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Swansons
FAMILY MEDICINE
REVIEW
A PROBLEM - ORIENTED APPROACH

Alfred F. Tallia
Joseph E . Scherger
Nancy W. Dickey *

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Swanson’s
FAMILY MEDICINE
REVIEW
Swanson’s
FAMILY MEDICINE
REVIEW8th Edition A PROBLEM-ORIENTED APPROACH

Editor-in-Chief

Alfred F. Tallia, Professor and Chair

Family Medicine and Community Health
MD, MPH Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Co-Editors

Joseph E. S
­ cherger, Vice President, Primary Care
Marie E. Pinizzotto, MD Chair of Academic Affairs
MD, MPH Eisenhower Medical Center
Rancho Mirage, California

Nancy W. ­Dickey, President Emerita, Texas A&M Health Science Center

Professor, Family and Community Medicine
MD Professor and Interim Chair, Clinical and Translational
Medicine
Executive Director, Rural and Community Health Institute
Texas A&M Health Science Center College of Medicine
College Station, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

SWANSON’S FAMILY MEDICINE REVIEW, EIGHTH EDITION ISBN: 978-0-323-35632-9

Copyright © 2017 by Elsevier, Inc. All rights reserved.

Previous editions copyrighted 2013, 2009, and 2003

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechan-
ical, including photocopying, recording, or any information storage and retrieval system, without permission in
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sions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

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our understanding, changes in research methods, professional practices, or medical treatment may become
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Library of Congress Cataloging-in-Publication Data

Names: Tallia, Alfred F., editor. | Scherger, Joseph E., editor. | Dickey,
Nancy, editor.
Title: Swanson’s family medicine review : a problem-oriented approach /
editor-in-chief, Alfred F. Tallia, co-editors, Joseph E. Scherger, Nancy
W. Dickey.
Other titles: Family medicine review
Description: 8th edition. | Philadelphia, PA : Elsevier, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2015049807 | ISBN 9780323356329 (pbk. : alk. paper)
Subjects: | MESH: Family Practice | Examination Questions
Classification: LCC RC58 | NLM WB 18.2 | DDC 616.0076--dc23 LC record available at
­http://lccn.loc.gov/2015049807

Content Strategist: Suzanne Toppy

Content Development Specialist: Janice Gaillard
Publishing Services Manager: Patricia Tannian
Project Manager: Ted Rodgers
Design Direction: Amy Buxton

Printed in United States of America

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

 To the lasting memory of
Dr. Richard Swanson
An extraordinary physician and educator
Contributors

Lani K. Ackerman, MD Noemi C. Doohan, MD, PhD

Associate Professor Family Physician
Family Medicine Ukiah Valley Medical Center
Texas A&M Health Science Center College Ukiah, California
of Medicine,
College Station, Texas Kinder Fayssoux, MD
Family physician Center for Family Medicine
Scott and White Clinic Eisenhower Medical Associates,
College Station, Texas La Quinta, California

Adity Bhattacharyya, MD, FAAFP Negin Field, MD

Assistant Professor Resident Physician
Family Medicine and Community Health Family Medicine
Rutgers Robert Wood Johnson Medical School Eisenhower Medical Center
New Brunswick New Jersey Rancho Mirage, California

Michael Bogey, MD Kory Gill, DO

Emergency Medicine Program Director
Eisenhower Medical Center, Family Medicine and Sports Medicine
Rancho Mirage, California Texas A&M Health Science Center College of Medicine
Family Medicine Residency
Robert Chen, MD College Station, Texas
Clinical Assistant Professor
Family Medicine and Community Health David F. Howarth, MD, MPH
Rutgers Robert Wood Johnson Medical School Associate Professor of Family Medicine
New Brunswick, New Jersey Department of Family Medicine and Community
Health Director of Geriatric Training
Amanda Curnock, MD Rutgers Robert Wood Johnson Medical School
Physican and Co-Director Argyros 365 Primary care New Brunswick, New Jersey
Eisenhower Medical Center
La Quinta, California Alexandra G. Ianculescu, MD, PhD
Resident Physician
André de Leon, MD, MS Internal Medicine
Core Faculty Eisenhower Medical Center
Non-Surgical Sports Medicine/Family Medicine Rancho Mirage, California
Eisenhower Family Medicine Residency
Rancho Mirage, California Glenn M. Jabola, MD
Family Medicine
Tate de Leon, MD, MS Eisenhower Medical Center
Core Faculty Rancho Mirage, California
Family Medicine
Eisenhower Family Medicine Residency James D. King II, MD
Rancho Mirage, California Primary Care and Sports Medicine
Baylor Scott & White
Nancy W. Dickey, MD College Station, Texas
President Emerita, Texas A&M Health Science Center Orthopedist
Professor, Family and Community Medicine Baylor Scott and White Healthcare
Professor and Interim Chair, Clinical and Translational College Station, Texas
Medicine
Executive Director, Rural and Community Health Martha Lansing, MD
Institute Associate Professor and Vice Chair
Texas A&M Health Science Center College of Medicine Family Medicine and Community Health
College Station, Texas Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey

