Diagnosketch Adhikari

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 Advance Praise for Diagnosketch
This book is equally as useful to patients as it is to doctors. The
illustrations cover the most common diagnoses in the ED and
reflect the diversity of patients we see every day. Everyone will
find themselves represented here.
—Thea James, MD, EM Physician; Vice President of
Mission and Associate Chief Medical Officer, Boston
Medical Center

Not only does Diagnosketch help patients understand their

anatomy, it also gives physicians, nurses, PAs, and others the
opportunity to maximize use of the very small amount of time
they have with their patients. With this book at the bedside, we
can be more efficient and patients leave with a better
understanding of their ED visit.
—Andrew Ulrich, MD, Professor of Emergency
Medicine, Vice Chair of Operations, Yale School of
Medicine

This book is an extremely helpful tool for real-time patient

education, there is really nothing available that is comparable to
Diagnosketch. It is the best resource for concise and easy-to-
understand explanations for patients of their diagnoses, while
still maintaining medical accuracy and appropriate level of detail.
It helps me get through to my patients and makes bedside
education much smoother and more meaningful.
—Celia Pagano, PA-C in Emergency Medicine for 6+
years

As a nurse who spends a fair amount of time educating patients

and their families, this book is a brilliant idea! It allows me the
opportunity to impact patients’ understanding of their disease,
and is an excellent resource in triage.
—Elizabeth Gibb, BSN, RN, Emergency Department
Nurse for 41 years at the busiest EDs in New
England

I could really have used these illustrations to explain to my

patient with an ovarian cyst what was going on! She was in the
hospital with her dad and the doctor here was a man. I had to
give the poor girl a crash course in A&P, menstruation, and
explain what was going on without scaring her to death. My
artwork is subpar at best, I really wish I had this book!
—Kim Belton, RN, ER Nurse at Atrium Health with
11+ years’ experience

I use Diagnosketch not only with my patients at work, but also

to explain my job to my children at home. It’s a fantastic
teaching tool!
—Jaclyn Davis, MD, EM Physician with 10+ years’
experience and Medical Staff President, Atrium
Health Pineville

I work in a rural outpatient clinic setting and make rough

drawings on my own all day for patients on the paper covering
the tables or the back of glove boxes. I really enjoy this book;
patients find the pictures easy-to-understand and I like how
clear they are.
—Carol Venable, MD of 20+ years, EM/IM Physician,
Port Townsend, WA

This book replaces the need to pull up Google at the bedside to

search for images. All common diagnoses are compiled and
easy-to-understand!
—John Burger, MD, EM Physician with 10+ years’
experience in Charlotte, NC
This book is amazing! The simplicity of it, with the wonderful
illustrations, makes this an awesome teaching tool for our
patients. I can’t wait to share this with my team.
—Rachel Smitek, MD, Senior Director of Quality, US
Acute Care Solutions; Board-Certified Emergency
Medicine doctor with 10+ years of practice

I love this book, there are so many great visuals for the bread
and butter of what we see and explain all of the time. What a
great resource!
—Katrina Barnett, MD, On Staff, El Camino Hospital,
Mountain View and Los Gatos, CA; On Staff, Palo
Alto VA, CA; ER physician for 15+ years

