Goodman and Snyder’s Differential

Diagnosis for Physical Therapists -

Screening for Referral, 7e (Jun 2,
2022)_(0323722040)_(Elsevier) 7th
Edition John Heick
Visit to download the full and correct content document:
https://ebookmass.com/product/goodman-and-snyders-differential-diagnosis-for-physi
cal-therapists-screening-for-referral-7e-jun-2-2022_0323722040_elsevier-7th-edition-j
ohn-heick/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Differential Diagnosis of Common Complaints, 7E [TRUE

PDF] 7th Edition Edition Andrew B. Symons

https://ebookmass.com/product/differential-diagnosis-of-common-
complaints-7e-true-pdf-7th-edition-edition-andrew-b-symons/

Functional Anatomy for Physical Therapists 1st Edition

https://ebookmass.com/product/functional-anatomy-for-physical-
therapists-1st-edition/

Differential Diagnosis of Common Complaints 7th Edition

https://ebookmass.com/product/differential-diagnosis-of-common-
complaints-7th-edition/

Stroke: Pathophysiology, Diagnosis, And Management 7e

2021 7th Edition James Grotta

https://ebookmass.com/product/stroke-pathophysiology-diagnosis-
and-management-7e-2021-7th-edition-james-grotta/
Differential Diagnosis of Common Complaints 7th Edition
Robert H. Seller

https://ebookmass.com/product/differential-diagnosis-of-common-
complaints-7th-edition-robert-h-seller/

Chapman & Nakielny’s Aids to Radiological Differential

Diagnosis 7th Edition Hameed Rafiee

https://ebookmass.com/product/chapman-nakielnys-aids-to-
radiological-differential-diagnosis-7th-edition-hameed-rafiee/

Music for Sight Singing, 7e 7th Edition Thomas E.

Benjamin

https://ebookmass.com/product/music-for-sight-singing-7e-7th-
edition-thomas-e-benjamin/

Fundamentals of Aerodynamics, 7e 7th Edition John D.

Anderson Jr.

https://ebookmass.com/product/fundamentals-of-
aerodynamics-7e-7th-edition-john-d-anderson-jr/

Zitelli and Davis’ Atlas of Pediatric Physical

Diagnosis 7th Edition – Ebook PDF Version

https://ebookmass.com/product/zitelli-and-davis-atlas-of-
pediatric-physical-diagnosis-7th-edition-ebook-pdf-version/
 GOODMAN AND SNYDER’S
DIFFERENTIAL DIAGNOSIS
FOR PHYSICAL THERAPISTS
SCREENING FOR REFERRAL
 7
EDITION
th

GOODMAN AND SNYDER’S

DIFFERENTIAL DIAGNOSIS
FOR PHYSICAL THERAPISTS
SC REENING FOR REFERRAL

John D. Heick, PT, DPT, PhD, OCS, NCS, SCS

Associate Professor
Department of Physical Therapy and Athletic Training
Northern Arizona University
Flagstaff, Arizona

Rolando Lazaro, PT, PhD, DPT

Professor
Department of Physical Therapy
California State University Sacramento
Sacramento, California
ELSEVIER

3251 Riverport Lane

St. Louis, Missouri 63043

GOODMAN AND SNYDER’S DIFFERENTIAL DIAGNOSIS ISBN: 978-0-323-72204-9

FOR PHYSICAL THERAPISTS, SEVENTH EDITION

Copyright © 2023 by Elsevier Inc. All rights reserved

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions

is book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,
editors or contributors for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.

Previous editions copyrighted 2018, 2013, 2007, 2000, 1995, and 1990.

Senior Content Strategist: Lauren Willis

Senior Content Development Manager: Luke Held
Senior Content Development Specialist: Maria Broeker
Publishing Services Manager: Deepthi Unni
Project Manager: Aparna Venkatachalam
Design Direction: Ryan Cook

Printed in the United states of America

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

 e profession of physical therapy was founded by women. One hundred
years ago, women worked as reconstruction aides to serve injured soldiers
during World War I. ey may not have realized what was ahead, but they
did what they felt was right and always with the patient in mind.
e concept of this textbook on Dierential Diagnosis was also started by a
woman, Catherine Goodman. Catherine’s vision for unrestricted direct access
continues to advance. is edition of this textbook is dedicated to the women
who started this great profession that much like Catherine have advanced
our profession beyond our expectations.
JH and RTL
 C O N T R I B U TO RS
Annie Burke-Doe, PT, MPT, PhD Lecturer and Skills Coordinator in Musculoskeletal &
Dean Rheumatological Physiotherapy Master, Sapienza
Department of Physical erapy University of Rome
West Coast University Lecturer in the Musculoskeletal & Rheumatological
Los Angeles, California Physiotherapy Master, University of Molise
President of Gruppo di Terapia Manuale e Fisioterapia
Marty Fontenot, PT, DPT, OCS, SCS Muscoloscheletrica Italiano (IFOMPT MO) - AIFI
Assistant Professor Sovrintendenza Sanitaria Regionale Puglia INAIL
Physical erapy Program Bari, Italy
Murphy Deming College of Health Sciences at Mary
Baldwin University Seth Peterson, PT, DPT, OCS, CSCS, FAAOMPT
Fishersville, Virginia Founder
Physical erapy
William Garcia, PT, DPT, OCS, FAAOMPT e Motive
Associate Professor Oro Valley, Arizona
Department of Physical erapy Adjunct Professor
California State University, Sacramento Physical erapy
Sacramento, California Arizona School of Health Sciences, A.T. Still University
Mesa, Arizona
Erin Green, PT, DPT, OCS, FAAOMPT
Associate Professor Michael Ross, PT, DHSc, OCS, FAAOMPT
Department of Physical erapy Associate Professor
California State University, Sacramento Physical erapy Department
Sacramento, California Daemen College
Amherst, New York
John D. Heick, PT, DPT, PhD, OCS, NCS, SCS
Associate Professor Richard Severin, PT, DPT, PhD, CCS
Department of Physical erapy and Athletic Training Clinical Assistant Professor
Northern Arizona University Baylor University
Flagsta, Arizona Waco, Texas

Rolando Lazaro, PT, PhD, DPT Elizabeth Shelly, PT, DPT, WCS, BCB PMD
Professor Physical erapy
Department of Physical erapy Beth Shelly Physical erapist
California State University Sacramento Moline, Illinois
Sacramento, California
Brian A. Young, MS, PT, DSc, OCS, FAAOMPT
Jeannette Lee, PT, PhD Clinical Associate Professor
Associate Professor Assistant Program Director &
UCSF/SFSU Graduate Program in Physical erapy Graduate Program Director, Physical erapy Department
San Francisco State University Robbins College of Health and Human Sciences
San Francisco, California Baylor University
Waco, Texas
Filippo Maselli, PT BSc, MSc, PhD, OMPT, Cert. SMT,
Cert. VRS, Cert. HN
Orthopaedic Manipulative Physical erapist, Physiotherapy,
Ph.D. in Neuroscience, DINOGMI Department, University
of Genova

