at
each corner. Here Chaucer used to visit John of Gaunt and the
Duchess Blanche of Lancaster, on whose death, in 1369, he wrote
his “Book of the Duchess.” The castle, after the Civil Wars, sank into
decay, and the gate-house, the last of the masonry, fell in 1815. The
road onwards comes out opposite Hagnaby Priory. William de
Romara, who three years later founded Revesby Abbey, had for his
wife the second Lady Lucia, the heiress of the Saxon Thorolds, an
honoured name among Lincolnshire families. She brought him,
among other possessions, the manor of Bolingbroke. Her second
husband was the Norman noble, Ranulph, afterwards earl of Chester.
The Thorolds were descended from Turold, brother of the Lady
Godiva. There apparently were two Lady Lucias, whose histories are
rather mixed up by the ancient chroniclers. The earlier of the two
was, it seems, the sister of the Saxon nobles, Edwin and Morcar, and
of King Harold’s queen Ealdgyth. Her hand was bestowed by the
conqueror upon his nephew, Ivo de Taillebois (= Underwood), who
became, according to Ingulphus and others, a monster of cruelty,
and died in 1114.
There are several by-ways to the north-west of HARRINGTON
Spilsby, which all converge on Harrington. Here the
church contains several monuments of interest. At the east end of
the nave, a knight in chain armour with crossed legs and shield is
said to be Sir John Harrington (circa 1300); and against the chancel
wall, but formerly on the pavement, is the brass of Margaret
Copledike (1480). Her husband’s effigy is missing. Under the tower
window is the monument to Sir John Copledike (1557), and in the
chancel south wall a canopied tomb with a brass of Sir John
Copledike (1585). Opposite is a Jacobean monument, which testifies
to the illiteracy of the age with regard to spelling, to Francis
Kopaldyk, his wife and two children (1599). In the time of Henry III.
it was spelt Cuppeldick. A Perpendicular font with the Copledike
arms stands against the tower arch.
Close to the church is Harrington Hall, with its fine old brick front
and projecting porch. Hanging over the doorway is a large dial with
the Amcotts arms, a curiously shaped indicator, and the date 1681.
On either side of the porch which runs up the whole height of the
house, are twelve windows, under deep, projecting, corbelled eaves.
Inside is an old oak-panelled room, most richly carved. The house is
the property of the Ingilby family, and at present the residence of E.
P. Rawnsley, Esq., who has been for many years Master of the
Southwold Hunt.
Somersby is but two miles off, and we may without hesitation turn
our thoughts to the terraced garden of this delightful old hall when
we read in Tennyson’s “Maud”:—

“Birds in the high Hall-garden

When twilight was falling,
Maud, Maud, Maud, Maud,
They were crying and calling.”

The poet loved to tell how, when he was reading this and paused to
ask, “Do you know what birds those were?” a lady, clasping her
hands, said, “Oh, Mr. Tennyson, was it the nightingale?” though in
reading it he had carefully given the harsh caw of the rooks.
To get from here to Somersby you pass through BAG ENDERBY
Bag Enderby, where there is a fine church, now in
a very ruinous state. The very interesting old font, which stands on
two broken Enderby tombstones, has some unusual devices carved
on it, such as David with a viol, and the Virgin with the dead Christ.
One, the most remarkable of all, is a running hart turning back its
head to lick off with its long tongue some leaves from the tree of life
growing from its back. This symbolism is purely Scandinavian; and
that it could be used on a Christian font shows how thoroughly the
two peoples and their two religions were commingling.[25] The large
number of villages about here ending in “by”—Danish for hamlet—is
sufficient evidence of the number of settlers from over the North Sea
who had taken up their abode in this part of the county.
 Somersby Church.