Physicians are expected to provide excellent medical care; but it

is equally important for them to explain diagnoses and
treatments in a manner that gives the non-medical both
understanding and reassurance. Diagnosketch, by emergency
physician Dr. Sapana Adhikari, uses simple illustrations and text
to bridge the communication gap between physician and patient
so that even complex issues can be comprehended at the
bedside. This will prove to be an essential tool for every
emergency department.
—Edwin Leap, MD, Emergency Physician with 30
years’ experience; Columnist
Diagnosketch
 Diagnosketch: A Visual Guide to
Medical Diagnosis for the Non-
Medical Audience
Created and Illustrated by
Sapana P. Adhikari, MD
Oxford University Press is a department of the University of Oxford. It furthers the
University’s objective of excellence in research, scholarship, and education by
publishing worldwide. Oxford is a registered trade mark of Oxford University Press
in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Sapana Adhikari, MD 2022
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, without the prior
permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights
organization. Inquiries concerning reproduction outside the scope of the above
should be sent to the Rights Department, Oxford University Press, at the address
above.
You must not circulate this work in any other form and you must impose this same
condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Adhikari, Sapana P., author.
Title: Diagnosketch : a visual guide to medical diagnosis for
the non-medical audience / created and illustrated by Sapana P. Adhikari.
Description: New York, NY : Oxford University Press, [2022] |
Includes bibliographical references and index. |
Identifiers: LCCN 2022012638 (print) | LCCN 2022012639 (ebook) |
ISBN 9780197636954 (paperback) | ISBN 9780197636978 (epub) |
ISBN 9780197636985 (online)
Subjects: MESH: Diagnostic Techniques and Procedures |
Medical Illustration | Health Communication—methods |
Patient Education as Topic | Critical Care | Pictorial Work
Classification: LCC RC71.3 (print) | LCC RC71.3 (ebook) | NLM WB 17 |
DDC 616.07/5—dc23/eng/20220525
LC record available at https://lccn.loc.gov/2022012638
LC ebook record available at https://lccn.loc.gov/2022012639
DOI: 10.1093/med/9780197636954.001.0001
This material is not intended to be, and should not be considered, a substitute for
medical or other professional advice. Treatment for the conditions described in this
material is highly dependent on the individual circumstances. And, while this
material is designed to offer accurate information with respect to the subject
matter covered and to be current as of the time it was written, research and
knowledge about medical and health issues is constantly evolving and dose
schedules for medications are being revised continually, with new side effects
recognized and accounted for regularly. Readers must therefore always check the
product information and clinical procedures with the most up-to-date published
product information and data sheets provided by the manufacturers and the most
recent codes of conduct and safety regulation. The publisher and the authors
make no representations or warranties to readers, express or implied, as to the
accuracy or completeness of this material. Without limiting the foregoing, the
publisher and the authors make no representations or warranties as to the
accuracy or efficacy of the drug dosages mentioned in the material. The authors
and the publisher do not accept, and expressly disclaim, any responsibility for any
liability, loss, or risk that may be claimed or incurred as a consequence of the use
and/or application of any of the contents of this material.
Mayo Foundation does not endorse any particular products or services, and the
reference to any products or services in this book is for informational purposes
only and should not be taken as an endorsement by the authors or Mayo
Foundation. The incidental appearance of brand names on any equipment or the
mention of brand names in the narration in the accompanying videos has been
avoided when at all possible; any occurrences were left to preserve the
educational integrity of the videos and should not be taken as endorsement by the
authors or Mayo Foundation. Care has been taken to confirm the accuracy of the
information presented and to describe generally accepted practices. However, the
authors, editors, and publisher are not responsible for errors or omissions or for
any consequences from application of the information in this book and make no
warranty, express or implied, with respect to the contents of the publication. This
book should not be relied on apart from the advice of a qualified health care
provider.
 CONTENTS

Introduction
About the Author/Illustrator

1 Skin
Blood draw
IV: Intravenous insertion
Cut: Laceration
Options for repair
Boil: Abscess
MRSA: Methicillin-resistant Staphylococcus
aureus
Paronychia
Crushed finger: Subungual hematoma
Superficial clot: Superficial thrombophlebitis
Airway anatomy

2 EENT (eye, ear, nose, throat)

Eye pain: Corneal abrasion & conjunctivitis
 Toothache: Dental caries vs dental abscess
Nosebleed: Epistaxis
Sinus infection: Sinusitis
Inner ear infection: Otitis media
Swimmer’s ear: Otitis externa
Sore throat: Strep pharyngitis & peritonsillar
abscess (PTA)

3 Cardiopulmonary
Bronchitis vs pneumonia
Emphysema: Chronic obstructive pulmonary
disease (COPD)
Blood clot: Deep vein thrombosis (DVT) &
pulmonary embolism (PE)
Swollen legs: Pedal edema
Heart attack: Myocardial infarction (MI)
Chest pain evaluation
Heart failure: Congestive heart failure (CHF)
Heart failure causes: Diastolic vs systolic disease
High blood pressure: Hypertension (HTN)
HTN+Symptoms: Hypertensive urgency
Irregular heart beat: Atrial fibrillation
 Fluid around heart: Pericarditis vs pericardial
effusion
Aortic dissection
Aortic aneurysm
Poor circulation: Peripheral artery disease &
venous insufficiency

4 Gastrointestinal
Digestion
Abdominal pain
Heartburn: Gastroesophageal reflux disease
(GERD)
Gastritis & ulcer
Vomiting blood: Upper gastrointestinal bleed
(UGIB)
Rectal bleed: Lower gastrointestinal bleed (LGIB)
Hiatal hernia
Hernia: Normal vs incarcerated
Foreign body in esophagus: Esophageal stricture
Bowel blockage: Small bowel obstruction (SBO)
Gallbladder disease: Biliary colic
Pancreatitis
 Diverticular disease: Diverticulosis, diverticulitis,
& perforation
Constipation
Perirectal abscess
Hemorrhoids
Appendicitis