ix
 A NOTE FRO M C AT H E R I N E G O O D M A N
Author’s Vision for the Future: Cloudy with a Chance of
Meatballs
e associate editors of DDPT (to whom I have entrusted
the future of this text) asked me (Catherine) to provide a
vision of our future as a profession. When I think about our
future, the title of a children’s book Cloudy With a Chance of
Meatballs (Judi and Ron Barrett, Atheneum Books for Young
Readers, 1978) comes to mind, as uncertainty with unex-
pected outcomes may be the most apt description.
As we prepare this text for its seventh edition, the American
Physical erapy Association is celebrating its Centennial
Year. One hundred years have passed and our profession is
in need of clarity more than ever before. Centered around
these Centennial celebrations, articles and editorials with a
wide range of “visions for our future” abound. ere has been
much discussion as to how we will interact with articial intel-
ligence, how we will integrate with digital health care, how
physical therapy education will evolve, how the profession
will be impacted by the growth of telehealth, how research
will provide data to direct treatment protocols, and more as
the digital revolution comes to healthcare. As questions and
predictions continue to circulate, all that is currently clear is
that the crystal ball is cloudy… with a chance of meatballs.
Our (Catherine and Ellen) vision is informed by the past as
much as by our hope for the future. What can we learn from
looking back that will help us move successfully forward?
Our history is rich and ripe with good advice for us today.
Physical therapy was born of a need as Reconstruction Aides
stepped up to care for our injured soldiers during the rst
World War. Decades of subsequent war and a polio epidemic
further developed our rehabilitation skills and expanded our
toolkits as wound care, splinting, and electrical stimulation
entered our repertoire in answer to the calls of injured sol-
diers, military veterans, and children. Cardiac rehabilitation
and more advanced neurorehabilitation skills were added to
the toolbox during a mid-century spike in heart attacks and
strokes, another example of physical therapy nding a way
to meet crisis with action. Time and again we have adapted
the old ways and developed new ways to rise up and meet the
challenges of the day.
As physical therapists, we pride ourselves on our “can-do”
attitude and have a long track record of putting that attitude
to work in the world. e rst edition of this text was born
from both a passion as a clinician and a clear need within the
profession — we were at the doorstep of Direct Access with-
out adequate training in medical screening and I (Catherine)
was ready to put my “can-do” attitude to work. e absence
of this training was potentially dangerous; the rst edition
aimed to ll in the gap for the modern physical therapist.
It was only 30 years ago we dared to publish a physical
therapy text with the word “diagnosis” as part of the title.
Today, the word “diagnosis” has become an accepted word in
our lexicon. Diagnosis evolved to dierential diagnosis, then
further parsed out to include screening for medical disease,
and nally screening for referral. e next logical step now is
to create dierential diagnoses of neuromuscular and muscu-
loskeletal conditions within the scope of a physical therapist’s
practice from which to create a best practice plan of care.
With some form of Direct Access currently available in all
50 states, the heat I (Catherine) took for that decision seems
unimaginable now. But that was when Direct Access was still
just a “vision of the future.” e future always seems further
away than it actually is. So, we can dream, can’t we? And those
dreams of the future can absolutely become our present.
We are in a similar place today, standing in the doorway of
a transition to primary care without a clear understanding of
the links between medical pathology and what we see as neu-
romusculoskeletal impairments. e aging Baby Boom gen-
eration and more complex health conditions are becoming
new challenges for our profession. It is my hope (Catherine)
that texts such as Dierential Diagnosis for Physical erapists:
Screening for Referral and Ellen Helinski’s forthcoming text,
A Physical erapy Approach to the Modern Pain Patient, will
lead the way into the future of physical therapy care.
In the not-so-distant future, healthcare may look more like
the science ction of the not-so-distant past. Physical therapy
evaluations could be performed via articial intelligence with
no physical visit even necessary as machines do the bulk of
our work for us. Imagine handheld devices or automated
kiosks where a person need only place a hand on the screen to
get an immediate read out of biologic age and telomere length,
Body Mass Index, blood type, and indicators of health and/or
disease such as blood values, inammatory markers, condi-
tion of the gut microbiome, and body/organ frequencies and
functions. Practical suggestions to improve health or address
disease would then be oered based on these ndings.
Today this new vision may seem far away. Standing at the
precipice of our future yet mired in the messy trenches of
patient/client care, it has been (and continues to be) a dicult
time for the physical therapy profession. Declining referrals,
plummeting reimbursement rates, soaring educational costs,
and the inexhaustible pain epidemic — each of these variables
is taking a toll, contributing to both burnout and what many
have called an identity crisis at a time when we (and our his-
tory of can-do) are needed more than ever. How will the pro-
fession get back on its feet and meet the challenges of the day?
Call us biased, but we feel the answer is in the evolution of
dierential diagnosis.
We see a more immediate future where the physical thera-
pist is the gatekeeper and primary practitioner for all neu-
romusculoskeletal conditions, including pain. Established
standards like dierential diagnosis and screening for refer-
ral will be the foundation from which we build new skills
in pharmacology, diagnostic imaging, functional medicine,
indirect manual therapy, and wellness education and practice.
A standardized emphasis on integration will mean no one is
viewed in terms of separate pieces and parts, but rather as a
whole being—a multifaceted summation of all parts.
xi
xii Author’s Introduction
We see a future where what once was called “alternative”
is nally seen as advanced and where all students of physical
therapy hit the eld with the tools they need to contribute and
thrive. To get there, we will need to take on our new role as a
doctor in healthcare by leading a shi from standardization
to individualization, exclusion to inclusion, specialization to
holism, and compartmentalization to integration. e task is
big, the need immense. We must bring the lessons of the past
to carve the way to this new future.
With rising incidences of diabetes, cancer, immunocom-
promise, and neurologic disorders, all healthcare profession-
als need to step back and embrace a more integrated view
of the body. Patient/client presentations are no longer as
straightforward as they once were. Individual medical condi-
tions do not exist in isolation from the neuromusculoskeletal
conditions we target. Specialization plays out like a game of
pass-the-buck as patients/clients are sent from one profes-
sional to the next, with no one tracking the big picture (i.e.,
the individual person). We see a vision of the future in which
the physical therapist takes the helm for complex patients,
such as the aging adult and those struggling with pain.
Pain is the new battleeld in America for the physical ther-
apist. e knowledge, skills, and tools needed to ght this bat-
tle will push us out of our comfort zone as movement experts
into uncharted waters. If we have any hope of truly winning
the war against pain, we will need to step up and take on our
new role as a doctor in healthcare as we discover how thin
the line has become between neuromuscular/musculoskeletal
pain and dysfunction and medical pathology.
Now more than ever, we must conduct careful and thor-
ough interviews (whether in person or via telehealth visits),
identify associated signs and symptoms, note risk factors for
specic diseases, and screen for yellow and red ags. We need
to overcome our outdated beliefs, learn new tools to meet
the needs of each individual, and embrace new methods for
addressing variables we have only begun to consider, such as
epigenetics and the microbiome. e decision to treat, refer,
or treat and refer remains the question of the day, only now
with many more layers to peel back, more variables to con-
sider, and a bigger role for the physical therapist to play.
As the role of the physical therapist continues to expand
toward a more holistic, advanced approach, the basics will
remain the same. We will still be responsible for evaluating
each individual to make sure a dierential diagnosis is made
in order to be as specic as possible when creating the most
appropriate plan of care. As always, screening begins the pro-
cess and continues throughout the evaluation and subsequent
treatment to determine the need for direct referral and/or
interprofessional collaboration.
Like death and taxes, healthcare will remain a certainty,
front and center in all our lives, but change is 100% guaran-
teed. In this moment, will we choose to be the profession that
steps up and helps dene the future of healthcare, or will we
let that future dene us?
So, with our history at our backs, let us move forward
together with bravery, curiosity, anticipation, and joy as we
cra and make manifest what we want for our profession, for
patients and clients, and for all our futures. Here’s to blue skies
ahead…sans meatballs.
Catherine Cavallaro Goodman, MBA, PT
Ellen Hope Helinski, MS, PT, IMT.C

It is my pleasure and honor to write the foreword for the
seventh edition of Dierential Diagnosis for Physical
erapists: Screening for Referral. is textbook has been a
staple in physical therapy programs for over 30 years and has
stood the test of time. If you are in graduate school learning
to become a physical therapist, this book is a requirement. I
will go one step further. If you are a practicing clinician who
treats patients, this book is a requirement. Since its inception
in 1990, this text has documented the changes in our profes-
sion from one dominated by referral from physicians to that
of direct access. Dierential diagnosis and screening for refer-
ral continues to be increasingly important as more physical
therapists, in a greater number of states, have increased auton-
omy due to direct access. Patients are coming into our clinics
with more co-morbidities, more complex medical issues than
ever before. As a physical therapist, we need to know how to
navigate this tide of change which has opened our practices
to the ability to see more varied and unique cases. As a pro-
fessor who has been teaching orthopedics for over 20 years,
and a practicing orthopedic and sports clinician for almost
30 years, I understand the importance of clearly knowing
what pathologies may be masquerading as something benign.
Dierential diagnosis and screening for referral is founda-
tional to our present practice of physical therapy.
Differential Diagnosis for Physical Therapists:
Screening for Referral helps us navigate these changes by
presenting a screening model that is rooted in standard
F O R E WO R D
clinical practice and reflects the patient management pro-
cess in the Guide to Physical Therapists Practice. This text,
like previous versions, is divided into three main sections.
Section I: Introduction to the Screening Process; Section
II: Viscerogenic Causes of Neuromusculoskeletal Pain
and Dysfunction; and Section III: Systemic Origins of
Neuromusculoskeletal Pain and Dysfunction. Each chap-
ter has been edited and updated with relevant references
that have become available since the last edition. These
updates within each chapter clearly describe new and
evolving methods of medical screening. One clear example
of the latest updated edition of the text is the chapter on
neurologic screening. This chapter is updated with new
relevant references and concisely describes the screening
process for a patient with neurological issues.
I congratulate John Heick and Rolando Lazaro for their
eorts to continue Catherine Goodman’s tradition of edu-
cating physical therapists through the seventh edition of
the foundational textbook. Any physical therapist entrusted
in examining and treating patients will benet from this
textbook.
Robert C. Manske, PT, DPT, MPT, MEd, SCS, ATC, CSCS
Professor
Department of Physical erapy
College of Health Professions
Wichita State University
xiii

e vision of the American Physical erapy Association
(APTA) is to “Transform society by optimizing movement
to improve the human experience.”1 To reach this vision,
the APTA goal is to “Drive demand and access to physical
therapy as a proven pathway to improve the human experi-
ence.”2 e expected outcome that APTA hopes to achieve is
“Use of and access to physical therapist services as a primary
entry point of care for consumers will increase.”2 is text-
book supports this outcome as physical therapists are ideal
health care providers to work in a primary care setting. is
movement towards primary care makes sense as physical
therapists work across a wide range of clinical settings, are
doctorate trained musculoskeletal experts, and an important
profession that contributes to the health of society by screen-
ing all systems of the body. is overarching theme is present
within this updated edition of this textbook. e focus on this
seventh edition is to continue to look forward and improve
the abilities of physical therapy students and physical thera-
pist clinicians to consider the three options when the therapist
evaluates a patient/client, that is: 1) treat, 2) treat and refer, or
3) refer the patient.
is process is done on an ongoing basis throughout the
episode of care for the patient/client and follows the standards
of competency established by the APTA related to conduct-
ing a screening examination. roughout this text, we pres-
ent a screening model that allows for an ecient examination
that includes the critical parts of the screening process. is
screening model is an accepted part of standard clinical prac-
tice and reects the patient/client management process in the
updated edition of the Guide to Physical erapist Practice.
is screening process has also contributed to the movement
towards a diagnostic classication scheme for our profession.
Dierential diagnosis has been an area of concentration
that has vastly increased over the past decade in physical ther-
apy and is well represented on the physical therapist licensure
examination. In addition, screening for medical referral con-
tinues to be an increasingly important component of physical
therapist practice in all clinical practice settings, due to physi-
cal therapy direct access, medical complexity of individuals
being seen by physical therapists, and limitations in health
care reimbursement. As we updated the literature in this edi-
tion of the text, we have found even stronger documented
evidence on the role of the physical therapist in the screen-
ing process, showing the skill and capability of the therapist
1
Vision Statement for the Physical erapy Profession. American
Physical erapy Association. Available at: https://www.apta.org/
apta-and-you/leadership-and-governance/vision-mission-and-
strategic-plan Accessed February 15, 2022.
2
APTA Strategic Plan 2022-2025. American Physical erapy
Association. Available at: https://www.apta.org/apta-and-you/
leadership-and-governance/vision-mission-and-strategic-plan/
strategic-plan Accessed February 15, 2022.
P R E FAC E
to identify the need for referral to other health professionals,
therefore saving lives as well as optimizing the quality of lives
of individuals under their care. Information contained in this
text is therefore immensely important in all clinical practice
settings in the contemporary and future practice of physical
therapy.
is text is divided into three sections. Section I intro-
duces the screening process as well as a focus on interviewing
the client with clarity. Chapters 3 and 4 dive deeper into pain
presentations and physical assessment of the patient/client.
Section II follows a systems approach that focuses on the
nine viscerogenic causes that may masquerade as a neuro-
musculoskeletal presentation. Each system is presented and
the common conditions that occur within this system as
well as red ags, risk factors, clinical presentations, and signs
and symptoms are reviewed for the system. Clinical practice
guidelines and helpful screening clues supported by evidence
of all levels are presented for each system.
Section III covers the axial and appendicular regions of the
body and reviews the systemic origins to consider when treat-
ing a patient/client with a condition in these regions.
At the end of each chapter, the reader is presented with
practice questions to check for understanding and further
facilitate learning. In this edition, we updated the practice
questions and added several more items for review.
A comprehensive index can be found at the end of the text
to allow the reader to more easily nd content in the text.
e Appendices can be found in the accompanying eBook.
It is important to note that part of the Appendices is a list of
specic questions to consider asking when screening specic
problems (e.g., headache, depression, substance use/abuse,
bladder function, joint pain) (Appendix B). is list is pro-
vided alphabetically and is a special feature of the appendix.
We also encourage the reader to access additional resources
related to this text in the accompanying eBook to provide you
with a complete learning experience. e resources include
forms that can be used in clinical practice, practice questions,
weblinks, and references. For instructors, we also provide
additional resources to support the use of this text in your
courses, including selected images, PowerPoint slides, and a
test bank.
It is our intention to provide the physical therapist cli-
nician and physical therapist student with evidence-based
approaches to screen for systemic conditions that mimic neu-
romusculoskeletal conditions and assist the physical therapist
in optimal decision-making to benet the patient/client. We
feel that this textbook moves the profession one step closer
to realizing our vision of transforming society by optimizing
movement to improve the human experience.
xv
 AC K N OW L E D G M E N T S
As we started editing the seventh edition of this book, we real- Michael Ross
ized how much has changed in such a short period of time! Richard Severin
We were able to include a new chapter on screening for the Beth Shelly
neurologic system in this edition and we feel that this chapter Brian Young
will add to the understanding of the physical therapist. We To our partners at Elsevier, thank you for the help and
are fortunate to have had the expertise and support of sev- support behind the scenes:
eral individuals who made the task easier and more enjoy- Lauren Willis, Senior Content Strategist
able. Your immense contribution to the text is very much Maria Broeker, Senior Content Development Specialist
appreciated. Aparna Venkatachalam, Project Manager
To the following content experts who provided support To Sherrill Brown at the University of Montana Skaggs
and/or edited chapters: School of Pharmacy: thank you for helping us update several
Annie Burke-Doe tables related to drug information in the text.
Marty Fontenot To our research assistants: Sherene ompson and Gita
Bill Garcia Mariel L. Manuel, thank you for assisting us with numerous
Erin Green research and editing tasks.
Jeanette Lee John Heick
Seth Peterson Rolando T. Lazaro
Filippo Maselli