Anna Lichorad, MD
Assistant Professor
Family Medicine
Texas A&M College of Medicine,
Bryan, Texas
Benjamin Mahdi, MD, MPH
Family Medicine
Eisenhower Medical Center
Rancho Mirage, California
Laura E. Marsh, MS, MD, CAQSM
Clinical Associate Professor
Family Community Medicine
Texas A&M Health Science Center
Bryan, Texas
Physician
Central Texas Sports Medicine and Orthopaedics
Bryan, Texas
Barbara Jo McGarry, MD
Associate Professor
Family Medicine and Community Health
Program Director, Family Medicine Residency
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey
Carmen Morales-Litchard, MD
Universidad Xochicalco
Tijuana, Mexico
Family Medicine
Eisenhower Medical Center
Palm Desert, California
Gregory A. Pecchia, DO
Staff Physician
Family and Geriatric Medicine
Eisenhower Medical Center
Rancho Mirage, California
Director
Eisenhower Wellness Institute
Eisenhower Medical Center
La Quinta, California
Bhavika Shivlal Rakholia, BA, MD
Resident Physician
Family Medicine
Eisenhower Medical Center
Rancho Mirage, California
Joshua J. Raymond, MD, MPH
Assistant Professor
Family Medicine and Community Health
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey
C o n tr i b u to rs vii
Damoun A. Rezai, MD
Resident Physician
Family Medicine
Eisenhower Medical Center
La Quinta, California
Beatrix Roemheld-Hamm, MD, PhD
Professor
Family Medicine and Community Health
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey
Joseph E. Scherger, MD, MPH
Vice President, Primary Care
Marie E. Pinizzotto, MD Chair of Academic Affairs
Eisenhower Medical Center
Rancho Mirage, California
John F. Simmons, MD
Assistant Professor
Family Medicine
Director of the Advanced Obstetrical Track
Texas A&M Family Medicine Residency
Bryan, Texas
Alex Spinoso, MD
Family Medicine
Eisenhower Medical Center
Rancho Mirage, California
Maureen Strohm, MD, MSEd
Vice President of Graduate Medical Education/DIO
HCA Far West Division
Henderson, Nevada
Alfred F. Tallia, MD, MPH
Professor and Chair
Family Medicine and Community Health
Rutgers Robert Wood Johnson Medical School,
New Brunswick, New Jersey
K. Douglas Thrasher, DO, FAAFP
Chairman
Department of Family Medicine
Eisenhower Medical Center
La Quinta, California
Sangeetha Vinayagam, MD
Family Medicine
Eisenhower Medical Center
Rancho Mirage, California
Preface
This is the eighth edition of Swanson’s Family Medicine
Review. As an enduring and marvelous educational tool
for several generations of clinicians, this text is a testi-
mony to the founding genius of Dr. Richard Swanson,
the family physician who gave birth to the Review. The
text continues to be not only an effective tool for family
physicians preparing for certification or recertification,
but also an excellent review for clinicians simply desiring
to hone their familiarity with the basic concepts pertinent
to primary care.
The primary goals of the eighth edition are to update
the content and retain the special essence that made
previous editions such valued and popular educational
instruments. The book is divided into 11 sections. Ten
represent a clinical area of Family Medicine, while the
eleventh section is a popular illustrated review.
Each section contains chapters covering specific sub-
jects relevant to that section. Each chapter presents clini-
cal cases that simulate actual clinical situations, providing
the learner with a sense of reality designed to enhance
retention of content. Each clinical case is followed by
questions concerning diagnosis and management. The
question section is followed by an answer section, which
provides a detailed discussion relevant to each question.
Finally, each chapter contains a short summation of key
learning points and selected readings and references,
including websites. This time tested learning methodol-
ogy is designed to increase retention and to expand and
refine the reader’s knowledge of the diagnostic methods,
therapeutics, and patient management techniques pre-
sented by each case.
As with the previous edition, distinguished family
physicians Nancy W. Dickey, MD, President Emerits
of the Texas A&M Health Science Center and professor
of family and community medicine in the Texas A&M
College of Medicine, and Joseph E. Scherger, MD, MPH,
Vice President for Primary Care and Academic Affairs
at Eisenhower Medical Center and founding dean of the
Florida State University College of Medicine, served as
my co-editors on this edition. As a team, we reviewed
the chapters and case problems for relevance, and chose
areas of emphasis and ways to organize the content. We
selected the content to reflect the broad core of knowl-
edge required of every family physician. We also received
valuable input from other family medicine clinicians with
special expertise in specific content areas.
We recruited as chapter authors the finest practicing
family medicine experts from academic centers across
the United States. They reaffirmed and updated chapter
content on the basis of thorough needs analyses, includ-
ing opinions of readers, participants, and faculty in live
continuing medical education conferences, expert opin-
ion, and other accepted methodologies. The editors and
authors anticipate that the reader will both enjoy and
profit from the work that went into preparing this vol-
ume. Happy studying and learning!
Alfred F. Tallia, MD, MPH
Editor-in-Chief
Acknowledgments
As editor-in-chief, I am indebted to many individuals
for their support and assistance in the preparation of
the eighth edition of Swanson’s Family Medicine Review.
To begin, I wish to thank my two co-editors, Nancy W.
Dickey, MD, and Joseph E. Scherger, MD, MPH, for
their hard work and understanding.
Collectively, we would like to thank our spouses, Eliz-
abeth Tallia, Carol Scherger, and Frank Dickey; and our
entire families, as well as those of the authors, for their
sacrifice of time and their understanding as we prepared
this edition.
Thanks to Janice Gaillard, Suzanne Toppy, Ted
­ odgers, and the staff at Elsevier for their inspiration and
R
support. Finally, much gratitude to our colleagues in the
academic and clinical communities that we call home for
their help and understanding of the demands that prepa-
ration of this edition required.
Alfred F. Tallia, MD, MPH
Editor-in-Chief
Contents