The green-sand, which underlies the chalk, and of which almost all
the churches are built, crops out by the roadside in fine masses both
here and at Somersby and Salmonby, as it does too at Raithby,
Halton, Keal, all in the immediate neighbourhood of the chalk wolds.
Inside the church, slabs on the floor of the chancel retain their brass
inscriptions to Thomas and Agnes Enderby (1390), and Albinus de
Enderby, builder of the tower (1407); and on the wall is a monument
to John and Andrew Gedney (1533 and 1591). The latter
represented in armour and with his wife and family of two sons and
two daughters. The wife, whose name is spelt first Dorithe, then
Dorathe, “died the 7th of June 1591 and Andrew ____” the blank
being left unfilled.
The knives and scourges of Crowland Abbey (see Chap. XLI.) are
seen in the old glass. The custom of giving little knives to all comers
at Crowland on St. Bartholomew’s Day was abolished by Abbot John
de Wisbeche in the reign of Edward IV. In the tower is a fine peal of
disused bells.
Dr. Tennyson held this living with Somersby. This SOMERSBY
is a smaller building, but it retains in the CROSS
churchyard a remarkable and perfect cross, a tall, slender shaft with
pedimented tabernacle, under which are figures, as on the gable
cross at Addlethorpe and on the head of the broken churchyard
cross at Winthorpe—the Crucifixion is on one side and the Virgin and
Child on the other.
From Somersby there are two roads to Horncastle—each passes
over the brook immortalised in “In Memoriam” and in the lovely little
lyric, “Flow down cold rivulet to the sea,” and branching to the left,
one passes through Salmonby, where Bishop William of Waynflete is
said to have been rector. This is doubtful, but probably he was
presented to the vicarage of Skendleby by the Prior of Bardney in
1430. The other and prettier road goes by Ashby Puerorum and
Greetham, and both run out into the Spilsby and Horncastle road
near High Toynton. Ashby Puerorum (or Boys’ Ashby) gets its name
from an estate here bequeathed to support the Lincoln Minster choir
boys. At this place, and again close by Somersby, the hollows in the
Wold which this road passes through are among the prettiest bits of
Lincolnshire.
 CHAPTER XXXI
SOMERSBY AND THE TENNYSONS
Tennyson’s Poetry descriptive of his home—Bronze Bust of the Poet—
Dedication Festival—A Long-lived Family—Dialect poems.

This little quiet village, tucked away in a fold of the hills, with the
eastern ridge of the Wolds at its back and the broad meadow valley
stretching away in front of it and disappearing eastwards in the
direction of the sea, had no history till now. It was only in 1808 that
Dr. George Clayton Tennyson came to Somersby as rector of
Somersby and Bag Enderby, incumbent of Beniworth and Vicar of
Great Grimsby. He came as a disappointed man, for his father, not
approving, it is said, of his marriage with Miss ffytche of Louth (a
reason most unreasonable if it was so) had disinherited him in
favour of his younger brother Charles, who became accordingly
Charles Tennyson d’Eyncourt of Bayons Manor near Tealby.
Dr. Tennyson’s eldest son George was born in the parsonage at
Tealby, in 1806, but died an infant. Frederick was born at Louth in
1807, and the other ten children at Somersby. Of these, the first two
were Charles (1808) and Alfred (1809).
They were a family of poets; their father wrote good verse, and
their grandmother, once Mary Turner of Caister, always claimed that
Alfred got all his poetry through her. Her husband George was a
member of Parliament and lived in the old house at Bayons Manor.
From the fourteenth century the Tennysons, like THE TENNYSONS
their neighbours the Rawnsleys, had lived in
Yorkshire; but Dr. Tennyson’s great-grandfather, Ralph, had come
south of the Humber about 1700 to Barton and Wrawby near Brigg,
and each succeeding generation moved south again. Thus, Michael,
who married Elizabeth Clayton, lived at Lincoln, and was the father
of George, the first Tennyson occupant of Bayons Manor. He had
four children: George Clayton, the poet’s father; Charles, who took
the name of Tennyson d’Eyncourt; Elizabeth, the “Aunt Russell” that
the poet and his brothers and sisters were so fond of; and Mary, the
wife of John Bourne of Dalby, of whom, though she lived so near to
them, the Somersby children were content to see very little, for she
was a rigid Calvinist, and once said to her nephew, “Alfred, when I
look at you I think of the words of Holy Scripture, ‘Depart from me,
ye cursed, into everlasting fire.’” At Somersby, then, the poet and all
the children after Frederick were born in this order: Charles, Alfred,
Mary, Emilia, Edward, Arthur, Septimus, Matilda, Cecilia, Horatio.
They were a singularly fine family, tall and handsome, taking after
their father in stature (he was six feet two inches) and after their
mother (a small and gentle person, whose good looks had secured
her no less than twenty-five offers of marriage) in their dark eyes
and Spanish colouring. She was idolised by her eight tall sons and
her three handsome daughters, of whom Mary, who became Mrs.
Ker, was a wonderfully beautiful woman. Frederick, who outlived all
his brothers, dying at the age of ninety-one after publishing a
volume of poems in his ninetieth year, alone of the family had fair
hair and blue eyes. Matilda is alive still at the age of ninety-eight.
The three elder sons all went to the Grammar DR. KEATE AND
School at Louth in 1813, when Alfred was but WELLINGTON
seven. Frederick went thence to Eton in 1817, and
to St. John’s, Cambridge, in 1826; Charles and Alfred stayed at
Louth till 1820, and they left it with pleasure for home teaching. Few
could have been better qualified to teach than the Doctor. He had a
good library and he was a classical scholar; could read Hebrew and
was not without a knowledge of mathematics, natural science and
modern languages; also he was a rigid disciplinarian, and, like all
good schoolmasters, was held in considerable awe by his pupils. I
should like to have heard him had anyone in his day outlined to him
as the method of the future the Montessori system. This power of
terrifying a whole class and causing each one of a set of ordinarily
plucky English lads to feel for the space of half an hour that his
heart was either in his mouth or in his shoes, would be incredible,
were it not that there are so many English gentlemen now living who
have experience of it. How well I remember the terrible, if irrational,
state of funk which the whole of any class below the upper sixth was
always in, when going up for their weekly lesson to that really most
genial of men, Edward Thring, and it was the same elsewhere, and
given the same sort of circumstances, the grown-up man could feel
as frightened as the boy; witness this delightful story of the Iron
Duke. No one could call him a coward, but on his return from
Waterloo he went down on the fourth of June to Eton, and first told
some one in his club that he meant to confess to Keate that he was
the boy who had painted the Founder’s Statue or some such iniquity,
the perpetrator of which Keate had been unable to discover. His
friend extracted a promise that after his interview he would come
and report at the club. He came, and being questioned by a group of
deeply interested old Etonians, he said, “Well, it was all different, not
at all like what I expected. I seized the opportunity when Keate
came to speak with me by the window and said, “You remember the
Founder’s Statue being defaced, sir?” “Certainly. Do you know
anything about it?” he said sharply. “No, sir.” “You don’t mean to say
you said that?” “Certainly I do, and what is more, every one of you
would, in the circumstances, have said just the same,” and then and
there they all admitted it; so difficult is it to shake off the feelings of
earlier days. And yet he was not naturally terrible, and I who write
this, never having been under him, have, as a small boy, spoken to
Keate without a shadow of fear.
This reminds me of a remark of Gladstone’s, who was giving us
some delightful reminiscences of his days at Eton, and, speaking
enthusiastically of Alfred Tennyson’s friend, Arthur Hallam, when on
my saying that I had spoken with Keate, he turned half round in his
chair and said, “Well, if you say you have seen Keate I must believe
you, but I should not have thought it possible.” He had forgotten for
the moment that Keate, after retiring from Eton, lived thirteen years
at Hartley Westpall (near Strathfieldsaye), where my father was
curate.
To return to Somersby. We read in the memoir of the poet an
amusing account, by Arthur Tennyson, of how the Doctor’s approach
when they were skylarking would make the boys scatter.
In 1828 Charles and Alfred went up to Trinity, EARLY VOLUMES
Cambridge. Frederick was already a University
prize-winner, having got the gold medal for the Greek ode, and
Charles subsequently got the Bell Scholarship, and Alfred the English
Verse prize. The boys’ first poetical venture was the volume “Poems
by Two Brothers,” published in 1826 by Jackson of Louth, who gave
them £20, more than half to be taken out in books. To this volume
Frederick contributed four pieces, the rest were by Charles and
Alfred. The latter used very properly to speak with impatience of it in
later years as his “early rot.” And it is quite remarkable how
comparatively superior is the work done by Alfred as a boy of
fourteen, and how little one can trace in the two brothers’ volume of
that lyrical ability which in 1830 produced Mariana and The Arabian
Nights, The Merman, The Dying Swan and the Ode to Memory. The
majority of these poems were written at Cambridge, but there is
much reference to Somersby in at least two of them, and the song,
“A Spirit haunts the year’s last hours,” was, we know, written in the
garden there with its border of hollyhocks and tiger-lilies. In the Ode
to Memory he invokes her to arise and come, not from vineyards,
waterfalls, or purple cliffs, but to