xvii
 CONTENTS
SECTION I INTRODUCTION TO THE SCREENING PROCESS

1 Introduction to Screening for Referral in Physical erapy, 1

2 Interviewing as a Screening Tool, 35

Seth Peterson

3 Pain Types and Viscerogenic Pain Patterns, 98

4 Physical Assessment as a Screening Tool, 152

Brian A. Young, Michael Ross, and Richard Severin

5 Screening for Neurologic Conditions, 217

John D. Heick

SECTION II VISCEROGENIC CAUSES OF NEUROMUSCULOSKELETAL PAIN AND DYSFUNCTION

6 Screening for Hematologic Disease, 235

7 Screening for Cardiovascular Disease, 249

8 Screening for Pulmonary Disease, 299

9 Screening for Gastrointestinal Disease, 330

10 Screening for Hepatic and Biliary Disease, 366

11 Screening for Urogenital Disease, 389

Marty Fontenot

12 Screening for Endocrine and Metabolic Disease, 416

Annie Burke-Doe

13 Screening for Immunologic Disease, 460

Erin Green and William Garcia

14 Screening for Cancer, 502

Jeannette Lee

SECTION III SYSTEMIC ORIGINS OF NEUROMUSCULOSKELETAL PAIN AND DYSFUNCTION

15 Screening the Head, Neck, and Back, 563

16 Screening the Sacrum, Sacroiliac, and Pelvis, 623

17 Screening the Lower Quadrant: Buttock, Hip, Groin, igh, and Leg, 654

18 Screening the Chest, Breasts, and Ribs, 689

19. Screening the Shoulder and Upper Extremity, 728

xix
xx Contents

APPENDICES*

Appendix A
A-1 Quick Screen Checklist, e1
A-2 Red Flags, e3
A-3 Systemic Causes of Joint Pain, e5
A-4 e Referral Process, e6

Appendix B
B-1 Screening for Alcohol Abuse: Alcohol Use Disorders Identication Test (Audit) Questionnaire, e7
B-2 Screening for Alcohol Abuse: Cage Questionnaire, e8
B-3 Assault, Intimate Partner Abuse, or Domestic Violence, e9
B-4 Screening Bilateral Carpal Tunnel Syndrome, e10
B-5 Screening Bladder Function, e11
B-6 Screening Bowel Function, e13
B-7 Screening the Breast, e14
B-8 Special Questions to Ask: Chest/orax, e15
B-9 Screening for Depression/Anxiety (See also Appendix B-10, Screening for Depression in Older Adults), e17
B-10 Screening for Depression in Older Adults, e18
B-11 Screening for Dizziness, e19
B-12 Screening for Dyspnea (Shortness of Breath [SOB]; Dyspnea on Exertion [DOE]), e20
B-13A Screening for Eating Disorders, e21
B-13B Resources for Screening for Eating Disorders, e22
B-14 Screening Environmental and Work History, e23
B-15 Screening for Fibromyalgia Syndrome (FMS), e24
B-16 Screening Questions for Gastrointestinal (GI) Problems, e25
B-17 Screening Headaches, e26
B-18 Screening Joint Pain (See also Appendix A-3: Systemic Causes of Joint Pain), e27
B-19 Screening Questions for Kidney and Urinary Tract Impairment, e28
B-20 Screening for Liver (Hepatic) Impairment, e29
B-21 Screening Questions Regarding So Tissue Lumps or Skin Lesions, e30
B-22 Screening Lymph Nodes, e31
B-23 Screening for Medications, e32
B-24 Screening for Men Experiencing Back, Hip, Pelvic, Groin, or Sacroiliac Pain, e33
B-25 Screening Night Pain, e34
B-26 Screening for Side Eects of Nonsteroidal Antiinammatory Drugs (NSAIDs), e35
B-27 Screening for Unusual Odors, e36
B-28 Screening Pain, e37
B-29 Screening for Palpitations (Chest or Heart), e39
B-30 Screening for Prostate Problems, e40
B-31 Screening for Psychogenic Source of Symptoms, e41
B-32A Taking a Sexual History, e42
B-32B Taking a Sexual History, e43
B-33 Sexually Transmitted Diseases, e44
B-34 Special Questions to Ask: Shoulder and Upper Extremity, e45
B-35 Screening Sleep Patterns, e47
B-36 Screening for Substance Use/Abuse, e48
B-37 Women Experiencing Back, Hip, Pelvic, Groin, Sacroiliac (SI), or Sacral Pain, e49

Appendix C
C-1 Family/Personal History, e51
C-2 Outpatient Physical/Occupational erapy Intake, e54
C-3 Patient Entry Questionnaire, e57

*All appendixes are included in the accompanying eBook

 Contents xxi

C-4A OSPRO-YF Assessment Tool, e60

C-4B Optimal Screening for Prediction of Referral and Outcome Red Flag Symptom Item Bank, e62
C-5A Wells’ Clinical Decision Rule for DVT, e65
C-5B Simplied Wells’ Criteria for the Clinical Assessment of Pulmonary Embolism, e66
C-5C Possible Predictors of Upper Extremity DVT, e67
C-6 Osteoporosis Screening Evaluation, e68
C-7 Pain Assessment Record Form, e69
C-8 Risk Factor Assessment for Skin Cancer, e71
C-9 Examining a Skin Lesion or Mass, e72

Appendix D
D-1 Guide to Physical Assessment in a Screening Examination, e73
D-2 Extremity Examination Checklist, e74
D-3 Hand and Nail Bed Assessment, e75
D-4 Peripheral Vascular Assessment, e76