SECTION ONE 22 Acute Coronary Symptoms and Stable Angina

Family, Community, and Population Health 1 Pectoris 99
Tate de Leon, Benjamin Mahdi
1 Family Influences on Health and Disease 1
23 
Hyperlipoproteinemia 106
Martha Lansing
K. Douglas Thrasher
2 Clinical Decision Making 4
24 
Heart Failure 113
Martha Lansing
Joseph E. Scherger, Alexandra G. Ianculescu
3 Consultation and Team Care 12
25 
Hypertension 119
Martha Lansing
Kinder Fayssoux, Sangeetha Vinayagam
4 Managing Multiple Morbidities 15
26 
Dysrhythmia 125
Martha Lansing
Joseph E. Scherger, Alexandra G. Ianculescu
5 
Quality Improvement 18
27 Deep Venous Thrombosis and Pulmonary
Martha Lansing
Thromboembolism 128
6 
Clinical Prevention 21 Alfred F. Tallia
Martha Lansing
28 Chronic Obstructive Pulmonary Disease 132
7 
Tobacco Dependency 25 Robert Chen, Joshua J. Raymond
Martha Lansing
29 
Asthma 139
8 
Alcohol 30 Alfred F. Tallia
Martha Lansing
30 The Diagnosis and Management of Community-
9 Diet, Exercise, and Obesity 37 Acquired Pneumonia in the Adult 150
Martha Lansing Alfred F. Tallia
10 Trends in Cancer Epidemiology 41 31 
Esophageal Disorders 154
Martha Lansing Alfred F. Tallia
11 
Cardiovascular Epidemiology 44 32 Peptic Ulcer Disease 160
Martha Lansing Alfred F. Tallia
12 
Bioterrorism 48 33 Hepatitis and Cirrhosis 164
Martha Lansing Alfred F. Tallia
13 Influenza and Other Emerging Diseases 52 34 
Pancreatitis 170
Martha Lansing Alfred F. Tallia
35 
Pancreatic Carcinoma 173
SECTION TWO
Alfred F. Tallia
Communication 59
36 Biliary Tract Disease 176
14 
Domestic Violence 59 Alfred F. Tallia
K. Douglas Thrasher 37 Inflammatory Bowel Disease 180
15 How to Break Bad News 63 Alfred F. Tallia
Maureen Strohm 38 Irritable Bowel Syndrome 185
16 The Physician-Patient Relationship 68 Barbara Jo McGarry, Beatrix Roemheld-Hamm
Joseph E. Scherger 39 
Acute Appendicitis 188
17 
Palliative Care 72 Alfred F. Tallia
Joseph E. Scherger 40 Colorectal Cancer and Other Colonic Disorders 193
18 Ethical Decision-Making Issues 77 Alfred F. Tallia
Joseph E. Scherger 41 
Diabetes Mellitus 200
19 
Integrative Medicine 83 Alfred F. Tallia
Joseph E. Scherger, Michael Bogey 42 
Thyroid 217
20 
Cultural Competence 88 Alfred F. Tallia
Joseph E. Scherger 43 Common Endocrine Diseases 225
Alfred F. Tallia
SECTION THREE
44 Immune-Mediated Inflammatory Disorders and
Adult Medicine 93
Autoimmune Disease 231
21 Acute ST-Segment Elevation Myocardial Joseph E. Scherger
Infarction 93 45 Human Immunodeficiency Virus Infection 235
Tate de Leon, Benjamin Mahdi Joseph E. Scherger
 C ontents xi