5 Genitourinary
Kidney Stone: Nephrolithiasis
Urinary Tract Infection: Cystitis vs pyelonephritis
Enlarged prostate: Benign prostatic hypertrophy
(BPH)
Urinary retention
Testicular swelling: Epididymitis
Testicular swelling: Hydrocele vs varicocele
Testicular torsion
Ovarian torsion
Ovarian cyst: Normal cyst vs ruptured cyst
Early pregnancy: Abdominal pain &/or vaginal
bleeding
Fibroids: Leiomyoma
Irregular periods: Abnormal uterine bleeding
Yeast infection: Vaginal candidiasis
 Vaginal discharge: Bacterial vaginosis
Pelvic infection: Pelvic inflammatory disease
(PID) & tubo-ovarian abscess (TOA)
Sexually transmitted infection
Lower abdomen: Male vs female

6 Orthopedics
Broken: Fracture
Growth plate injury
Arthritis: Degenerative joint disease
Bursitis
Rib fracture
Collapsed lung: Pneumothorax
Back pain: Musculoskeletal
Back pain: Sacroiliitis
Back pain: Side view
Sciatica: Lumbar radiculopathy
Neck pain: Cervical strain
Neck & back strain: Motor vehicle accident (MVA)
Knee arthritis: Osteoarthritis
Knee pain: Fracture vs sprain
Joint disease: Normal anatomy
Inflamed joint: Gout vs septic joint
 Baker’s cyst
Ankle pain: Fracture vs sprain
Wrist pain: Carpal tunnel syndrome
Foot pain: Plantar fasciitis
Broken back: Compression fracture

7 Neurology
Stroke: Cerebral vascular accident (CVA)
Mini-Stroke: Transient ischemic attack (TIA)
Brain bleed: Intracranial hemorrhage (ICH)
Brain aneurysm: Subarachnoid hemorrhage
(SAH)
Meningitis
Dizziness: Benign positional vertigo (BPV)
Bell’s palsy: 7th cranial nerve palsy
Concussion: Closed head injury

8 Miscellaneous
Cancer: Diagnosis & work-up
Diabetes: Diabetes mellitus type 2
Alternating medications: Fever control or pain
control
Bacteria vs virus
 Code status

Scripting
Index
 INTRODUCTION

Diagnosketch is a visual aid to explain medical

diagnoses to patients at the bedside. It uses
simplified images to illustrate complicated anatomy
and concepts. The title, Diagnosketch, combines the
term “diagnosis” with the term “sketch,” paralleling
the way the book combines a medical diagnosis with
a simplified sketch. It includes common pathologies
seen in an acute care setting, especially ones that
are easier to explain with pictures.
Many American patients are unfamiliar with human
anatomy and common medical diagnoses. Research
from the US Department of Education estimates that
only 12% of English-speaking adults in the United
States have proficient health literacy skills.1 Studies
indicate that almost 90% of adults have difficulty
understanding health information that is currently
available.2 These patients are often unequipped to
make important decisions about their own health
care.
Diagnosketch improves health care literacy for the
non-medical population. It simplifies human anatomy
and pathophysiology into memorable,
understandable images. It relies on the concept of
“picture superiority effect.” The picture superiority
effect states that HEARING information will lead to
10% retention of the content, but HEARING and
SEEING information leads to 65% retention of
content. Diagnosketch not only explains difficult
concepts to patients, but also helps patients
remember them.
Diagnosketch serves as the visual guide that
medical professionals use with every patient at the
bedside. Excellent medical care involves diagnosing
and treating disease, but just as importantly,
communicating well with patients. Diagnosketch
helps achieve this goal.

Key Components of Diagnosketch

Simplicity
The images in the book intentionally simplify
information to help educate a non-medical audience.
The images leave out details that may not be
clinically relevant and overemphasize those that are.
Although the general anatomy is correct, certain
organs are exaggerated. For example, the
gallbladder is quite small in the human abdomen, yet
in the images, it is depicted much larger to
emphasize its clinical relevance. Also, human
physiology has been simplified with colors. For
example, in some images blood vessels are depicted
in red whether they carry oxygenated or
deoxygenated blood. In addition, the images
intentionally leave out smaller anatomical structures
(like nerves and smaller blood vessels) for simplicity’s
sake.

Practicality
The images in the book depict only the most
common diagnoses seen in an acute care setting and
only those that would benefit from an image. In busy
settings, sometimes the health care encounter lasts
just a few minutes. Diagnosketch presents a simple,
clear image that improves understanding as quickly
and efficiently as possible. In addition, the labels are
minimal and are written in colloquial, non-medical
language. This encourages the patient to listen to
the explanation from the medical professional, rather
than read and become confused by complicated
medical terminology.