Answers to Practice Questions, e77

Index, 757
SECTION I
Introduction to the Screening Process
Introduction to Screening for Referral
in Physical erapy
In this ever-changing health care system, physical therapists
must screen our patients/clients* to make sure that they are
appropriate candidates for physical therapy. e term screen-
ing denotes a methodical examination which is aimed to
separate into various diagnostic groups. In this textbook,
the focus is to screen for referral. e authors make this dis-
tinction because the term dierential diagnosis invokes two
dierent ideas. One is to dierentiate between one condi-
tion versus another condition. A simplistic example of this
would be a patient complaining of knee pain who potentially
has patellofemoral pain syndrome or has peripatellar bursi-
tis. e second idea of dierential diagnosis is that a physical
therapist needs to rule out diseases and conditions that mas-
querade as musculoskeletal conditions. e latter of these two
approaches is the direction that the authors of this textbook
take, that is screening for referral. In both scenarios, physical
therapists perform within their scope of practice to provide
optimal health care. By doing so we determine what biome-
chanical or neuromusculoskeletal problem is present that
aects the client’s activity and participation, and then treat
the problem as specically as possible.
As part of this process of practicing within our scope, it
is the therapist’s responsibility to screen for medical disease.
As a health care provider, the physical therapist must be able
to identify signs and symptoms of systemic disease that can
mimic neuromuscular or musculoskeletal (herein referred to
*e Guide to Physical erapist Practice1 denes patients as “indi-
viduals who are the recipients of physical therapy care and direct
intervention” and clients as “individuals who are not necessarily sick
or injured but who can benet from a physical therapist’s consulta-
tion, professional advice, or prevention services.” In this introduc-
tory chapter, the term patient/client is used in accordance with the
patient/client management model as presented in the Guide. In all
other chapters, the term client is used except when referring to hos-
pital inpatients/clients or outpatients/clients.
CHAPTER
1
as neuromusculoskeletal, or NMS) dysfunction. Peptic ulcers,
gallbladder disease, liver disease, and myocardial ischemia
are only a few examples of systemic diseases that can cause
shoulder or back pain. Other diseases can present as primary
neck, upper back, hip, sacroiliac (SI), or low back pain and/or
symptoms.
e purpose and the scope of this text are not to teach ther-
apists to be medical diagnosticians. e purpose of this text
is twofold. e rst is to help therapists recognize the areas
that are beyond the scope of a physical therapist’s practice or
expertise. e second is to provide a step-by-step method for
therapists to identify clients who need a referral or consulta-
tion to a physician or other health professionals who can then
best manage the patient.
As more states move toward unrestricted direct access,
physical therapists are increasingly becoming the practitioner
of choice and thereby the rst contact that patients/clients
seek particularly for the care of musculoskeletal dysfunction.
is makes it critical for physical therapists to be well versed
in determining when and how referral to a physician, nurse
practitioner, physician assistant, nutritionist, psychologist,
another health professional, or even another physical thera-
pist who is a certied specialist in an area that the patient/
client needs. Each patient/client case must be reviewed care-
fully (see Fig. 1.1).
Even without unrestricted direct access, screening is an
essential skill because any client can present with red ags, or
warning signs, requiring reevaluation by a medical specialist.
e methods and clinical decision-making model for screen-
ing presented in this text remain the same with or without
direct access and in all practice settings.
THE USE OF YELLOW OR RED FLAGS
A large part of the screening process is identifying yellow
(caution) or red (warning) ag histories and identifying
signs and symptoms during the examination (Box 1.1). A
1
2 SECTION I Introduction to the Screening Process
Fig. 1.1 Physical therapist referrals to other providers. PT =
physical therapist, MD = doctor of medicine, DO = doctor of
osteopathy, DDS = doctor of dental surgery, NP = nurse practitioner,
PA = physician assistant. (From APTA Guide to Physical Therapist
Practice, American Physical Therapy Association.)
BOX 1.1 RED FLAGS
e presence of any one of these symptoms is not usually
cause for extreme concern but should raise a red ag for the
alert therapist. e therapist is looking for a pattern that sug-
gests a viscerogenic or systemic origin of pain and/or symp-
toms. e therapist will proceed with the screening process,
depending on which symptoms are grouped together. Oen
the next step is to conduct a risk factor assessment and look
for associated signs and symptoms.
Past Medical History (Personal or Family)
• Personal or family history of cancer
• Recent (last 6 weeks) infection (e.g., mononucleosis,
upper respiratory infection [URI], urinary tract infec-
tion [UTI]; bacterial such as streptococcal or staphylo-
coccal; viral such as measles, hepatitis), especially when
followed by neurologic symptoms 1 to 3 weeks later
(Guillain-Barré syndrome), joint pain, or back pain
• Recurrent colds or u with a cyclical pattern (i.e., the cli-
ent reports that he or she just cannot shake this cold or
the u—it keeps coming back over and over)
• Recent history of trauma, such as motor vehicle accident
or fall (fracture, any age), or minor trauma in older adult
with osteopenia/osteoporosis
• History of immunosuppression (e.g., steroids, organ
transplant, human immunodeciency virus [HIV])
• History of injection drug use (infection)
yellow ag is a cautionary or warning symptom that signals
“slow down” and is used specically to assess pain-associated
psychological distress. A useful screening tool to identify yel-
low ags is the Optimal Screening for Prediction of Referral
and Outcome for Yellow Flags (OSPRO-YF)1. e OSPRO-YF
asks the patient questions to identify negative coping, negative
mood, and positive aect/coping domains via a multidimen-
sional questionnaire. is tool assists clinicians in recognizing
the need for referral to other health care providers to benet
the patient/client.
Red ags are features of the individual’s medical history
and clinical examination thought to be associated with a high
risk of serious disorders, such as infection, inammation,
cancer, or fracture.2 ink of a red ag as a means to stop and
consider the information gathered in history-taking or within
the examination of a patient/client. When a pattern emerges
to reveal a cluster of red-ags, the clinician should stop and
evaluate if the patient/client requires immediate attention, or
to pursue further screening questions and/or tests, or to make
an appropriate referral. A useful screening tool to identify red
ags is the Optimal Screening for Prediction of Referral and
Outcome-Review of Systems (OSPRO-ROS).3 e OSPRO-
ROS is a 10-item review of systems questionnaire completed
by the patient that helps the clinician identify symptoms that
suggest the need for referral to another health care provider
(see Appendix at the end of this chapter, p. 30).
e presence of a single yellow or red ag is not usually
a cause for immediate medical attention. Each cautionary or
Risk Factors
Risk factors vary, depending on family history, previous
personal history, and disease, illness, or condition pres-
ent. For example, risk factors for heart disease will be dif-
ferent from risk factors for osteoporosis or vestibular or
balance problems. As with all decision-making variables, a
single risk factor may or may not be signicant and must be
viewed in context of the whole patient/client presentation.
is represents only a partial list of all the possible health
risk factors.
Substance use/abuse Alcohol use/abuse
Tobacco use Sedentary lifestyle
Age Race/ethnicity
Gender Domestic violence
Body mass index (BMI) Hysterectomy/oophorectomy
Exposure to radiation Occupation
Clinical Presentation
No known cause, unknown etiology, insidious onset
Symptoms that are not improved or relieved by physical
therapy intervention are a red ag.
Physical therapy intervention does not change the clinical
picture; client may get worse!
Symptoms that get better aer physical therapy, but then
get worse again is also a red ag identifying the need to
screen further
Continued
 CHAPTER 1 Introduction to Screening for Referral in Physical erapy
BOX 1.1 RED FLAGS—cont’d
Signicant weight loss or gain without eort (more than
10% of the client’s body weight in 10 to 21 days)
Gradual, progressive, or cyclical presentation of symptoms
(worse/better/worse)
Unrelieved by rest or change in position; no position is
comfortable
If relieved by rest, positional change, or application of
heat, in time, these relieving factors no longer reduce
symptoms
Symptoms seem out of proportion to the injury
Symptoms persist beyond the expected time for that
condition
Unable to alter (provoke, reproduce, alleviate, eliminate,
aggravate) the symptoms during examination
Does not t the expected mechanical or
neuromusculoskeletal pattern
No discernible pattern of symptoms
A growing mass (painless or painful) is a tumor until
proved otherwise; a hematoma should decrease (not
increase) in size with time
Postmenopausal vaginal bleeding (bleeding that occurs
a year or more aer the last period [signicance
depends on whether the woman is taking a hormone
replacement therapy and which regimen is used])
Bilateral symptoms:
Edema Clubbing
Numbness, tingling Nail-bed changes
Skin-pigmentation changes Skin rash
Change in muscle tone or range of motion (ROM) for
individuals with neurologic conditions (e.g., cerebral
palsy, spinal cord injury, traumatic brain injury,
multiple sclerosis)
Pain Pattern
Back or shoulder pain (most common location of referred
pain; other areas can be aected as well, but these two
areas signal a particular need to take a second look)
Pain accompanied by full and painless range of motion
(see Table 3.1)
Pain that is not consistent with emotional or psychologic
overlay (e.g., Waddell’s test is negative or insignicant;
ways to measure this are discussed in Chapter 3);
screening tests for emotional overlay are negative
warning ag must be viewed in the context of the whole per-
son given the age, gender, past medical history, known risk
factors, medication use, and current clinical presentation
of that patient/client. For example, in the examination of a
patient that has had a stroke, the presence of clonus is not a
red ag sign because it is expected in this patient’s condition.
Clusters of yellow and/or red ags do not always warrant
medical referral. Each case is evaluated on its own. Clusters of
ags suggest it is time to take a closer look when risk factors for
3
Night pain (constant and intense; see complete description
in Chapter 3)
Symptoms (especially pain) are constant and intense
(Remember to ask anyone with “constant” pain: Are you
having this pain right now?)
Pain made worse by activity and relieved by rest (e.g.,
intermittent claudication; cardiac: upper quadrant
pain with the use of the lower extremities when upper
extremities are inactive)
Pain described as throbbing (vascular) knife-like, boring,
or deep aching
Pain that is poorly localized
Pattern of coming and going like spasms, colicky
Pain accompanied by signs and symptoms associated with
a specic viscera or system (e.g., GI, GU, GYN, cardiac,
pulmonary, endocrine)
Change in musculoskeletal symptoms with food intake or
medication use (immediately or up to several hours later)
Associated Signs and Symptoms
Recent report of confusion (or increased confusion); this
could be a neurologic sign; it could be drug-induced
(e.g., NSAIDs) or a sign of infection; usually it is a
family member who takes the therapist aside to report
this concern
Presence of constitutional symptoms (see Box 1.3) or
unusual vital signs (see Discussion, Chapter 4); body
temperature of 100° F (37.8° C) usually indicates a
serious illness
Proximal muscle weakness, especially if accompanied by
change in DTRs (see Fig. 14.3)
Joint pain with skin rashes, nodules (see discussion of
systemic causes of joint pain, Chapter 3; see Table 3.6)
Any cluster of signs and symptoms observed during the
Review of Systems that are characteristic of a particular
organ system (see Box 4.15; Table 14.5)
Unusual menstrual cycle/symptoms; association between
menses and symptoms
It is imperative, at the end of each interview, that the thera-
pist ask the client a question like the following:
• Are there any other symptoms or problems anywhere
else in your body that may not seem related to your cur-
rent problem?
specic diseases are present, or both risk factors and red ags are
present at the same time. Even as we say this, the heavy emphasis
on red ags in screening has been called into question.4,5
It has been reported that in the primary care (medical) set-
ting, some red ags have high false-positive rates and have
very little diagnostic value when used by themselves.6 Eorts
are being made to identify reliable red ags that are valid
based on patient-centered clinical research. Whenever pos-
sible, those yellow/red ags are reported in this text.7,8
4 SECTION I Introduction to the Screening Process
EVIDENCE-BASED PRACTICE
All components of evidence-based practice are incorporated
in the practice of physical therapy. Clinical decisions must be
a product of the integration of the therapist’s clinical exper-
tise, the client’s values and preferences, and the best available
research evidence.9
Each therapist must develop the skills necessary to assimi-
late, evaluate, and make the best use of evidence when screen-
ing patients/clients for possible medical diseases. Clinical
practice guidelines (CPG) are ideal evidence-based tools to
consider as they facilitate this process of using the evidence
available to facilitate screening. At the current time, the pro-
fession of physical therapy has developed 25 CPGs that are
open-access available electronically, free and easy to down-
load. At the time of publication of this book, a dierential
diagnosis-specic CPG is being conducted.
In the latest edition of this text, every eort has been made
to consider pertinent literature, but it remains up to the reader
to keep up with peer-reviewed literature reporting on the like-
lihood ratios; predictive values; measurement properties such
as reliability, sensitivity, and specicity; and validity of yel-
low (cautionary) and red (warning) ags and the condence
level/predictive value behind screening questions and tests.
erapists will want to build their set of specic screening
tools based on their practice setting by using the best evidence
screening strategies available. ese strategies are rapidly
changing and require careful attention to current patient-
centered peer-reviewed research/literature. One suggestion by
the editors is to consider using Pubmed as it allows for push
evidence as opposed to pull evidence. ese terms refer to the
work that the physical therapist has to do to receive literature,
i.e., push evidence is evidence that is sent to the therapist via
email, and pull evidence involves the therapist searching for
the evidence. Push evidence such as MY NCBI from Pubmed
enables the therapist who works in outpatient, and treats spe-
cic populations such as those with spinal conditions, to have
literature specic to spinal conditions sent to them on a weekly
or daily basis, thus allowing the therapist to stay up-to-date in
their focused musculoskeletal area.
Evidence-based clinical decision-making consistent with
the patient/client management model as presented in the
Guide to Physical erapist Practice9 will be the foundation
upon which a physical therapist’s dierential diagnosis is
made. Screening for systemic disease or viscerogenic causes
of NMS symptoms begins with a well-developed client his-
tory and interview.
e foundation for these skills is presented in Chapter 2.
In addition, the therapist will rely heavily on clinical presenta-
tion and the presence of any associated signs and symptoms
to alert him or her to the need for more specic screening
questions and tests.
Under evidence-based practice, relying on a red-ag
checklist such as the OSPRO-ROS is a more evidence-based
approach that allows for consideration of serious disor-
ders. Eorts are being made to validate red ags currently
in use (see further discussion in Chapter 2). When serious
conditions have not been identied, it is not for a lack of spe-
cial investigation, but for a lack of adequate and thorough
attention to clues usually found during a thorough history.10,11
Some conditions will not be identied with screening
because the condition may be early in its presentation and
has not progressed enough to be recognizable. In some cases,
early recognition makes no dierence to the outcome, either
because nothing can be done to prevent progression of the
condition or there is no adequate treatment available.10
STATISTICS
How oen does it happen that a systemic or viscerogenic
problem masquerades as a neuromuscular or musculoskeletal
problem? ere are very limited statistics to quantify how oen
an organic disease masquerades or presents as NMS problems.
Osteopathic physicians suggest this happens in approximately
1% of cases seen by physical therapists, but little data exist to
conrm this estimate.12,13 At the present time, the screening
concept remains a consensus-based approach patterned aer
the traditional medical model and research derived from mili-
tary medicine (primarily case reports/studies).
Eorts are underway to develop a physical therapists’
national database to collect patient/client data that can assist
us in this eort. It is up to each of us to look for evidence in
peer-reviewed journals to guide us in this process.
Personal experience suggests the 1% gure would be
higher if therapists were screening routinely. In support of this
hypothesis, a systematic review of 78 published case reports
and case series reported that physical therapists involved in
the care referred 20 patients (25.6%) to a physician because
they either had worsening of symptoms or were not meet-
ing the original prognosis. Out of the 20 who were referred,
8 cases or 10% had new symptoms that were unrelated to
the initial primary symptoms.14 Physical therapists involved
in the cases were therefore routinely performing screening
examinations, regardless of whether or not the client was ini-
tially referred to the physical therapist by a physician. ese
results demonstrate the importance of a therapist screening
beyond the chief presenting complaint (i.e., for this group the
red ags were not related to the reason physical therapy was
started), or when new presenting signs and symptoms appear
to not be related to the primary condition. For example, it is
important to listen to our clients when they are not improving
in our care, either postoperatively15 or if the presentation does
not match the referring diagnosis.16 In these cases, red ags
may lead the therapist to further evaluate systems that are not
included in the original referring diagnosis by the health care
professional. is approach benets our clients/patients by
using our knowledge and providing the best care!
KEY FACTORS TO CONSIDER
ree key factors that create a need for screening are:
• Side eects of medications
• Comorbidities
• Visceral pain mechanisms
 CHAPTER 1 Introduction to Screening for Referral in Physical erapy
If the medical diagnosis is delayed, then the correct diag-
nosis is eventually made when:
1. e patient/client does not get better with physical therapy
intervention.
2. e patient/client gets better then worse.
3. Other associated signs and symptoms eventually develop.
ere are times when a patient/client with NMS com-
plaints is really experiencing the side eects of medications.
is may be the most common source of associated signs and
symptoms observed depending on the clinical setting. Side
eects of medication as a cause of associated signs and symp-
toms, including joint and muscle pain, will be discussed more
completely in Chapter 2. Visceral pain mechanisms may be
found in Chapter 3
As for comorbidities, many patients/clients are aected by
other conditions such as depression, diabetes, incontinence,
obesity, chemical dependency, hypertension, osteoporosis,
and deconditioning. ese conditions can contribute to sig-
nicant morbidity and mortality and must be documented
as a part of the problem list. Physical therapy intervention
is oen appropriate in aecting outcomes, and/or referral
to a more appropriate health care professional or to another
physical therapist with advanced skills or certications may
be needed.
Movement, physical activity, and moderate exercise aid the
body and boost the immune system,17,18 but sometimes such
measures are unable to prevail, especially if other factors are
present, such as inadequate hydration, poor nutrition, fatigue,
depression, immunosuppression, and stress. In such cases the
condition will progress to the point that warning signs and
symptoms will be observed or reported and/or the patient’s/
client’s condition will deteriorate. For these types of patients,
the need for medical referral or consultation becomes evident
over the episode of care.
REASONS TO SCREEN
ere are many reasons why the therapist needs to screen for
medical disease. Direct access (see denition and discussion
later in this chapter) is only one of those reasons (Box 1.2).
Early detection and referral is the key to prevention of fur-
ther signicant comorbidities or complications. In all prac-
tice settings, therapists must know how to recognize systemic
disease mimicking the clinical presentation of a neuromuscu-
loskeletal condition. is includes practice by physician refer-
ral, practitioner of choice via the direct access model, or as a
primary practitioner.
e practice of physical therapy has evolved over time
since the profession began as Reconstruction Aides. Clinical
practice, as it was shaped by World War I and then World
War II, was eclipsed by the polio epidemic in the 1940s and
1950s. With the widespread use of the live, oral polio vaccine
in 1963, polio was eradicated in the United States and clinical
practice changed again (Fig. 1.2).
Today most clients seen by therapists have impairments,
activity limitations, and participation restrictions that are
clearly NMS-related. Frequently the client history and
5
BOX 1.2 REASONS FOR SCREENING
• Direct access: erapist has primary responsibility or
rst contact.
• Quicker and sicker patient/client base.
• Signed prescription: Clients may obtain a signed pre-
scription for physical/occupational therapy based on
similar past complaints of musculoskeletal symptoms
without direct physician contact.
• Medical specialization: Medical specialists may fail to
recognize underlying systemic disease.
• Disease progression: Early signs and symptoms are dif-
cult to recognize, or symptoms may not be present at
the time of medical examination.
• Patient/client disclosure: Client discloses information
previously unknown or undisclosed to the physician.
• Client does not report symptoms or concerns to the phy-
sician because of forgetfulness, fear, or embarrassment.
• Presence of one or more yellow (caution) or red (warn-
ing) ags.
Fig. 1.2 Patients in iron lungs receive treatment at Rancho
Los Amigos during the polio epidemic of the 1940s and 1950s.
(Courtesy Rancho Los Amigos, 2005).
mechanism of injury point to a known cause of movement
dysfunction.
However, therapists practicing in all settings must be able
to evaluate a patient’s/client’s complaint knowledgeably and
determine whether there are signs and symptoms of a sys-
temic disease or a medical condition that should be evaluated
by a more appropriate health care provider. is text endeav-
ors to provide the necessary information that will assist the
therapist in making these decisions.
Quicker and Sicker
e aging of America has aected general health in signi-
cant ways. “Quicker and sicker” is a term used to describe
patients/clients in the current health care arena (Fig. 1.3).19,20
Another random document with
no related content on Scribd:
the preacher the congregation jumped up and ran out to see what was
toward, so that "there remained few or no people with the preacher."