46 
Multiple Sclerosis 243 71 Vulvovaginitis and Bacterial Vaginosis 370
Joseph E. Scherger, Alexandra G. Ianculescu Adity Bhattacharyya
47 
Fibromyalgia 247 72 
Cervical Abnormalities 376
Joseph E. Scherger Adity Bhattacharyya
48 Chronic Fatigue Syndrome 252 73 Premenstrual Syndrome and Premenstrual Dysphoric
Joseph E. Scherger, Bhavika Shivlal Rakholia Disorder 382
49 
Rheumatoid Arthritis 257 Adity Bhattacharyya
Joseph E. Scherger 74 
Postmenopausal Symptoms 386
50 
Osteoarthritis 261 Adity Bhattacharyya
André de Leon 75 
Dysmenorrhea 392
51 Acute Gout and Pseudogout 264 Adity Bhattacharyya
Joseph E. Scherger, Michael Bogey 76 Abnormal Uterine Bleeding 396
52 Acne, Rosacea, and Other Common Dermatologic Adity Bhattacharyya
Conditions 269 77 
Ectopic Pregnancy 403
Glenn Jabola, Sangeetha Vinayagam Adity Bhattacharyya
53 Common Skin Cancers 273 78 
Contraception 406
Glenn M. Jabola, Sangeetha Vinayagam Adity Bhattacharyya
54 Ear, Nose, and Throat Problems 277 79 Spontaneous and Elective Abortion 417
Alfred F. Tallia Adity Bhattacharyya
55 Disorders of the Eye 285 80 Sexually Transmitted Diseases 423
Alfred F. Tallia Adity Bhattacharyya
56 
Headache 290 81 
Infertility 434
Barbara Jo McGarry, Beatrix Roemheld-Hamm Adity Bhattacharyya
57 
Seizures 297
SECTION FIVE
Robert Chen, Joshua J. Raymond
Maternity Care 439
58 
Sleep Disorders 302
Robert Chen, Joshua J. Raymond 82 Family-Centered Maternity Care 439
59 Common Renal Diseases 307 Lani K. Ackerman
Joseph E. Scherger, Alexandra G. Ianculescu 83 
Preconception Care 443
60 
Renal Stones 312 Nancy W. Dickey
Joseph E. Scherger, Negin Sanchez 84 Routine Prenatal Care 447
61 Urinary Tract Infections 315 Lani K. Ackerman
Amanda Curnock 85 Immunization and Consumption of Over-the-Counter
62 Fluid and Electrolyte Abnormalities 320 Drugs During Pregnancy 453
Noemi C. Doohan Lani K. Ackerman
63 
Anemia 323 86 Exercise and Pregnancy 457
Amanda Curnock Lani K. Ackerman
64 Certain Hematologic Conditions 330 87 Common Problems in Pregnancy 460
Amanda Curnock John F. Simmons
65 Breast, Lung, and Brain Cancer 337 88 
Spontaneous Abortion 463
Gregory A. Pecchia John F. Simmons
66 Cancer Pain Management 341 89 Thyroid Disease in Pregnancy 466
Amanda Curnock John F. Simmons
67 
Developmental Disabilities 348 90 Gestational Diabetes and Shoulder
Kinder Fayssoux, Carmen Morales-Litchard Dystocia 470
68 
Travel Medicine 352 Anna Lichorad
Joseph E. Scherger, Alex Spinoso 91 Hypertension in Pregnancy 475
John F. Simmons
SECTION FOUR
92 Intrauterine Growth Restriction 478
Women’s Health 357
John F. Simmons
69 
Osteoporosis 357 93 
Postterm Pregnancy 482
Adity Bhattacharyya Anna Lichorad
70 
Breast Disease 363 94 
Labor 485
Adity Bhattacharyya John F. Simmons
xii Contents