“Come from the Woods that belt the grey hill side,
The seven elms, the poplars four
That stand beside my father’s door,
And chiefly from the brook that loves
To purl o’er matted cress and ribbèd sand.
...
O! hither lead thy feet!
Pour round mine ears the livelong bleat
Of the thick fleecèd sheep from wattled folds,
 Upon the ridgèd wolds.”

This is reminiscent of Somersby.

Then again, Memory calls up the pictures of “the sand-built ridge
of heaped hills that mound the sea” at Mablethorpe, and the view
over “the waste enormous marsh.”
In 1831 Dr. Tennyson died, aged fifty-two, and his sons left
Cambridge. His widow lived on for thirty-four years, dying at the age
of eighty-four, in 1865. They stayed on in the Somersby home till
1837, and a new volume came out in 1832, with a whole array of
poems of rare merit, showing how much the poet’s mind had
matured in that last year at Cambridge. This volume, like the Louth
volume, is dated for the year after that in which it was really
published. It carried Alfred to the front rank at once, for in it was
The Lady of Shalott, The Palace of Art, The Miller’s Daughter,
Œnone, The May Queen, New Year’s Eve, The Lotus Eaters, A
Dream of Fair Women, and the Lines to James Spedding, on the
death of his brother Edward. Only think of all these wonderful poems
in a thin book of 162 pages written before he was twenty-three.
To Mablethorpe and Skegness on the Lincolnshire THE
coast we find frequent allusions in many poems, LINCOLNSHIRE
e.g., he speaks in The Last Tournament of “the COAST
wide-winged sunset of the misty marsh,” and when
the Red Knight in drunken passion, trying to strike the King
overbalances himself, he falls—

“As the crest of some slow arching wave,

Heard in dead night along that table shore,
Drops flat, and after, the great waters break
Whitening for half-a-league, and thin themselves,
Far over sands marbled with moon and cloud,
From less and less to nothing.”