"'Tis Master Francis Drake come home at last!" All Plymouth went
down to the water's edge to greet their special hero—Drake of Devon!

But Francis Drake had not arrived at a happy moment for himself. Alva
had been offering good terms, and the Queen was surrounded just then by
friends of Spain. Drake's position was one of danger; he might possibly be
given up to Philip as a mere pirate who had not the Queen's sanction. So he
took his ship round to Queenstown and hid in "Drake's Pool."

Time went on, and still politics made his life dangerous; so Drake with a
letter of introduction from Hawkins joined Essex in Ireland. It was a very
cruel and heartless war, even against women and children; and from what
we have seen of Drake's chivalry to women, it must have been most
loathsome to his great soul. However, when he returned to London things
had changed; this time the Queen was very angry with Philip, and she sent
Walsingham to seek out Drake. The Queen was very gracious, and said she
wanted Drake to help her against the King of Spain. How his heart must
have leapt up with a new hope; but the wind of policy veered again, and
nothing came of the interview at first. Still, it was something to have been
introduced to the Queen by Sir Christopher Hatton; and when that lady gave
Drake a sword and said, "We do account that he which striketh at thee,
Drake, striketh at us," he must have felt a proud man.

A man so frank and open as Francis Drake was, must have found it
difficult to follow the shifts and turns of policy. The Queen would not
openly give her sanction to a new expedition, but she secretly aided the
enterprise; and Sir John Hawkins and many others subscribed.

Drake was to sail in the Pelican, 100 tons; Captain Winter in the
Elizabeth, of 80. There were also the Marygold, the Loan, and the
Christopher, a pinnace, of 35 tons. The crews, officers and gentlemen,
amounted to some two hundred.

They sailed from Plymouth on the 15th of November 1577, but a

terrible storm off Falmouth obliged them to put back. They started afresh on
the 13th of December, and were to meet at Mogadore, on the coast of
Barbary. It seems that Burghley did not approve of Drake's bold venture,
and had sent Thomas Doughtie, with secret orders to do what he could to
limit the risks and scope of the expedition. Doughtie was a personal friend
of Drake, and it was some time before Sir Francis found out what Doughtie
was doing—such as tampering with the men and trying to lessen Drake's
influence. When they were near the equator, Drake, being very careful of
his men's health, let every man's blood with his own hands.

In February they made the coast of Brazil, without losing touch of one
another. Here they landed and saw "great store of large and mighty deer."
They also found places for drying the flesh of the nandu, or American
ostrich, whose thighs were as large as "reasonable legs of mutton." Further
south they stored seal-flesh, having slain over two hundred in the space of
an hour! The natives whom they saw were naked, saving only that they
wore the skin of some beast about their waist. They carried bows an ell
long, and two arrows, and were painted white on one side and black on the
other.