95 
Delivery Emergencies 489 121 Foot and Leg Deformities 608
John F. Simmons Kory Gill
96 Postpartum Blues, Depression, and Psychoses 493 122 
Mononucelosis 612
John F. Simmons Anna Lichorad
123 
Adolescent Development 617
SECTION SIX Nancy W. Dickey
Children and Adolescents 497 124 
Adolescent Safety 620
97 Common Problems of the Newborn 497 Nancy W. Dickey
John F. Simmons
SECTION SEVEN
98 
Infant Feeding 498
Geriatric Medicine 625
Lani K. Ackerman
99 
Colic 506 125 Functional Assessment of the Elderly 625
Nancy W. Dickey David F. Howarth
100 
Immunizations 508 126 Polypharmacy and Drug Reactions in the
Lani K. Ackerman Elderly 628
101 
Fever 514 David F. Howarth
Nancy W. Dickey 127 The Propensity and Consequences of Falls among
102 
Over-the-Counter Drugs 518 the Elderly 633
Nancy W. Dickey David F. Howarth
103 Diaper Rash and Other Infant Dermatitis 521 128 Urinary Incontinence in the Elderly 636
Lani K. Ackerman David F. Howarth
104 Failure to Thrive and Short Stature 526 129 
Prostate Disease 642
Nancy W. Dickey David F. Howarth
105 
Child Abuse 530 130 
Pressure Ulcers 647
Kory Gill David F. Howarth
106 
Common Cold 536 131 Constipation in the Elderly 653
Joseph E. Scherger, Alex Spinoso David F. Howarth
107 
Otitis Media 541 132 Pneumonia and Other Common Infectious Diseases
Maureen Strohm of the Elderly 658
David F. Howarth
108 Croup and Epiglottitis 546
K. Douglas Thrasher, Alex Spinoso 133 Polymyalgia Rheumatica and Temporal
Arteritis 663
109 Bronchiolitis and Pneumonia 549
David F. Howarth
K. Douglas Thrasher, Alex Spinoso
134 Hypertension Management in the Elderly 667
110 
Childhood Asthma 556
David F. Howarth
Lani K. Ackerman
135 
Cerebrovascular Accidents 671
111 
Allergic Rhinitis 563
David F. Howarth
Lani K. Ackerman
136 Depression in the Elderly 678
112 
Viral Exanthems 567
David F. Howarth
Anna Lichorad
137 Dementia and Delirium 682
113 
Cardiac Murmurs 574
David F. Howarth
Anna Lichorad
138 
Parkinson Disease 689
114 Vomiting and Diarrhea 579
David F. Howarth
Anna Lichorad
139 
Elder Abuse 694
115 Functional Abdominal Pain 585
David F. Howarth
Nancy W. Dickey
140 Emergency Treatment of Abdominal Pain in
116 
Enuresis 589
the Elderly 697
Nancy W. Dickey
David F. Howarth
117 Lymphoma and Leukemia 592
Nancy W. Dickey
SECTION EIGHT
118 Sickle Cell Disease 596
Behavioral Health 701
Anna Lichorad
119 Physical Activity and Nutrition 599 141 
Depressive Disorders 701
Lani K. Ackerman Joseph E. Scherger, Alexandra G. Ianculescu
120 The Limping Child 604 142 
Bipolar Disorder 709
Kory Gill Joseph E. Scherger, Alexandra G. Ianculescu
 C ontents xiii

143 Generalized Anxiety Disorder 714 159 Heat and Cold Illness 778
Joseph E. Scherger, Damoun A. Rezai Kory Gill
144 Posttraumatic Stress Disorder 719 160 High Altitude and Barotrauma 782
Joseph E. Scherger, Damoun A. Rezai Kory Gill
145 
Obsessive-Compulsive Disorder 721
Joseph E. Scherger, Damoun A. Rezai SECTION TEN

146 
Attention-Deficit/Hyperactivity Disorder 724 Sports Medicine 785
Joseph E. Scherger, Damoun A. Rezai 161 
Preparticipation Evaluation 785
147 Conduct Disorder and Oppositional Defiant James D. King II
Disorder 729 162 
Exercise Prescription 788
Joseph E. Scherger, Damoun A. Rezai Laura Marsh
148 Diagnosis and Management of Schizophrenia 732 163 
Concussions 791
Joseph E. Scherger James D. King II
149 
Drug Abuse 737 164 Acceleration and Deceleration Neck Injuries 796
Maureen Strohm James D. King II
150 
Eating Disorders 742 165 Upper Extremity Injuries 798
Maureen Strohm Laura E. Marsh
151 
Somatoform Disorders 745 166 Low Back Pain 801
Joseph E. Scherger Laura E. Marsh
152 
Sexual Dysfunction 750 167 Lower Extremity Strains and Sprains 806
Joseph E. Scherger, Negin Field Kory Gill
153 Psychotherapy in Family Medicine 756 168 Joint and Soft Tissue Injections 809
Joseph E. Scherger Kory Gill