A most accurate picture of that flat Lincolnshire coast with its

“league-long rollers,” and hard, wet sands shining in the moonlight.
In another place he speaks of “The long low dune and lazy-plunging
sea.”
In his volume of 1832 there are many pictures drawn from this
familiar coast, e.g., in The Lotus Eaters, The Palace of Art, The
Dream of Fair Women; and in his 1842 volumes he speaks of
“Locksley Hall that in the distance overlooks the sandy flats And
the hollow ocean ridges roaring into cataracts.”
A relative of mine was once reading this poem to the family of one
of those Marsh farmers who had known “Mr. Alfred” when a youth,
and who lived in the remotest part of that coast near the sandy
dunes and far-spread flats between Skegness and “Gibraltar Point”;
but she had not got far when at the line—

“Here about the beach I wandered, nourishing a youth sublime,

With the fairy tales of science——”

she was stopped by the farmer’s wife. “Don’t you believe him, Miss,
there’s nothing hereabouts to nourish onybody, ’cepting it be an owd
rabbit, and it ain’t oftens you can get howd of them.”
In Memoriam has many cantos descriptive of IN MEMORIAM
Somersby, both of the happy summer evenings on
the lawn, when Mary

“brought the harp and flung

A ballad to the bright’ning moon,”

or of the walks about home with Arthur Hallam—

by “Gray old grange or lonely fold,

Or low morass and whispering reed,
Or simple stile from mead to mead,
Or sheepwalk up the windy wold.”

Or the winter nights when

 “The Christmas bells from hill to hill
Answer each other in the mist.”

And nothing could be more full of tender feeling than this farewell to
the old home in Canto CI., beginning—

“Unwatched, the garden bough shall sway,

The tender blossom flutter down,
Unloved, that beech will gather brown,
This maple burn itself away.”

And in Canto CII.—

“We leave the well-beloved place

Where first we gazed upon the sky;
The roofs that heard our earliest cry
Will shelter one of stranger race.

We go, but ere we go from home

As down the garden walks I move,
Two spirits of a diverse love
Contend for loving masterdom.

One whispers ‘here thy boyhood sung

Long since its matin song, and heard
The low love-language of the bird
In native hazels tassel-hung.’

The other answers, ‘yea, but here

Thy feet have strayed in after hours
With thy lost friend among the bowers,
And this hath made them trebly dear.’

These two have striven half the day,

And each prefers his separate claim,
Poor rivals in a loving game,
That will not yield each other way.
 I turn to go: my feet are set
To leave the pleasant fields and farms;
They mix in one another’s arms
To one pure image of regret.”

Other sections speak of Arthur Hallam, and as ARTHUR HALLAM

each Christmas comes round, or each birthday of
his friend, the poet’s feelings are voiced in such a way that, if we
read it with care, the poem gives us a good deal of the author’s own
life history.
Arthur Hallam died on September 15, 1833, at Vienna, and his
remains were brought home at the end of the year and interred at
Clevedon in Somersetshire on January 4, 1834.

“The Danube to the Severn gave

The darken’d heart that beat no more;
They laid him by the pleasant shore
And in the hearing of the wave.”

Immediately after his death Tennyson had turned to work as the one
solace in his overwhelming grief, although, but for those dependent
on his aid, such as his sister Emily who was betrothed to Hallam, he
said that he himself would have gladly died. He wrote the fine classic
poem Ulysses, in which he voiced the need he felt of going forward
and braving the struggle of life, and then, before it had reached
England, he wrote the first section of In Memoriam No. 9 addressed
to the ship with its sad burden.

“Fair ship that from the Italian shore

Sailest the placid ocean plains
With my lost Arthur’s loved remains,
Spread thy full wings and waft him o’er.”

At some later time, possibly many years later, for In Memoriam was
sixteen years in the making, he added section 10—“I hear the noise
about thy keel”—which carries on the subject, and also alludes to
Somersby church

“where the kneeling hamlet drains

The chalice of the grapes of God.”

For the time he wrote no more sections, but busied himself with
The Two Voices, only towards the end of 1834 he wrote section 30,
which he afterwards prefaced by sections 28 and 29, all describing
the sad first Christmas of 1833, the first since Arthur’s death. In 28
he hears the bells of four village steeples near Somersby rising and
sinking on the wind. He had more than once wished that he might
never hear the Christmas bells again, but the sound of church bells
had always touched him from boyhood, just as the words “far, far
away” which always set him dreaming. In section 29 he bids his
sisters, after decorating the church, make one more wreath for old
sake’s sake, to hang within the house.
Then section 30 tells how they wove it.