They were a tall, merry race; delighted in the sound of the trumpet, and
danced with the sailors. One of them, seeing the men take their morning
draught, took a glass of strong Canary wine and tossed it off; but it
immediately went to his head, and he fell on his back. However, the savage
took such a liking to the draught that he used to come down from the hills
every morning, bellowing "Wine! wine!"

A few days later there was a scuffle at Port Julian with the natives, and
Robert Winter was killed. But a greater tragedy was impending.

Sixty years before, Magellan had crushed a mutiny on this spot, and the
old fir-posts that formed the gallows still stood out on the windy headland.

For some months now Drake had been harassed by mutinous conduct,
and all the evidence pointed to his old friend Doughtie being at the bottom
of it. One day Drake, in a sudden burst of wrath, had ordered Doughtie to
be chained to the mast. Yet, as the ships rode south into the cold winds, the
crews murmured more savagely. Doughtie and his friends were
demoralising Captain John Winter's ship. Something must be done, and
done quickly, if the expedition was not to fail.

On the last day of June the crews were ordered ashore. There, hard by
Magellan's gallows, an English jury or court-martial, with Winter as
president, was set to try Doughtie for treason and mutiny. The court, after
much wrangling, found the prisoner "Not guilty." But Doughtie in the midst
of the trial had boasted that he had betrayed the Queen's secret to Burghley.
Thereat Drake took his men down to the shore and told them all how the
Queen's consent had been privately given, and how Doughtie had done his
best to overthrow their enterprise.

"They that think this man worthy of death," he shouted, "let them with
me hold up their hands." As he spoke almost every man's hand went up.

"Thomas Doughtie, seeing no remedy but patience for himself, desired

before his death to receive the communion, which he did at the hands of
Master Fletcher, our minister, and our general himself accompanied him in
that holy action." Then in quiet sort, after taking leave of all the company,
Doughtie laid his head on the block and ended his life. Then Drake
addressed his men. He forgave John Doughtie, but said all discords must
cease, and the gentleman must haul and draw with the mariner. From that
moment discipline was established, and there were no more quarrels.

The Pelican, the Elizabeth, and the Marygold, the only ships that
remained, now set sail, and on August 20, 1578, hove to before the Straits
of Magellan. It was here that Drake changed the name of his ship to the
Golden Hind, perhaps in compliment to his friend Sir Christopher Hatton,
who bore it in his arms.

So rapid was the passage through the Straits that in a fortnight they had
reached the Pacific. Drake's intention was to steer north and get out of the
nipping cold, but a gale from the north-east came on and lasted three weeks,
when the Marygold went down, and Winter, after waiting a month for
Drake within the Straits, went home. Drake in the Golden Hind was swept
south of Cape Horn, "where the Atlantic Ocean and the South Sea meet in a
large and free scope."
 Drake went ashore, and leaning over a promontory, amused himself by
thinking that he had been further south than any man living.

After anchoring for some time in southern islands, Drake sailed north,
and finding an Indian pilot, steered for Valparaiso.

In the harbour lay a Spanish ship waiting for a wind to carry them to
Panama with their cargo of gold and wine of Chili. When the lazy crew saw
a sail appearing, they made ready to welcome the newcomers with a pipe of
wine, and beat a drum as a merry salute.

No foreign ship had ever been seen on those western coasts; they had no
thought of danger, when a boat drew alongside, and Thomas Moon
clambered up and shouted, "Abaxo perro!" ("Down! you dog!"), and began
to lay about him lustily.

The eight Spaniards and three negroes on board were soon safely
secured under hatches; then they rifled the little town, and took the prize out
to sea for more leisurely search: 1770 jars of Chili wine and 60,000 pieces
of gold and some pearls rewarded their efforts. Drake now wished to sack
Lima and find Winter. Meanwhile he tarried in a hidden bay for a month,
and refreshed his men in a delightful climate.

Then they proceeded slowly along the coast. One day while looking for
water they came upon a Spaniard lying asleep with thirteen bars of silver by
his side. "Excuse us, sir, but we could not really allow you to burden
yourself with all this." Several merry raids of this sort kept the men jolly
and in good temper. Leisurely though the Golden Hind was sailing
northwards, no news had come to Lima of the English rover being on the
sea.

A Portuguese piloted Drake into the harbour of Callao after nightfall,

"sailing in between all the ships that lay there, seventeen in number." These
they rifled, and heard that a ship, the Cacafuego, laden with silver, had just
sailed. As they were getting ready to follow, a ship from Panama entered
the harbour and anchored close by the Golden Hind. A custom-house boat
put off and hailed them, and a Spaniard was in the act of mounting the steps
when he saw a big gun mouthing at him. He was over the side in a moment
and in his boat crying the alarm! The Panama vessel cut her cable and put to
sea, but the Golden Hind followed in pursuit and soon caught her.

In the next few days, as they were following the Cacafuego, they made
a few prizes, which pleased the men vastly; and after crossing the line on
24th February, saw the Cacafuego about four leagues ahead of them.

The Spanish captain slowed down for a chat, as he supposed; but when
Drake hailed them to strike, they refused. "So with a great piece he shot her
mast overboard, and having wounded the master with an arrow, the ship
yielded."

Four days they lay beside her transferring the cargo—gold, silver, and
precious stones—so that the Golden Hind was now ballasted with silver.

The whole value was estimated at 360,000 pieces of gold. Drake gave
the captain a letter of safe conduct in case he should meet his other ships.

"Master Wynter, if it pleaseth God that you should chance to meet with
this ship of Señor Juan de Anton, I pray you use him well, according to my
word and promise given unto them; and if you want anything that is in this
ship, I pray you pay them double the value of it, which I will satisfy again;
command your men not to do her any hurt.... I desire you, for the passion of
Christ, if you fall into any danger, that you will not despair of God's mercy,
for He will defend you and preserve you from all danger, and bring us to
our desired haven: to whom be all honour, glory, and praise, for ever and
ever. Amen.—Your sorrowful captain, whose heart is heavy for you,
FRANCIS DRAKE."

We are told that Robin Hood liked to attend mass every morning, but
even he does not astonish us by his piety so much as this "great dragon" of
the seas. No doubt it was all genuine, and he believed he was only doing his
duty when he robbed King Philip's ships, and thereby weakened his power
for persecuting those who did not agree with him in his religious views.

"They that take the sword shall perish with the sword."
 Francis Drake felt himself commissioned by a greater than Queen
Elizabeth. "I am the man I have promised to be, beseeching God, the
Saviour of all the world, to have us in His keeping "—so he writes in his
letter to Winter.

The question now before them was how to get home. The whole west
coast of America was now alarmed, and the Spaniards would stop him if he
tried to return by the Straits as he came. So Drake called the ship's company
together and took them into counsel. He desired to sail north and find a way
home by the North-west Passage; for he, too, was possessed by that
chimerical idea.

"All of us," writes one of his company, "willingly hearkened and

consented to our general's advice; which was, first, to seek out some
convenient place to trim our ship, and store ourselves with wood and water
and such provisions as we could get; thenceforward to hasten on our
intended journey for the discovery of the said passage, through which we
might with joy return to our longed homes."

On 16th March they made the coast of Nicaragua and effected some
captures. Swooping down upon the little port of Guatuleo, they found the
judges sitting in court, and as a merry change for them, the whole court,
judges and counsel and prisoners, were carried off to the Golden Hind,
where, amid hearty laughter, the chief judge was bidden to write an order
for all the inhabitants to leave the town for twenty-four hours. Then Drake
and his men went ashore and replenished their cupboards from the Spanish
storehouses. The next capture was a vessel containing two Chinese pilots,
who had all the secret charts for sailing across the Pacific.

We may well believe that Drake, as he pored over these in his little
cabin, may have thought to himself, "Why should not we go home that way,
and thus have sailed round the globe?"

On 3rd June they had reached latitude 42° N., and were feeling the cold
extremely. A storm was blowing as they reached Vancouver Island, and
here they turned back, and after turning south ten degrees put into a fair and
good bay, where the white cliffs reminded them of home, probably near San
Francisco.
 The natives came round in their canoes, and one threw a small rush
basket full of tabah, or tobacco, into the ship's boat.

Tents were put up on the shore and fortified by stones, but the red folk
who assembled seemed to be worshipping the strangers as gods. Presents
were exchanged, but their women "tormented themselves lamentably,
tearing chest and bosom with their nails, and dashing themselves on the
ground till they were covered with blood." Drake at once ordered all his
crew to prayers. The natives seemed to half-understand the ceremony, and
chanted a solemn "Oh!" at every pause.

Next day the great chief came with his retinue in feathered cloaks and
painted faces. The red men sang and the women danced, until the chief
advanced and put his coronet on Drake's head. These people lived in
circular dens hollowed in the ground; they slept upon rushes round a central
fire. The men were nearly naked; the women wore a garment of bulrushes
round the waist and a deer-skin over the shoulders.

When at the end of July the Golden Hind weighed anchor, loud
lamentations went up and fires were lit on the hilltops as a last sacrifice to
the divine strangers. For sixty-eight days they sailed west and saw no land;
then they came to islands where the natives pilfered; then they made the
Philippines, and in November the Moluccas. Drake anchored at a small
island near Celebes, east of Borneo, and spent four weeks in cleaning and
repairing his ship. Here they saw bats as big as hens, and land-crabs, "very
good and restoring meat," which had a habit of climbing up into trees when
pursued.

As they sailed west they got entangled among islands and shoals, and on
the 9th of January 1579 they sailed full tilt upon a rocky shoal and stuck
fast.

Boats were got out to find a place for an anchor upon which they might
haul, but at the distance of a boat's length they found deep water and no
bottom. The ship remained on the shoal all that night. First they tried every
shift they could think of, but the treasure-laden vessel refused to budge.
Then Drake, seeing all was hopeless, and that not only the treasure, but all
their lives, were likely to be lost, summoned the men to prayers. In solemn
preparation for death they took the Sacrament together.

Then, when the ship seemed fast beyond their strength to move her,
Drake, with the same instinct that prompted Cromwell after him to say,
"Trust in God, but keep your powder dry," gave orders to throw overboard
eight guns.

They went splash into the six feet of water by the side, and the ship took
no notice at all; so Drake, with a sigh, cried, "Throw out three tons of
cloves—sugar—spices—anything;" till the sea was like a caudle all around.
And the Golden Hind still rested quietly on the shelving rock, with only six
feet of water on one side, whereas it needed thirteen to float her. The wind
blew freshly and kept her upright as the tide went down. The crew began to
look curiously at one another, and to wonder what would happen when all
their food was consumed.