Inclusivity
The images in the book intentionally use various skin
tones and physical features to represent the diversity
seen across patients in various medical settings.
Different diagnoses can affect any ethnicity. Aside
from problems that affect a particular biological sex,
diagnoses are depicted in the male or the female in a
non-specific way.

How Does Diagnosketch Work?

Diagnosketch consists of 100 images of medical

illnesses commonly diagnosed in an acute care
setting. It is meant to be used at the bedside to
help communicate complicated concepts to a non-
medical audience quickly. Most medical encounters
between doctors and patients occur verbally.
Although visual aids are sometimes used, they are
not standard. This book changes this paradigm by
incorporating a simplified, colorful graphic visual to
assist patients to better understand their diagnoses
in real time.
Imagine the following scenario:
A patient presents to the emergency room for
severe abdominal pain. You run tests: blood, urine,
ultrasound. You diagnose cholecystitis. You verbally
explain to your patient that her gallbladder is
infected, and that she will need emergency surgery.
Your patient looks dumbfounded. She never
expected this. She thought that she might have
eaten something bad but is now on her way to
surgery? She quietly pretends that she understands
but does not really know where her gallbladder is
located, let alone what it does. She does not even
know what questions she should ask. You sense that
she does not completely understand everything, so
you quickly grab a paper towel and sketch a crude
image of her anatomy. Although you’d like to stay
longer, you feel the pressure of a waiting room full of
patients, still waiting to be seen. You rush out,
knowing that although you expertly diagnosed her
condition and arranged for proper treatment, you
could have communicated better.
Now imagine that same patient, but this time you
use Diagnosketch. You return to the patient’s room
and explain her condition verbally AND visually. You
show your patient where her gallbladder is in relation
to her other organs. You show her a gallstone and
explain how it blocked her biliary tract. You show her
how this caused her pain and eventually her
infection. She asks pertinent questions, and you give
her immediate answers. You have a two-way
dialogue. In just a few minutes, you have relieved
her fears and increased her anatomical knowledge.
You know that you communicated in a way that she
understands. When you walk out of the room, you
feel confident in your skills as both a master
clinician/diagnostician and, just as importantly, a
master communicator.

How is Diagnosketch Organized?

Diagnosketch is organized into seven different

categories by organ systems. The categories are:
skin, EENT (eye, ear, nose, throat), cardiopulmonary,
gastrointestinal, genitourinary, orthopedics, and
neurology. The last section, Miscellaneous, includes
images that do not fit into particular organ system.
There is a section on sample scripting that
corresponds to each image. This section includes
sample wording that serves as a starting point for
better patient communication. Finally, there is an
Index that includes both the medical jargon and
more colloquial language a patient may use, making
it easier to quickly find a particular image. Notice
that on a particular image, where possible, each title
is written in a colloquial language with the medical
terminology listed underneath. Notice also that the
labels are written in colloquial language to simplify
what is happening for the non-medical patient.
Different images are helpful at different stages of a
patient encounter. There are three major categories
of images: diagnosis images, procedure images, and
concept images.
 Diagnosis images: are used to explain basic
diagnoses and basic anatomy (e.g. biliary colic,
kidney stone, pulmonary embolism). Many of
these simplified images have a “normal” side and
an “abnormal” side so that the patient can easily
compare what their body part is supposed to
look like with what it looks like when affected.
The images also may use the “1, 2, 3 approach”
that show three common problems for a
particular disease (e.g. diverticulosis,
diverticulitis, diverticular abscess/perforation).
Procedure images: are used to explain a
procedure to a patient before performing it (e.g.
IV insertion, nasogastric tube insertion, drainage
of paronychia).
Concept images: are used to explain a concept
visually (e.g. how to alternate ibuprofen with
acetaminophen for fever reduction; how diabetes
mellitus actually causes high glucose; what “code
status” means).
Obviously, the images can be used in whatever way
is most helpful. Here are a few real-life examples of
where Diagnosketch has been helpful in the acute
care setting:
• A nurse showed the image of “Digestion” to
explain to a reluctant 10-year-old why she had to
drink a bottle of contrast for an abdominal CT
 scan to rule out appendicitis. After the patient
learned her anatomy and understood that her
appendix would “light up” when she drank the
contrast, she willingly drank the entire bottle
without a fuss. This saved hours of time in a
busy emergency room.
• A physician showed the image of “Back pain—
side view” to explain the anatomy of the back to
a disgruntled patient who felt that he needed an
x-ray. After he understood his anatomy and why
an x-ray was not indicated, he was happy to
avoid unnecessary radiation exposure. This also
saved the cost of an unnecessary test.
• A physician showed the image of “Urinary
retention” to explain to an uncomfortable older
gentleman how his enlarged prostate blocked his
bladder, making it impossible to urinate. After he
learned his anatomy, he felt comfortable with the
insertion of the foley catheter and experienced
much relief.
• A nurse showed the image of “Intravenous
insertion” to her patient in the triage bay to
explain how an IV works. She hoped to dispel
the common misconception that an IV is a
needle that stays in the arm when it is just a
flexible piece of plastic.
• A physician showed the image of a “Heart
attack” to the anxious male who presented with
chest pain after smoking cocaine. After he
visually saw how cocaine could cause his heart
muscle to die, he vowed to never use it again.
This potentially deterred future drug usage.