“With trembling fingers did we weave

The holly round the Christmas hearth;”

After this we hear how they made a “vain pretence”

“Of gladness with an awful sense

Of one mute Shadow watching all.”

They attempt the usual Christmas games, but they have no heart for
them, and all pause and listen to the wind in the tree-tops and the
rain beating on the window panes. Afterwards they sit in a circle and
think of Arthur, they try to sing, but the carols only bring tears to
their eyes, for only last year he, too, was singing with them. After
this Alfred sits alone and watches for the dawn which rises, bringing
light and hope.
Section 104 brings us to another Christmas. Four LEAVING
years have elapsed since that last described. The
Tennysons have left Somersby, with what regret SOMERSBY
they did so is beautifully told in the four sections
immediately preceding this. And now, listening as of old for the
Christmas bells, he hears not “four voices of four hamlets round,”
but only

“A single peal of bells below,

That wakens at this hour of rest
A single murmur in the breast,
That these are not the bells I know.”

The following section continues the subject. They are living at High
Beech in Essex “within the stranger’s land.” He thinks of the old
home and garden and his father’s grave. The flowers will bloom as
usual, but there, too, are strangers,

“And year by year our memory fades

From all the circle of the hills.”

The change of place

“Has broke the bond of dying use.”

They put up no Christmas evergreens, they attempt no games and

no charades. His sister Mary does not touch the harp and they
indulge in no dancing, though it was a pastime of which they were
extremely fond. But as of old Alfred looks out into the night and sees
the stars rise, “The rising worlds by yonder wood,” and receives
comfort. All this points to the sad year 1837, when they left the well-
beloved place of his birth. And now in section 106 we have a New
Year’s hymn of a very different character. It has a jubilant sound,
and was certainly written some years after its predecessors. In 1837
he was in no mood to say “Ring happy bells across the snow.” But
there is no allusion in this splendid hymn to Arthur Hallam at all, and
in the following section they keep Arthur’s birthday, not any more in
sadness, but
 “We keep the day, with festal cheer,
With books and music, surely we
Will drink to him, whate’er he be
And sing the songs he loved to hear.”

But to return to Somersby.

Tennyson’s Home, Somersby.

The quaint house with its narrow passages and THE OLD HOME
many tiny rooms, the brothers’ own particular little
western attic with its small window from which they could see the
‘golden globes’ in the dewy grass which had “dropped in the silent
autumn night,” the dining-room and its tall gothic windows with
carved heads and graceful gables, the low grey tower patched with
brick, just across the road, (for the “noble tall towered churches”
spoken of in The Memoir are not in this part of the county,) and the
pre-Reformation (not “Norman”) cross near the porch, all these may
still be seen much as they were one hundred years ago.
True, the church has been lately put in good THE CHURCH RE-
repair, and a fine bronze bust of the poet placed in OPENED
the chancel. This was unveiled, and the church re-
opened on Sunday, April 6, 1911, being the fulfilment of the plan
projected on the occasion of the centenary celebration two years
previously. On that Sunday the little church was more than filled with
neighbours and relatives who listened to sermons from the Bishop of
Lincoln and the Rev. Canon Rawnsley. Next day was Bank Holiday,
and in a field near the rectory hundreds of Lincolnshire folk of every
kind—farmers, tradespeople, gentry, holiday makers—assembled to
do honour to their own Lincolnshire poet, and for a couple of hours
listened intently to speeches about him and laughed with a will at
the humours of the “Northern Farmer” read in their own native
dialect, just as the poet intended; whilst the relatives of the poet
and those who were familiar with his works looked with glad interest
upon a scene of rural beauty which brought to the mind the
descriptions in The Lady of Shalott, seeing on the slopes before
them the promise of crops soon to “clothe the wold and meet the
sky,” while far away to the left stretched the valley which pointed to
Horncastle, the home of the poet’s bride, and on the right was the
churchyard where the stern “owd Doctor” rests, and the church
where for five and twenty years he ministered. The whole was a
remarkable assemblage and a remarkable tribute, and the setting
was a picture of quiet English rural life, one which the poet himself
must often have actually looked out upon, and such as he has
himself beautifully described in The Palace of Art:—

“And one an English home—gray twilight pour’d

On dewy pastures, dewy trees,
Softer than sleep—all things in order stored,
A haunt of ancient Peace.”