At the lowest of the tide the wind suddenly fell, and the ship losing this
support, fell over sideways towards the deep water.

So they were to be drowned after all, for she must fill now.

No; there was a harsh scraping sound heard. Could it be possible? Yes;
her keel was slipping down the slope very gently and mercifully.

What a shout these sea-worn mariners raised; how they thanked God for
this salvation; for the relief had come at low tide, when all their efforts
seemed to be useless. Surely it was a miracle—an answer to their captain's
prayers. On reaching Java, Drake was informed that there were large ships
not far off—Portuguese settlements were rather too near to be safe; so he
steered for the Cape of Good Hope, which his men thought "a most stately
thing, and the fairest cape they had seen in the whole circumference of the
earth."

As the Golden Hind sailed along by Sierra Leone and towards Europe,
the great sea rover must have felt that the prayer he had breathed within the
mammoth tree on Darien six years before was at last fulfilled.
 He had sailed the South Sea and crossed the Pacific and made the
compass of the round world in the Golden Hind within three years.

As they reckoned, when nearing Plymouth Sound, it was Monday,

September 25, 1580, but within an hour they learnt that they had arrived on
Sunday.

No one expected them; no one at first realised what vessel it was that
came silently to anchorage, heavy and slow from the barnacles and weeds;
for the news had come home that Drake had been hanged by the Spaniards.
But only in August last, Mendoza, the Spanish ambassador, had come to
Burghley with a wild tale sent him by the Viceroy of Mexico, that El
Draque had been ravaging the Pacific, and playing the pirate amongst King
Philip's ships. The Queen pretended she knew nothing about it, and pacified
the ambassador by seeming to agree with him that Drake was a very
naughty man indeed. So, when the Golden Hind dropped her anchor, a few
friends took boat and told her captain how things were going at Court.

Drake's blue eyes at first looked steely. Had he sailed round the world
and brought all this treasure home to be given over to Spain?

But a moment's thought brought a merry twinkle into those eyes, and he
gave a sharp order: "Up with the anchor, there! Warp her out behind St.
Nicholas Island!"

If he must be treated as a pirate, then they must catch him if they can.
"You will take my excuses to the Mayor, and tell him how gladly I would
land; but you have the plague, I hear, at Plymouth; our constitutions are
hardly strong enough to bear an attack of plague."

Meanwhile a messenger was sent by Drake post-haste to London, with

gifts for the Queen and Burghley; then a visit from Drake's wife and some
friends made the time pass pleasantly enough. Yet it was somewhat galling
to the brave adventurer to have to wait a week for tidings as to whether he
was to lose his head for piracy, or win a Queen's admiration for performing
a great feat of seamanship. At last a summons to Court was brought to
Plymouth. Drake, of course, obeyed the Queen's command, but he did not
venture to London alone. Many friends rode with him, and no doubt they
enjoyed themselves, as sailors will, on their long journey, especially when
they came to Sherborne Castle and Sir Walter Raleigh. A long train of pack-
horses followed, laden with delicate attentions for royal ladies. Just as he
was drawing near London, the news came that Philip had seized Portugal
and was posing as the master of the world. Still more startling news came
that a Spanish force had landed in Ireland. The Council were half disposed
to make peace on any terms, when Drake came stalking in amongst the
half-hearted courtiers.

The Queen saw him, heard the strange story of his madcap adventures,
caught the audacious spirit of her bravest seaman, and stood firm against
the timid proposers of peace. Besides, she was simply charmed by the
lovely presents he offered her, and sent Drake back to Plymouth with a
private letter under her sign-manual, ordering him to take ten thousand
pounds worth of bullion for himself. The rest was sent up to the Tower, after
the crew had received their share. Then Drake brought the Golden Hind
round and up the Thames for all the town to gape and wonder at, while the
crew swaggered about the streets of Deptford like little princes; and so the
news of the great treasure flew from city to hamlet, and from hill to vale,
increasing with the miles it posted.

The Queen ordered that Drake's ship should be drawn up in a little creek
near Deptford, and there should be kept as a memorial for ever.

Then, the more to honour her champion, she went on board and partook
of a grand banquet under an awning on the main deck. "Francis Drake,
kneel down." The sword was lightly placed on his shoulder, and he rose "Sir
Francis."

The Golden Hind remained at Deptford, as a show vessel that had been
round the world, until it dropped to pieces. From one of its planks a chair
was made and presented to the University of Oxford.

Thus the politics of England were influenced by a seaman—a hero who

knew not fear, and who dared to say what he thought, even though it was to
his Queen.
 CHAPTER X

SIR FRANCIS DRAKE, THE QUEEN'S GREATEST

SEAMAN

When people saw the Queen pacing up and down the paths with Sir
Francis Drake in Greenwich Gardens, and heard her laugh heartily as she
stopped with her hand to her side, they knew he was entertaining her with
stories of his mad adventures in the Pacific, bracing her to resist Mendoza
and King Philip, and putting tough spokes in many of the wheels of his
Holiness the Pope.

Twice had Mendoza asked for an audience, but no, Elizabeth had no
wish to talk about returning all those pretty jewels and the muckle treasure,
now safely stored in the strong-rooms at the Tower.

The little stout seaman, with the crisp brown hair and high, broad
forehead, the small ears, and grey-blue eyes lit with merriment, and
sometimes with fiery wrath, seemed to have won for a time his Queen's full
confidence.

The palace servants stared with awe at the bronzed and bearded face,
and the loose seaman's shirt belted at the waist and the scarlet cap braided
with gold. For they recognised in the wearer a king of men—one who could
make a nation of traders into great conquerors, and who might, if only he
were allowed, convert a small island into a worldwide empire.

Drake was teaching the Queen and her ministers the uses of a strong
navy. Elizabeth had always been proud of her royal ships, but she was apt to
treat them like her best china, and liked to see them securely placed on
some high shelf, where they would not be broken. She had often written to
her captains and admirals to be prudent and take no risks—"Don't go too
near any batteries—don't let my ships catch fire—do be careful."

Now Drake was instructing her in the art and policy of taking risks. And
the Queen, as she looked down upon her jewelled dress, found merry Sir
Francis a very incarnate fiend to tempt her out of her devious ways of
caution and political jugglery—for a time, at least.

Now Terceira, one of the Azores, refused to recognise the Spanish

conquest, and Don Antonio, who had been hunted from the throne of
Portugal, was now in Paris and imploring help against Philip.

"Here, madam," we may fancy Drake saying, "is a splendid opening for
your honest seamen. Terceira lies on the direct road of the fleets coming
home both from the East and West Indies. Permit your humble servant to
seize this island as a base, and we will destroy the trade of Spain, and
thereby secure this island-realm from Spanish invasion."

Walsingham was on Drake's side. Hawkins and Drake were preparing

the fleet, courtiers and merchants were subscribing, and brave young
noblemen were offering to serve on board. Fenton and Yorke, Frobisher's
trusty lieutenants, had command of ships; Bingham, Carleill, and many
others were getting ready; Don Antonio had come over secretly; and all had
been arranged.

But the admirals waited in vain for the order to sail. Was the Queen
losing heart, fearing the perilous risk? trying to make terms with King
Philip instead of fighting him?

Drake began to swear very loud, especially when he received a scolding

letter from the Queen, because he had spent two thousand pounds more than
the estimate. Officers, having nothing to do, began to be quarrelsome; many
resigned their commissions; and at last the expedition was broken up.

The Queen was waiting until she could get France on her side. She
thought Drake's idea too risky, so she let him be chosen Mayor of
Plymouth, just to keep him busy with plans for defence.
 Drake had a great sorrow this year, as well as a bitter disappointment,
for his wife fell ill and died. To add to his anxieties, King Philip had offered
forty thousand pounds reward to any who would kidnap and stab the British
corsair. John Doughtie, the brother of that Thomas whom Drake had tried
by court-martial for treason, was approached; and out of revenge, though
Drake had once forgiven him his share in the treason, John embraced the
opportunity to get rich and rid himself of an enemy.

Unfortunately for him John Doughtie could not help boasting of what he
was going to do. His arrest was obtained from the Council, and he spent the
remainder of his life in some discomfort and squalor in one of her Majesty's
prisons.

So the months went by, and Drake became member for Bossiney or
Tintagel, and made some fiery speeches at Westminster, where they began
to believe that an invasion was really possible—nay, if Drake thought so,
even probable.

In February 1585 he married Elizabeth Sydenham, a Somersetshire

heiress; but news came at the end of May that Philip had invited a fleet of
English corn-ships to relieve a famine in Spain, and then had seized the
ships.

This was too bad. This was to imitate Drake a little too closely.

Everybody, from the Queen to the newest cabin-boy, felt that such an
outrage must be severely dealt with.

By the end of July Sir Francis received letters of marque to release the
corn-ships, and hoisted his flag in the Elizabeth Bonaventure, with
Frobisher for his vice-admiral and Carleill as lieutenant-general with ten
companies of soldiers under his command. The squadron consisted of two
battleships and eighteen cruisers, with pinnaces and store-ships. There were
two thousand three hundred soldiers and sailors, and it was no easy matter
to get stores for so many. Before Drake could get away Sir Philip Sidney
came down to Plymouth with the intention of joining the expedition.
 Drake remembered too well how unpleasant the presence of courtiers
had been on a former voyage, and he secretly sent off a messenger to Court,
asking if Sir Philip had the Queen's permission to join.

The Queen replied by ordering her naughty courtier back to Greenwich,

and Drake sailed for Finisterre, though still short of supplies.

Resolved to get water and provisions before he started on his long

voyage, he ran into Vigo Bay and anchored under the lee of the Bayona
Islands.

His officers were dismayed at their leader's effrontery. Does he wish to

let all Spain know what he is about to do?

But Drake knew that this very insolence would paralyse the hearts of
the foe. He ordered out the pinnaces and so frightened the governor that he
offered the English water and victuals; wine, fruit, and sweetmeats were
also sent, as if the Spaniards had been entertaining their best friends.

A three days' storm compelled the ships to go up above Vigo, and there
many caravels laden with goods were taken by Carleill.