How do Patients Feel After Seeing

Diagnosketch?

Patients often ask for a copy of the Diagnosketch

image to take home. Sometimes, they take a picture
on their cell phone to explain to their family
members later. Many patients have access to the
internet at home and can extensively research their
diagnosis. Yet, once they leave the hospital, they
almost always do not. Instead, they rely on the
simple, familiar images that the medical professional
explained to them that they understand.
There are many beautiful anatomy books available
with detailed pictures. There are hundreds of images
on the internet about anatomy and diagnoses. There
is helpful information on discharge paperwork from a
hospital or clinic. Diagnosketch does not try to
compete with these very useful resources. Instead, it
serves as the first basic primer to understanding the
medical diagnosis. Once the medical encounter ends,
the patient is now equipped with solid knowledge of
basic anatomy and physiology and encouraged to
further investigate more complicated medical
information.
Diagnosketch is a quick, useful tool that greatly
enhances the patient’s experience. All images are in
one place. All images are at a simplistic level of
detail. And, all images are clinically useful and
relevant to the medical problem at hand.
1Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The
Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006-483). Washington, DC: US
Department of Education, National Center for Education Statistics.
2
US Department of Health and Human Services, Office of Disease
Prevention and Health Promotion. (2010). National Action Plan to
Improve Health Literacy. Washington, DC: Author.
ABOUT THE AUTHOR/ILLUSTRATOR
I have worked as an emergency medicine physician
for 20 years and have seen poor health literacy affect
my patients firsthand. For this reason, I developed
Diagnosketch. I believe that each patient deserves
customized knowledge about their anatomy and
pathology relevant to their health care encounter.
Early in my career, I drew stick figures and
anatomy on paper towels or on whiteboards in my
patients’ rooms. I saw the utility of visual aids to
explain medical concepts. Over the years, I created
better images that incorporated real-time patient
feedback. I tried many different iterations: everything
from more realistic, traditional images to super
“cartoony” images. I found that the perfect style of
illustration lies between the two. The style in
Diagnosketch works best because it relays accurate
information in a simple, colorful, and non-threatening
way. It gets the point across without being too
cartoony or “dumbed down.” I now use these images
with the majority of my patients. It is satisfying to
know that I have not only treated diseases but also
helped my patients understand their diagnoses.
I realized that we, as medical professionals, do a
great job diagnosing disease. We run blood tests,
urine tests, x-rays, and CT scans. We come up with
an accurate diagnosis and start proper treatments.
Yet, sometimes, when we try to explain everything to
our patients, we may not communicate the
information as clearly as possible. I hope that
Diagnosketch will be used to fill this gap.
Diagnosketch is a multiyear project with multiple
revisions and rounds of feedback. I welcome your
suggestions, comments, and feedback to make it a
useful tool for all patient education needs. Thank you.

Sapana Adhikari, MD
https://www.diagnosketch.com
diagnosketch@gmail.com
 Skin

Blood draw
IV: Intravenous insertion
Cut: Laceration
Options for repair
Boil: Abscess
MRSA: Methicillin-resistant Staphylococcus
aureus
Paronychia
Crushed finger: Subungual hematoma
Superficial clot: Superficial thrombophlebitis
Airway anatomy
 EENT (eye, ear, nose, throat)

Eye pain: Corneal abrasion & conjunctivitis

Another random document with
no related content on Scribd:
 Boy. How they jump! how they run to the gate! why do they run
so?
Maid. They are glad to see me. They know me; I feed them when
they want food; and you see they love me.
Boy. I like to see them so glad. I like to see a pig fed; but I love a
lamb; may I not love a lamb more than I do a pig?
Maid. Yes; but you must be good to all.
Boy. My aunt has a tame lamb, I love to give him milk; once I saw
a fawn, I do not mean in a park, but I saw a tame fawn; the old doe
was dead, so we fed the fawn at home. We kept him a long time, but
he bit off the buds.
Maid. Have you seen a goat?
Boy. Yes; he has not wool; he has hair.
Maid. Now you may go with me. We will go and see the cows.
Boy. Why is one duck by itself?
Maid. The duck sits; she has a nest just by. I must feed her: she
will not go far from her nest. The rest can get food. You may give her
some corn; we will get some for her. Come.
Boy. I like to feed the poor duck.
 THE DOLL.
IN WORDS OF FOUR LETTERS.