The spirit of the poet seemed still to be a haunting A LONG-LIVED

presence in the place, and as then, so now and for FAMILY
all time his works speak to us. But three-quarters
of a century have passed since a Tennyson has had his home in
Somersby. They left in 1837, and though Mary went back at times to
see the “beloved place,” Alfred never set eyes on it again. Charles
married in that year Louisa Sellwood, whose mother was a sister of
Sir John Franklin, and thirteen years later Alfred married her sister
Emily. They left Somersby; but Lincolnshire still kept possession of
Charles, who took the name of Turner in addition to his own, and
ministered happily at Grasby near Caistor, being both vicar and
patron of the living; and he and his wife both died there in the
spring of 1879, at the comparatively early age, for a Tennyson, of
seventy-one, for the family have been a remarkably long-lived one.

The Mother died in 1865, aged 84

Charles ” ” 1879 ” 71
Mary ” ” 1884 ” 74
Emilia ” ” 1889 ” 78
Alfred died on October 6, 1892 ” 83
Emily Lady Tennyson died in 1896 ” 83
Frederick ” ” 1898 ” 91
Arthur died in June, 1899 ” 85
Horatio died in October, 1899 ” 80
Cecilia died in 1909 ” 92

Matilda, who was born before Cecilia and Horatio, still survives. I
went to see her in the summer of 1913. I found her well and full of
early memories. She was a girl in the schoolroom when she first saw
Arthur Hallam, an event of which she had a vivid recollection. I said,
“I suppose you get out every fine day for a drive.” “Oh,” she said, “I
go out for a walk every day and take the dog.” I thought that rather
wonderful at her age. “Yes, I am ninety-seven,” she said, “and I
mean to live to be 105.” I told her how Queen Victoria, who was
always looking forward to reunion with the dear departed—but ever
a ceaseless worker—used to say, “my dear, you should always act as
if you were going to live for ever.”
Alfred, who succeeded Wordsworth as Poet THE MASTER’S
Laureate in 1850, was raised to the Upper House in OPINION
1884. He is buried in Westminster Abbey side by
side with his great contemporary, Robert Browning, and on his grave
was laid a wreath of bay-leaves from a tree derived from the bay
which flourishes over Virgil’s tomb near Naples, and on the wreath
were Tennyson’s own magnificent lines, written at the request of the
Mantuans for the nineteenth centenary of their poet’s death (1881).

“I salute thee, Mantovano,

I that loved thee since my day began,
Wielder of the stateliest measure
Ever moulded by the lips of man.”

The recent appearance (October, 1913) of a THE POET’S

notable volume of Tennyson’s poems, introduced RANGE OF
by a Memoir and concluding with the poet’s own KNOWLEDGE
notes, may well serve as the text for some remarks
on his poems generally. The volume bound in green cloth is priced at
10s. 6d. The Memoir is somewhat abbreviated from the two
interesting volumes published by his son in 1897, which appeared
again as the first four volumes of Messrs. Macmillan’s fine twelve-
volume edition of 1898. There are, however, a few additions, notably
a letter from the Master of Trinity, Cambridge, telling how he once,
years ago, asked Dr. Thompson, the Master, whether he could say,
not from later evidence, but from his recollection of what he thought
at the time, which of the two friends had the greater intellect,
Hallam or Tennyson. “Oh, Tennyson,” he said at once, with strong
emphasis, as if the matter was not open to doubt. This is very high
praise indeed, for Gladstone said that Hallam was far ahead of
anyone at Eton in his day, and Monckton Milnes thought him the
only man at Cambridge to whom he “bowed in conscious inferiority
in all things.” The Notes first appeared in the very pleasant
“Annotated Edition” edited also by Hallam Lord Tennyson within the
last five years. The present generation can never know the delight of
getting each of those little green volumes which came out between
’32 and ’55, and sequels to which kept following till ’92. But for
general purposes it is far more convenient to have a one-volume
edition, such as we have had for some time now. This new edition,
however, with its Memoir, gives us what, as the years go by, is more
and more valuable, enabling us to read the poet in his verses and to
know what manner of man he was, and how his environment
affected him at the different stages of his life. The Notes add an
interest, and though it is seldom that in any but the In Memoriam
Cantos any explanation is needed to poems that are so clear and so
easily intelligible, one gains information and finds oneself here and
there let into the author’s secrets, which is always pleasant. The
book runs to over a thousand pages, and is so beautifully bound that
it lies open at any page you choose. There is an interesting appendix
to the Notes, giving the music to “The Silent Voices,” composed by
Lady Tennyson and arranged for four voices by Dr. Bridge for Lord
Tennyson’s funeral at the Abbey, October 12, 1892. Also a previously
unpublished poem of his later years, entitled “Reticence.” She is
called the half-sister of Silence, and is thus beautifully described:—

“Not like Silence shall she stand,

Finger-lipt, but with right hand
Moving toward her lip, and there
Hovering, thoughtful, poised in air.”