SECTION NINE 169 

Fracture Management 812
Kory Gill
Emergency Medicine 761
170 Infectious Disease and Sports 815
154 
Cardiac Arrest 761 James D. King II
Anna Lichorad 171 Female Athlete Triad 818
155 Advanced Trauma Life Support 766 Laura E. Marsh
Nancy W. Dickey
156 
Diabetic Ketoacidosis 769 SECTION ELEVEN
John F. Simmons Illustrated Review 823
157 Acute and Chronic Poisoning 772 172 
Illustrated Review 823
Anna Lichorad Alfred F. Tallia
158 Urticaria Angioneurotic Edema 775 173 
Color Plates 834
Nancy W. Dickey
Tips on Passing the Board Examinations
This section briefly discusses the philosophy and tech-
niques of passing board examinations or other types of
medical examinations. Most examinations, such as the
certification and recertification examinations of the
American Board of Family Medicine, have moved to
computer-based administration. If this applies to your
examination, read and study the demonstrations provided
on the Internet or elsewhere.
First, realize that you are “playing a game.” It is, of
course, a very important game, but a game neverthe-
less. When answering each question ask yourself, “What
information does the examiner want?” How do you “out-
fox the fox”?
To find out, let us turn our attention to the most com-
mon type of question, the multiple choice. Following
these simple rules will maximize your chances.
RULE 1: Allocate your time appropriately. At the begin-
ning of the examination, divide the number of questions
by the time allotted. Pace yourself accordingly, and check
your progress every half hour.
RULE 2: If using a computer-administered examination,
take time before the examination to become familiar with
the mechanics of maneuvering through the examination
program. Learn whether you can return to questions you
weren’t sure about, or whether this is not allowed.
RULE 3: Answer every question in order. On some
computer-administered examinations you run the risk
of not being able to return to an unanswered ques-
tion. Although American Board of Family Medicine
examinations allow you to return, not all examinations
permit this. Some examinations use unfolding ques-
tion sequences that do not let you return to a previous
question. On paper-­administered examinations, you
run the risk of mis-sequencing your answers and thus
submitting all answers out of order.
RULE 4: Do not spend more than your allotted time on
any one question. If you don’t know the answer and you
are not penalized for wrong answers, simply guess.
RULE 5: Even if you are penalized for wrong answers
(most examinations no longer do this) and you can elim-
inate even one choice, answer the question. Percentages
dictate that you will come out ahead in the end.
RULE 6: If there is a question in which one choice is sig-
nificantly longer than the others and you do not know
the answer, select the longest choice.
RULE 7: If you are faced with an “all of the above” option,
realize that these are correct far more often than they are
incorrect. Choose “all of the above” if you do not know
the answer.
RULE 8: Become suspicious if you have selected more than
three choices of the same letter in a row. Two in a row
of the same letter is common, three is less common, and
four is extremely uncommon. In this case, recheck your
answers.
RULE 9: Answer choices tend to be very evenly distrib-
uted. In other words, the number of correct “a” choices
is close to the number of correct “b” choices, and so on.
However, there may be somewhat more “e” choices than
any other, especially if there is a fair number of “all of
the above” choices. If you have time, do a quick check to
reassure yourself.
RULE 10: Never change an answer once you have recorded
it on the computer unless you have an extraordinary rea-
son for doing so. Many people taking multiple-choice
examinations, especially if they have time on their hands
after completing questions, start second-guessing them-
selves and thinking of all kinds of unusual exceptions.
Resist this temptation.
RULE 11: Before you choose an answer, always read each
and every choice. Do not get caught by seeing what you
believe is the correct answer jump out at you.
RULE 12: Scan the lead-in to the answers and the potential
answers first, then read the clinical case/vignette. This
way you will know what is being tested and will better
attend to the necessary facts. Read each question care-
fully. Be especially careful to read words such as not,
except, and so on.
Following these suggestions cannot guarantee success;
however, I do believe that these tips will help you achieve
better results on your board examinations.
Alfred F. Tallia, MD, MPH
Editor-in-Chief
Continuing Medical Education

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Swanson’s
FAMILY MEDICINE
REVIEW