Girl. What a nice doll! I like this; pray may I have this? I wish to
have a wax doll.
Mother. You must then take care to keep her cool, else you will
melt her face; and she must be kept dry, or this nice pink on her face
will be lost.
 Girl. What a neat coat! I love a blue silk. And her hat! I love a doll
in a hat. What sort of a cap have you, miss! but a poor one; but it is
not much seen. She has some soil on the neck. I can rub it off, I see.
No, that will not do; I must not wet her skin. What sort of a foot have
you? O! a nice one; and a neat silk shoe: a blue knot, too; well, that
is what I like; to suit her coat. I am fond of blue, too. Now, miss,
when I have you home with me, then I am to be your maid; to wait on
you. Will not that be nice! I will take care of you, and keep you so
neat! and I will work for you; you can not sew, nor hem; and I will
read to you in my new book; and I will take you out with me when
you are good. You shall sit by me near the tree, on a low seat, fit for
you. I wish you to walk. Can not I make you walk? so—step on—see
how my new doll can walk!
Mother. You will pull off her legs, my dear.
Girl. Now if I had a pin to pin this sash back. Stay, I can tie it. O
me! see! here is a bag for her work! who has seen the like? a bag for
her work! I must have this doll—if you like it, I mean.
Mother. You must then work for her. You will have much to do. To
make and mend all that your doll will want to wear. Will not you wish
her in the shop? I fear that you will; you who are so fond of play.
Girl. Work for my doll will not tire me.
Mother. Take it, then.
Girl. You are so good! pray let me kiss you. I must kiss you too, my
dear doll, for joy.
 THE TOILET.
IN WORDS OF FOUR LETTERS.

Girl. I like this frock; but it will not keep on. Why will it not keep on?
Maid. It is too big for you, miss.
Girl. It is off; it will fall off.
Maid. You had best lay it down, miss.
Girl. I like to have it; I will put it on.
Mother. My dear! lay it down when you are bid to do so; do not
wait to be made to do well.
Girl. I will not, mamma. Jane, I will be good. Pray may I look in this
box?
Mother. You see it is shut now; you may see it by-and-by.
Girl. I will not hurt the lock.
Mother. You must not try.
Girl. May I play with your muff?
Mother. You may.
Girl. What is this made of?
Mother. Fur; and fur is skin with the hair on.
Girl. It is like puss; how soft it is! How warm it is when I hold it to
my nose! it is like wool.
Mother. Now come and kiss me; I am sure you will be good to
John; go and play with him.
Girl. Do you stay all day? do you stay till John is in bed?
Mother. Yes; till you are both in bed. Now go.
Girl. Pray let me get my work-bag first. May I get my work-bag?
Mother. Why do you want it?
Girl. I want some silk out of it, that I may work a ball for John.
 THE FAN.
IN WORDS OF FOUR LETTERS.

Lady. What does the baby want? what does that mean?
Girl. It is his way to say please.
Lady. And what does he wish?
Girl. To have your fan: but he will tear it.
Lady. Can you take care of it?
Girl. O yes; I can show it to him.
Lady. Take it; and let him see it.
Girl. Now sit by me. Pray sit him down by me. Look! no, you must
not have it. I must keep it in my hand. You can not hold it. Here is a
boy. See, he runs to get that bird. O fie! do not get the bird. No! you
must not put the bird in a cage. Let the bird fly; let him sing; and let
him help to make a nest. Do not hurt the poor bird. You must be
good and kind. You must not vex the bird. Here is a girl. Look at her
pink coat. Here is her foot. She has a blue shoe. She is at play with
the boy. Miss! you must be good. You must tell the boy to be good,
that we may love him. All good folks will love him, if he be good, not
else. Now let us turn the fan. Now we will look at this side. Here is a
nice pink. This is a rose. That is a fly.
Mother. Now John will walk. Ring the bell. Go and walk with the
maid.
Girl. Am I to go?
Mother. As you like.
Girl. I like best to stay; but John says with his hand, “pray go.” I will
go then; dear boy! I will go with you.
Mother. Good girl.
 Girl. John! you must love me; I wish to stay here, and you hear
that I may stay.
Mother. Take hold of him and lead him out. You will meet the maid
at the door.
 THE BOOK-SHOP.
IN WORDS OF FOUR AND FIVE LETTERS.