Then comes a facsimile of the poet’s MS. of “Crossing the Bar,”

finally, besides the usual index of first lines, the book ends with an
index to In Memoriam, and, what we have always wanted, an index
to the songs.
Undoubtedly in the future this new edition will be the Tennyson for
the library shelf, and a very complete and compact volume it is.
Personally, I like the little old green volumes, but if I were now
recommending an edition not in one volume, I would say, “Have the
Eversley or Annotated Edition in nine volumes, which exactly
reproduces the page and type of those old original volumes with the
added advantage of the Notes.” It is hardly to be expected that the
spell with which Tennyson bound all English-speaking people for
three generations should not in a measure be relaxed, but though
we have a fuller chorus of singers than ever before, and an
unusually appreciative public, the attempt so constantly made to
decry Tennyson has no effect on those who have for years found in
him a charm which no poet has surpassed, and, indeed, it will be
long before a poet arises who has, as Sir Norman Lockyer observes,
“such a wide range of knowledge and so unceasing an interest in the
causes of things and the working out of Nature’s laws, combined
with such accuracy of observation and exquisite felicity of language.”
Let me give one more criticism, and this time by a noted scholar, Mr.
A. Sidgwick, who speaks of his “inborn instinct for the subtle power
of language and for musical sound; that feeling for beauty in phrase
and thought, and that perfection of form which, taken all together,
we call poetry.” That perfection was the result of labour as well as of
instinct. He had an ear which never played him false, hence he was
a master of melody and metre, and he was never in a hurry to
publish until he had got each line and each word right. “I think it
wisest,” he wrote to one of his American admirers, “for a man to do
his work in the world as quietly and as well as he can, without much
heeding the praise or dispraise.” He was a lover of the classics, and
in addressing Virgil on the nineteenth centenary of his death, as
quoted above, he himself alludes to this. Without being what we call
a great scholar, in his classic poems he is hard to beat, while in his
translations of Homer he certainly has no equal. Then in his
experiments in classic metres, whether in the “Metre of Catullus” or
in the Alcaics in praise of Milton, his perfect accuracy is best
understood if we turn to the similar experiments by living poets, who
never go far without a blunder, at least none that I have ever read
do.
To the Lincolnshire folk, his dialect poems, THE DIALECT
written in the dialect which was current in his POEMS
youth at Spilsby and in the country about it (and
still used there, I am glad to say, though not so universally or so
markedly as of yore), give genuine pleasure, and are full of humour
and of character, and it is a tribute to his accurate ear and memory
that, after an absence of some twenty-seven years, he should have
got the Lincolnshire so correct. He did it all right, but for fear he
might have forgotten and got wrong, he asked a friend to look at it
and criticise; unfortunately the friend lived in the north of the county
and knew not the dialect of “Spilsbyshire,” so he altered it all to that
which was spoken about Brigg, which is more like Yorkshire, and it
had to be put back again. But some of the northern dialect has
stuck, and in “The Northern Farmer Old Style” the ‘o’ is seen in
‘moind,’ ‘doy,’ ‘almoighty,’ etc., where the Spilsby sound would be
better rendered by using an ‘a.’ This ‘o’ is never found in any of his
subsequent dialect poems, and in a note to the text in the “Northern
Cobbler” the poet points out that the proper sound is given by ‘ai.’
One sign of the remarkable way in which our FAMILIAR
Lincolnshire poet has made himself the poet of the QUOTATIONS
English-speaking race is the extraordinary number
of familiar quotations which he has given us. For the last fifty years
in book and newspaper, in speech and sermon, some line or some
phrase of his has constantly occurred which the user felt certain that
his hearer or readers would recognise, until our literature has
become tessellated with Tennysonian expressions, and they have
always given that satisfaction which results from feeling that in using
his words we have said the thing we wished to say in a form which
could not be improved upon. In this respect of “daily popularity and
application,” I think Shakespeare alone excels him, though Pope and
Wordsworth may run him close.
Little Steeping.
 CHAPTER XXXII
ROADS FROM SPILSBY
Road to Louth—Partney—Dr. Johnson—His letter on Death of Peregrine
Langton—Dalby—Langton and Saucethorpe—View from Keal Hill with
Boston Stump—“Stickfoot Stickknee and Stickneck”—The Hundleby
Miracle—Raithby—Mavis Enderby—Lusby—Hameringham—The
Hourglass Stand—Winceby—Horncastle—The Horse Fair—The
Sleaford Road—Hagnaby—East Kirkby—Miningsby—Revesby Abbey—
Moorby—Wood Enderby—Haltham—Tumby Wood—Coningsby—
Tattershall—Billinghay—Haverholme Priory.