On 8th October Drake sailed for the Canaries, while the Spanish Court
was buzzing with rumours, and the Marquis of Santa Cruz advised his
master that a fleet should sail out in pursuit of the English, before they
sacked Madeira, the Canaries, and the Cape de Verde Islands, or crossed the
Atlantic and did worse.

However, the Spaniards, as is their custom, took a long time to get

ready, and Drake passed by the Canaries and pounced upon Santiago, the
chief town of the Cape de Verde Islands, where William Hawkins had been
treacherously attacked some years before. They seized the town easily and
stayed there a fortnight, the inhabitants having fled inland, and much they
enjoyed the pleasant gardens and orchards. All might have gone well, and
no great damage done, had not some Spaniards seized and killed an English
boy and shamefully treated his body; for they found him lying dead, with
his head severed and his heart and bowels scattered about in savage manner.
 This so enraged the men that they set fire to all the houses except the
hospital, and left in various places a paper declaring the reason why they
had so acted.

The English had not been many days at sea when a disease broke out,
and in a few days over two hundred men had died. A hot burning, and
continual agues seized the sick, followed by decay of their wits and strength
for a long time.

In some there appeared small spots as of the plague; but in eighteen

days they came to the island of Dominica, inhabited by savage people
whose naked skins were painted tawny red; strong, well-made fellows, who
very kindly helped to carry fresh water from the river to the boats. They
brought also, and exchanged for glass and beads, a great store of tobacco
and cassava bread, very white and savoury.

Thence the English went on to St. Christopher's, a desert island, where

they spent Christmas, refreshed the sick, and cleansed their ships.

Then they sailed for Hispaniola and the city of St. Domingo, the largest
Spanish city in the New World, founded by Columbus in 1496.

Drake learned from a frigate that it was a barred harbour commanded by

a strong castle, but that there was a landing-place two miles to the westward
of it.

About 150 horsemen opposed them, but the English ran in so fast that
the Spaniards had only time to fire one volley and flee. There was no gold
or silver, only copper money, but good store of fine clothes, wine and oil.
The native Indians had all been killed by the cruelty of the Spaniards, and
the work in the mines was stopped.

Drake ordered the troops to entrench themselves in the Plaza, or Square,

and to occupy the chief batteries; so he held the city for a month.

Two hundred and forty guns were taken and put on board the English
ships, and a ransom equal to fifty thousand pounds of our money was
exacted. A great fleet of Spanish ships was burnt, and hundreds of galley-
slaves were set free, to their surprise and delight.

Thence Drake sailed for Cartagena on the mainland, the harbour of

which he knew as well as any local pilot. The fleet entered about three in
the afternoon without meeting any resistance. In the evening Carleill landed
about three miles west of the town; the idea being that the land forces
should advance at midnight along the shore, while the fleet drew the
attention of the Spaniards by a false attack upon a fort in the inner haven.

Some hundred horsemen met the troops, but hastened back to give the
alarm. Then the soldiers under Carleill came to the neck of the peninsula on
which the town was built. On one side was the sea, on the other a lake
communicating with the harbour. The narrow roadway was fortified across
with a stone wall and ditch, and the usual passage was filled up with barrels
full of earth, behind which were placed six great guns, while two great
galleys had been moored with their prows to the shore, carrying eleven
guns, to flank the approach, and containing three hundred harquebusiers.
The barricade of barrels was defended by some three hundred musketeers
and pikemen.

The Spaniards fired in the dark down the causeway, but the English
were marching close to the water's edge on lower ground and got no hurt.
Then they clambered up the sides of the neck and assaulted the barricade.
"Down went the butts of earth, and pell-mell come our swords and pikes
together, after our shot had given their first volley, even at the enemy's
nose."

The English pikes were longer than those of the Spaniards, so the latter
soon gave way, and were followed with a rush into the town, where other
barricades erected at every street's end had to be carried with yell and blow.

The Spaniards had stationed Indian archers in corners of advantage,

"with arrows most villainously empoisoned." Some also were wounded in
the fort by small stakes having the point poisoned. But when the city was
taken divers courtesies passed between the two nations, and they met at
feasts, so that the Governor and Bishop came to visit Sir Francis on his
ship, finding him very merry and polite.
 Cartagena yielded rich loot for the men, and for the merchants and
courtiers who had taken shares a ransom of 110,000 ducats came in as a
comfortable bonus.

By the end of April they were off Cuba and in want of water. After
search they found some rain-water newly fallen. Here, we are told, Sir
Francis set a good example to the men by working himself in his shirt
sleeves. We can see how conduct like this endeared him to his men; for they
said, "If the general can work with us in his shirt, we may well do our best."

"Throughout the expedition," says Gates, "he had everywhere shown so

vigilant care and foresight in the good ordering of his fleet, together with
such wonderful travail of body, that doubtless had he been the meanest
person, as he was the chiefest, he had deserved the first place of honour."

On reaching Florida they took Fort St. Augustine and a treasure-chest;

then they sailed north and sought Raleigh's colony in Virginia, whom they
brought home. "And thus, God be thanked, both they and wee in good
safetie arrived at Portsmouth the 2nd of July 1586, to the great glory of
God, and to no small honour to our Prince, our Countrey, and our selves."

Some seven hundred and fifty men were lost on the voyage, most of
them from the calenture or hot ague. Two hundred and forty guns of brass
and iron were taken and brought home.

Sir Francis wrote at once to Burghley reporting his return. He

apologised for having missed the Plate fleet by only twelve hours' sail
—"The reason best known to God;" but affirmed he and his fleet were
ready to sail again whithersoever the Queen might direct.

But the Faerie Queen was much harassed just now and affrighted; for
the Babington plot to assassinate her had just been revealed, and it was
known that Philip was making ready to spring upon England from Portugal
and the Netherlands. Mary Stuart was in prison, and France for her sake
was threatening war. So the Queen pretended to disavow the doings of Sir
Francis and his men. No peerage or pension for him now, lest Philip should
sail and invade her territory.
 Drake understood the moods of his intriguing mistress, shrugged his
strong shoulders and played a match at bowls on the Hoe.

But, if England was backward in applauding the hero, his name and
exploits were being celebrated wherever the tyranny of Rome was feared or
hated.

The Reformation had been losing ground latterly, the Netherlands still
held out, but their strength of endurance was nearly spent.

Then came the startling news that the English Drake had again flouted
and crushed the maritime power of Spain. Not only had he weakened her
for actual warfare, but her prestige was shaken by his exploits, and the
banks of Seville and Venice were on the verge of ruin. Philip found himself
unable to raise a loan of half a million ducats.

The sinews of war were cracked by this sea-rover, who was raising the
hopes of Protestant Europe once more, and winning the clamorous applause
of the west country openly, and of Burghley in private.

"This Drake is a fearful man to the King of Spain!" he could not help
confessing, though he wondered if England would not be obliged to give
him up to the wrath of Philip. War was so expensive, to be sure! Then, to
the delight of Elizabeth and the consternation of all true Catholics, Philip
wrote and accepted the Queen's timorous excuses.

The King of Spain was not quite ready for war. Drake's condign
punishment must be deferred for a season; there was a time for all things.
Meanwhile Drake with Sir William Winter had been employed in getting
ships ready and watching the narrow seas.

As autumn waned and no Armada came, the Queen summoned the bold
sea-rover to Court, and once more she listened to his brave words, feeling
almost convinced that boldness in action was safer than a crooked
diplomacy.

Anyhow she sent Sir Francis over on a secret mission to the Low
Countries, where he was everywhere received almost with royal honours,
and had conferences with leaders in all the great Dutch cities.

But in November Leicester returned to England, a confession of failure,

and in January the fort of Zutphen was betrayed to the Spaniards.

Again the scene shifted and the characters changed; for when Drake
returned to England, Walsingham gave him the cheering news that the
Queen's eyes were at last opened. He had shown her a paper taken from the
Pope's closet which proved that all Philip's preparations in port and harbour
and storehouse were intended solely for her destruction and the religious
education of her heretic realm. Then she flashed out in patriotic spirit and
threw economy to the winds.

Sir Francis Drake was made her Majesty's Admiral-at-the-Seas, and

William Burrows, Comptroller of the Navy, esteemed to be the most
scientific sea officer in England, was selected as his Vice-Admiral.

The people cheered and sang and made ready to fight for hearth and
home. One favourite stanza was that which had been nailed to the sign of
the Queen's Head Tavern at Deptford—

"O Nature! to old England still

Continue these mistakes;
Still give us for our King such Queens,
And for our Dux such Drakes."

Drake's commission was to prevent the joining together of the King of

Spain's ships out of their several ports, to keep victuals from them and to
follow any ships that should sail towards England or Ireland.

On the 2nd of April Sir Francis Drake wrote to Walsingham to say all
was ready for starting. "I thank God I find no man but as all members of
one body, to stand for our gracious Queen and Country against Anti-Christ
and his members."
 We always see that with Drake the motive for war was a religious
motive; it was to secure religious freedom of thought and put down the
Inquisition.

He ends thus: "The wind commands me away; our ship is under sail.
God grant we may so live in His fear, as the enemy may have cause to say
that God doth fight for her Majesty as well abroad as at home ... let me
beseech your Honour to pray unto God for us, that He will direct us the
right way."

Besides the Elizabeth Bonaventure, which Drake commanded, Captain

William Burrows as Vice-Admiral was in the Golden Lion, Fenner in the
Dreadnought, Bellingham in the Rainbow—these all Queen's ships.

The Merchant Royal was sent by the London citizens; the rest were
given by voluntary subscribers and private persons. There were twenty-
three sail in all, and the soldiers and sailors numbered 2648.

But while Drake was busy at Plymouth making ready for the voyage,
paid emissaries of Philip and those who hated Walsingham and the
Reformation were busy with the Queen, frightening her with threats of
foreign interference; so that she absolutely turned round again and issued an
order that all warlike operations were to be confined to the high seas.
Philip's ships being all snug in port, Drake's fleet would have nothing to do,
and no captures to win, if he merely sailed up and down the coast.

Swiftly rode the Queen's messenger, spurring from Surrey to

Hampshire, from Dorset to Devon, with many a change and relay of
smoking steeds.

The messenger knew well the purport of the fateful order: "You shall
forbear to enter forcibly into any of the said King's ports or havens, or to
offer violence to any of his towns or shipping within harbour, or to do any
act of hostility upon the land." The messenger and his armed escort had
been ordered to gallop in all haste, and they entered Plymouth and
dismounted before the Admiral of the Port. "In the Queen's name! a
despatch for Sir Francis Drake."