Boy. I will have a book. I will have one with a dog in it. May I not?
Mother. Yes, you may.
Boy. Let me see, here is a goat. Do look at his face; how like it is
to a goat! Here is a ball, and a lamb with wool on it, just like my lamb
that I feed at home. And here is a cock. Can you crow? Crow and tell
us that it is time to rise. Can you not? What a tail he has! a fine tail!
No, I will not have that, for his tail will soon be off. Some part of it is
come off now.
Mother. You must not pull; you do harm.
Boy. I did not pull hard.
Mother. You are a long time.
 Boy. O, here is a fine horse! I like this horse. I like his long tail. You
shall not have your tail cut—no, nor your ears: but you can not feel.
Come, sir, walk and trot. Do you move well? I will rub you down, and
give you oats and hay, and chop straw for you. I will be good to you,
not whip you much—No more than just to say—Now go on;—nor
spur you, nor gall your poor skin; no, nor let the hair rub off. So—you
set your tail well; but if you did not, Tom must not nick you; no, nor
yet dock your poor tail; you will want it to keep the flies from you
when it is hot. I see poor Crop toss his head all day; he does it to
keep the flies from him; but it is all in vain, he can not keep them off.
I will be good to you; I will tend and feed you; and I will not ride too
hard, and hurt your feet; nor trot on hard road, so as to make you fall
and cut your knees; but I will pat your neck when I get up, and I will
make you know me: so that you will turn your head, and seem to like
to have me get on your back. At night, you must have a warm bed.
When I have rode you in the day, I will see that you have good corn,
and hay, and straw; and Tom must wash the hot sand out of your
poor feet, so that they may not ache, and make you grow lame.
Mother. I can not but give you the horse, as you seem to plan so
well for him; I hope you will be good and kind to all things.
Boy. I do not care now for the lamb, nor for the—
Mother. My dear, I would have you know your own mind; if you get
the trick to like now this, now that, and now you know not what, it will
do you harm all your life.—So it is that boys and men spend too
much; so it is that they act like fools. I would give you all the toys in
the shop, if it were for your good to have them: the horse you have;
now take something else; take the book, do you like the book?
Boy. I do; I thank you, mamma. I will keep the horse, and I will give
the book to Jack. O! my dear horse, how I love you!
 THE WALK.
IN WORDS OF FIVE AND SIX LETTERS.

Father. Shall we take a walk, my son?

Boy. Yes, sir, where shall we go?
Father. Let us go by the farm yard into the fields.
Boy. See! a horse and a cow stand by the fence in the yard. Now
we are in the field. Is it full of nettles?
Father. No, not so, it is hemp.
 Boy. What is that for, papa?
Father. To make cloth of; the stalk has a tough peel on it, and that
peel is what they make thread of. The thread they weave, and make
strong cloth.
Boy. I want to know all the trees: pray what leaf is this?
Father. That is an oak; that bush is May; we call it too White-thorn;
it blooms late in May; its fruit are called Haws; so we call it Haw-
thorn. The birds eat the fruit. That is Black-thorn; that blooms soon in
Spring; it has a white bloom, and has then few or no leaves. The fruit
is a sloe. They are like a small blue plum; but so sour that you can
not eat them.
Boy. What is this?
Father. Wild rose; its fruit are Hips; they are kept, and we take
them for coughs. That is broom; it has a bloom like a pea in shape,
but it is yellow.
Boy. There is a bush of it in bloom.
Father. No: that is Furze, such as you see on heaths. Feel this;
Broom does not prick like this.
Boy. I will keep a leaf of each to show to James.
Father. You may put them in a book, and write what I have told
you.
Boy. I will get all sorts of plants; and I will mark by each the name,
the place, the bloom, the time when it blows, and the use which is
made of it.
 THE BABY HOUSE.
IN WORDS OF SIX LETTERS.

First Girl. My doll’s quilt is of chintz. What is this?