Family, Community,
and Population Health
CHAPTER 1
Family Influences on Health
and Disease
C L I N I CA L CA S E PR O B L E M 1
A Calculated Risk
A 32-year-old African-American man comes to your
office for the first time requesting a health maintenance
visit. He is married and the father of two young children.
He works as an accountant. His firm has just offered
a new health insurance plan, which pays for a preven-
tive health maintenance examination. He wants to stay
healthy and to live longer than both his parents.
S EL ECT T H E B EST A N SW ER TO T H E
F O L LOW I N G Q U EST I O N S
1. Regarding his risk, you would ask him about which of
the following?
a. diet history
b. exercise type and frequency
c. smoking history
d. family history
e. alcohol intake
f. all of the above
g. none of the above
2. You discover that his father had his first heart attack
at age 42 and died at age 49 following a second heart
attack. His mother had diabetes, hypertension, and
congestive heart failure and died at age 73. Consider-
ing this information you would recommend which of
the following screening tests at this time?
a. order a complete blood chemistry
b. order a cardiac non–stress test
c. perform a resting electrocardiogram (ECG) now
d. screen for lipids now
e. none of the above because he is still less than 35
years old
3. Which is true about family and risk?
a. family is one of the major influences on disease inci-
dence and prevalence
SECTION ONE
b. family risk outcomes are not modifiable
c. family risk need not be ascertained because there is
nothing you can do about it
d. family disease susceptibility is absolutely
transmittable
e. family risk is not ascertainable by current methods
of genetic screening
C L I N I CA L CA S E PR O B L E M 2
All in the Family
Two 75-year-old patients are hospitalized after both had
a stroke resulting in a left-sided hemiparesis. The size
and location of the thrombotic events in these patients
are almost identical, as is the initial degree of impair-
ment. Treatment received is also the same. One patient
lives alone and has a younger sibling living in a distant
state. The other patient is part of an extended family
with many social supports nearby, including grandchil-
dren who visit her often while she is in the hospital.
4. What outcomes would you predict for these patients
on the basis of their family social circumstances?
a. identical outcomes are likely given the identical
lesions and initial impairments
b. it is impossible to predict outcomes
c. the patient with more family supports is likely to
have a better outcome
d. the patient with fewer family supports is at lesser
risk of acute mortality
e. outcomes achieved are independent of any family
social factors
C L I N I CA L CA S E PR O B L E M 3
Risks of Omission and Commission
A 28-year-old woman presents to your office for the
first time for prenatal care. She is 14 weeks into her
first pregnancy. She is human immunodeficiency virus
(HIV) positive but stopped antiretroviral agents because
she had heard that taking medication during pregnancy
could harm the baby. She has a half-pack per day
smoking habit that she has been unable to stop despite
1
2 S ECTION O N E Family, Community, and Population Health
many attempts at quitting. She drinks at least a glass
of wine with dinner each night. She works in sales at a
local food bar. She asks you what she can do to give her
child a better chance in life than she had.
5. At this time, it is most appropriate to advise her of
which of the following?
a. perinatal transmission of the HIV virus poses the
child’s greatest risk
b. smoking is by far the most hazardous factor in her
prenatal history
c. alcohol consumption during pregnancy is a major
risk factor for fetal alcohol syndrome
d. she must restart antiretroviral medications immedi-
ately or risk certain death
e. none of the above
C L I N I CA L CA S E PR O B L E M 4
Unwanted Advice
A 25-year-old mother presents for the first time with her
2-week-old infant, her first child. Hovering in the back-
ground are the two grandmothers. The mother is visibly
concerned that the baby is “only” at the same weight
as he was at birth. One grandmother chimes in that
she knew breastfeeding was a bad idea, and the other
insists that it is time to introduce cereal to the baby’s
diet. They start arguing among themselves until you
escort everyone but the mother and the infant from the
examination room.
6. In addition to giving the mother accurate advice about
breastfeeding and nutrition, which of the following is
an appropriate intervention at this time?
a. refocus the attention of the grandmothers to some
other facet of the family experience
b.  establish and reinforce the competency of the
mother in her breastfeeding
c. use your expert authority as the physician to set
family rules for decision making in the mother’s
favor
d. acknowledge and reinforce the expert authority of
the grandmothers
e. a, b, and c are correct
7. Possible positive aspects of the previous family situa-
tion include which of the following?
a. evidence of closeness and connectedness
b. a lack of criticism and blame
c. the absence of protectionism and rigidity
d. all of the above
e. none of the above
8. You handle the situation with skill and care, and the
grandmothers leave feeling reassured of your careful
attention to their first and only grandson, and they
are impressed with his mother’s newly identified and
recognized competence. In future visits, anticipatory
guidance in this family should probably take into con-
sideration which of the following?
a. family beliefs about child discipline
b. family influences on exercise and diet
c. family beliefs about health and illness
d. none of the above
e. a, b, and c
A N SW ER S
1. f. Family influences on health and disease are
numerous and multifactorial. These influences can be
expressed across individual and family life cycles. One
of the most pronounced family effects is on genetic
and disease susceptibility. Although all the histori-
cal elements listed are important, the family history,
often recorded in the medical record pictorially as