The four roads from Spilsby go north to Louth, and south to

Boston, each sixteen miles; east to Wainfleet, eight miles; and west
to Horncastle, ten miles. The Wainfleet one we have already
described and two-thirds of that from Louth. The remaining third,
starting from Spilsby, only goes through two villages—Partney and
Dalby. Partney lies low in the valley of Tennyson’s “Cold rivulet,” and
those who have driven across the flat meadows between the village
and the mill after sundown know how piercingly cold it always
seems.
The place has a very long history. Bede, who died in 725, writing
twelve hundred years ago and speaking of the Christianising of
Northumbria by Paulinus, who was consecrated Bishop of York in
625, and his visit to the province of Lindissi, i.e., “the parts of
Lindsey” and Lincoln in particular, says that the Abbot of Peartaney
(= Partney, near Spilsby, which was a cell of Bardney) spoke to him
once of a man called Deda, who was afterwards, in 730, Abbot of
Bardney and a very truthful man, “presbyter veracissimus,” and said
that Deda told him that he had talked with an aged man who had
been baptised by Bishop Paulinus in the presence of King Ædwin, in
the middle of the day, and with him a multitude of people, in the
River Treenta, near a city called in the language of the Angles,
Tiovulfingaceaster; this was in 627. Many have taken the place to be
Torksey, though that in the Anglo-Saxon chronicle is Turcesig. Green
suggested it was at the ford of Farndon beyond Newark, but it was
far more likely to be at Littleborough Ferry, two miles north of
Torksey, where the Roman road (“Till bridge Lane”) from Lincoln
crossed the river. But certainly Torksey is the nearest point of the
river to Lincoln, and the Fossdyke went to it, as well as a road, so
that communication was easy and inexpensive, and on the whole I
should be inclined to say that Torksey was the place of baptism.
But to return to Partney. In addition to its being PARTNEY
a ‘cell’ of Bardney Abbey, we know there was a
very fine hospital at Partney, dedicated to St. Mary Magdalene,
before 1138, and among the tombs recently uncovered at Bardney is
one of Thomas Clark, rector of Partney, 1505. It appears to have
been a market town when Domesday Book was compiled, at a time
when Spilsby was of no account; but the Black Death in 1349 or the
plague in 1631, when Louth registered 500 deaths in two months,
and in the Alford neighbourhood Willoughby also suffered, severely
decimated the place, and tradition has it that some clothing dug up
eighty years after burial caused a fresh and violent outbreak.
Whenever it happened, for no records exist, the consequence was
that the glory of Partney as the next market town to Bolingbroke
departed, and Spilsby grew as Partney dwindled. Of course the
healthy situation of Spilsby had much to do with it. Yet Partney still
retains the two sheep fairs on August 1 for fat lambs and September
19 for sheep, and they are the biggest sheep fairs in the
neighbourhood. Two other fairs take place, on August 25 and at
Michaelmas, and it is noticeable that three of the four are held on
the eve of the festivals of the Virgin Mary and Mary Magdalen. In
1437 we find that Matilda, wife of Thomas Chaucer, the eldest son of
the poet, had a share of an eighteenth part of the Partney market
tolls. Fine brasses to her and her husband exist in Ewelme church,
near Oxford. On fair days sheep are penned all along the streets and
in adjoining fields, and “Beast” on the second day are standing for
half a mile down the Scremby road.
The church is dedicated to St. Nicolas, the most popular of all
church patrons, who was Bishop of Myra in Lycia in the fourth
century. As patron of fishermen he has many sea coast churches,
and he is also the peculiar saint of children, who know him by his
Dutch name of Santa Klaus. One of the oldest oaks in England is in
the churchyard. The chiming church clock, put in in 1869, is a
monument to the skill of a clever amateur, Sidney Maddison, Esq.,
who fitted it with “Dennison’s three-legged escapement,” which was
then a new and ingenious invention of the late Lord Grimthorpe.
In 1764 Dr. Johnson walked over from Langton DR. JOHNSON
with his friend, Bennet Langton, to see Bennet’s
Uncle Peregrine. He died two years later aged eighty-four, and the
doctor wrote to his friend: “In supposing that I should be more than
commonly affected by the death of Peregrine Langton you were not
mistaken: he was one of those I loved at once by instinct and by
reason. I have seldom indulged more hope of anything than of being
able to improve our acquaintance to friendship. Many a time have I
placed myself again at Langton, and imagined the pleasure with
which I should walk to Partney in a summer morning, but this is no
longer possible. We must now endeavour to preserve what is left us,
his example of piety and economy. I hope you make what enquiries
you can and write down what is told you. The little things which
distinguish domestic character are soon forgotten: if you delay to
enquire you will have no information: if you neglect to write,
information will be in vain. His art of life certainly deserves to be
known and studied. He lived in plenty and elegance upon an income
which to many would appear indigent, and to most, scanty. How he
lived, therefore, every man has an interest in knowing. His death I
hope was peaceful: it was surely happy.”
After Partney the road goes up the hill to Dalby. Here the old
house where Tennyson’s aunt, Mrs. Bourne, lived, was burnt down in