Second Girl. French Print.
First Girl. Let us take the doll up.
Second Girl. With all my heart.
First Girl. Where are her clothes?
Second Girl. Here they are; some in this trunk, and some hang in
the press.
First Girl. Bless me! what a nice press! I have a trunk at home, in
my doll’s house; but I have no press.
Second Girl. Here are her linen and coat; those shoes are her
best, do not put them on; take these.
First Girl. What gown does she put on?
Second Girl. Her white one. I will take it out, whilst you lace her
stays.
First Girl. What is her best cloak?
Second Girl. White; with a neat blond-lace round it.
First Girl. Mine has a muff; has your doll a muff?
Second Girl. No, she has not; my aunt says she will teach me to
do chain stitch; and then I am to work one.
First Girl. What is her best dress?
Second Girl. You shall see them all; there is the dress which I like
best.
First Girl. Why do you like it best?
 Second Girl. It is my dear mother’s work; see how neat it is; and
there is a green silk.
First Girl. My doll’s best dress is brown with a stripe of blue; and
she has a white, wrought with a moss rose, a pink, and a large
bunch of leaves: that was her best, but it is just worn out now; she
must leave it off soon.
Second Girl. Why does she wear it so long?
First Girl. I had a half-dollar to buy her a piece of silk; as I went in
the coach with my aunt to buy it, we met a poor child who had no
clothes, but the worst rags which you can think.
Second Girl. And you gave it to her. My doll should wear her old
gown for a long time, for the sake of such a use to put my half-dollar
to.
First Girl. I had more joy in that, than I could have had in my doll’s
new dress. Dolls can not feel the want of clothes.
Second Girl. Now let us go down stairs.
 THE COTTAGE GARDEN.
First Boy. I see no toys—How do you pass your time?
Second Boy. I feed the hens, and the ducks; I see the calf fed.
First Boy. And what do you do else?
 Second Boy. I go out and see the men plough; I see them sow;
and when I am good, they give me some corn.
First Boy. And what do you do with it?
Second Boy. I sow it; I love to see it come up. I have some oats of
my own; they are just come up; I wish they were ripe, we would cut
them.
First Boy. What is done with oats?
Second Boy. Horses eat them.
First Boy. We eat wheat. John says the bread is made of wheat.
Second Boy. I make hay; I have a rake and a fork; and I ride in the
cart. I rode last year.
First Boy. I ride in papa’s coach; and I walk when it is fair and
warm; but I have no tools to work with; I wish I had. I love a toy when
it is new, just the first day I love it; the next day I do not care for it.
Second Boy. I have a spade and a hoe, and a rake; and I can work
with them; and am never tired of them. When I am a man I will have
a scythe, and mow in the fields. I have a bit of ground of my own to
work in.
First Boy. Where is it? pray show it to me.
Second Boy. Here; come this way. There; you see I have a rose
bush; I wish I could find a bud. Here is a white pink: they blow in the
spring. Do you like pinks?
First Boy. We have fine large pinks at home; but these are as
sweet—I thank you.—I should like pinks of my own.
Second Boy. I will give you some slips in June; and show you how
to plant them; and I can give you some seeds which I took care of
last year.
First Boy. You are good to me I am sure; when you come to see
me, I will ask for some fruit to give to you.
Second Boy. I have a pear tree; that tree is mine, and we get nuts
from it.
 First Boy. We have grapes, and figs, and plums; but I love a peach
best, it is so full of juice.
Second Boy. We have none of them; I shall like to taste them. Now
I will show you our bees; the hives stand just by. When we take them
up, you shall have some comb.
 THE COUNTRY VISIT.
Miss. How do you do, nurse? I am come to see you. Mamma gave
me leave to come and spend the day with you.
Woman. I am glad to see you here, Miss.
Miss. Pray call me as you did when I came to you to stay; you
were so good to me! you soon made me well. I like you should say,
My dear. I love you.—I ought to love those who are kind to me, and
nurse me.
Woman. I did not think you would have me say so. But, my dear, if
you are so good, I think I cannot but love you.
Miss. Where is Betsy? I want to see her.
Woman. She shall come; she longs to see you; I see her; she is
just by.
 Little Girl. How do you do; I am glad to see you here, Miss.
Miss. Ah, Betsy! how you are grown! I should scarce know you.
Little Girl. You are as much grown, Miss; you were but so tall when
you were here.
Miss. Let us run and jump; and I want to see all your things.
Little Girl. Will you like to see the cows? or shall we go and see the
lambs?
Miss. O, yes! let us go.
Little Girl. They are just by. I have a tame lamb; I reared it with
milk, warm from the cow.
Miss. I like sheep, they look so mild; when I went home I had a
great deal to tell my sister. She did not know that a lamb was a
young sheep.
Woman. How could she, my dear, till she was told?—you would
not have known, if you had not been told.
Miss. I told her that we cut the wool off the backs of the sheep,
and wore it. I told her how I had seen the lambs frisk and jump. I told
her that I had seen you milk, and make cheese;—she did not know
that cream came off the milk!
Woman. Did you know when you came to me?
Miss. No—I did not.
Woman. You cannot know what you are not taught.
Miss. Tell me more, and when I go home I will tell my sister.
Woman. Come with me and we will talk; and I will show you the
cow and her calf.