a genogram, will provide a constant guide for the
assessment of symptoms as they are manifested across
the individual life cycle.
2. d. The U.S. Preventive Services Task Force
(USPSTF) recommends that men who are at
increased risk for coronary heart disease be screened
for lipid disorders between the ages of 20 and 35.
The preferred screening test is fasting or nonfasting
serum lipid levels (cholesterol, high-density lipo-
protein, and low-density lipoprotein). Risk factors
include family history of cardiovascular disease, along
with diabetes, history of previous coronary heart dis-
ease, or atherosclerosis, tobacco use, hypertension,
and obesity.
There is insufficient evidence to screen with a resting or
exercise ECG. Based on his family history it would also
be reasonable to screen for diabetes and hypertension at
this time.
3. a. Disease incidence and prevalence are directly
related to the interplay of family genetics, behaviors,
and the host environment. Physicians should attend to
known cues of family historical factors that can often
foreshadow overt disease in patients. Changes in diet,
exercise, and smoking habits can modify outcomes for
those with family risk factors.
4. c. A large literature exists on the influence of fam-
ily on survival and disease progression. Strong family
supports are protective and promote healing in acute
disease circumstances. Studies of disease outcomes in
myocardial infarction and stroke reveal striking sup-
portive effects of family supports even when other
variables are controlled for.
5. a. Family influence on prenatal and perinatal dis-
ease transmission is another important influence of
the family on health and disease. In 2005, of the 68
children diagnosed with AIDS in the United States,
 C H A P TER 1
67 had been infected perinatally. Pregnant women
with HIV can reduce the risk of transmitting HIV
to their babies to less than 1% if they take antiretro-
viral drugs during pregnancy. This mother can help
her child’s future most by resuming her antiretroviral
therapy.
6. e. How many of us have been confronted by the case
illustrated? Most experienced family physicians will
recognize the situation. Dealing with family members
beyond the presumed present patient is a common
occurrence in family medicine. In fact, skillful use
of family resources is a therapeutic advantage in the
family physician’s armamentarium if it is done care-
fully. The supportive closeness of this family must be
counterbalanced by the reinforcement of the compe-
tence of the mother in this scenario. Although being
careful not to alienate the grandmothers is important,
the mother’s competence and her decision-making
authority must ultimately be reinforced. Because the
physician possesses all forms of social power (expert,
S U M M A RY
The effects of family on health and disease are large and
multifactorial. They are expressed across the individual
and family life cycles. Family physicians and other health
care providers must be cognizant of these influences and
help individuals and families navigate the positive and less
positive effects. The potential effects of family on health
and illness include the following.
1. Genetics and disease susceptibility
Family effects through genetics are particularly
strong. Although they can be moderated by envi-
ronment and behavior, the effects are with us for
a lifetime. Certain diseases, such as Huntington
disease and Tay-Sachs disease, are directly relat-
ed to our parents; others, such as coronary heart
disease, hypertension, and diabetes, are strongly
mediated by family factors. Use of genetic testing
and expanded family history tools will be increas-
ingly important in the twenty-first century, and
physicians will need to evaluate such testing and its
uses wisely. A reliable resource for understanding
genetic testing can be found at www.ncbi.
nlm.nih.gov/sites/GeneTests/?ob=GeneTests.
2. Prenatal and perinatal transmission of disease
Generations of families have experienced prenatal
or perinatal transmission of diseases ranging from
syphilis to HIV infection. In many areas of the
world, this family influence has charted the des-
tiny of countless children. These risk factors can
be modified in many circumstances and should
be addressed when appropriate by the family
physician.
Family Influences on Health and Disease 3
legal, coercive, referent, and reward), this can readily
be accomplished.
7. a. Although answers b and c can be positive aspects
of family, they are absent in this situation.
8. e. Understanding of family influences on health and
disease is essential for effective practice as a family
physician. Understanding allows not only appropri-
ate interventions in acute disease but also anticipatory
guidance in the prevention of morbidity and future
illness, and the promotion of health and well-being.
Family factors that have protective influence on health
and illness include closeness and connectedness;
well-developed problem-focused coping skills; clear
organization and decision making; and direct commu-
nication. Family pathologies that can adversely influ-
ence health and illness include intrafamily hostility,
criticism, and blame; perfectionism and rigidity; lack
of extrafamily support systems; and the presence of
chronic psychopathology.
3. C hild rearing and nurturing
Belief systems ranging from when to have children to
how children should be raised and whether and how
much children should be held are all part of the
family influences on having and raising children.
4. Nutrition and lifestyle
Family traditions and socioeconomics play an im-
portant role in access to adequate nutrition. Many
lifestyle behaviors, such as smoking, diet, exercise,
and alcohol consumption, are influenced by our
parents and extended family and by their habits
and beliefs.
5. Access to and quality of care
Again, family socioeconomics along with race and
ethnicity are factors that influence the ability to ac-
cess health care and successfully navigate complex
health care systems.
6. Spread of infectious disease
Family living situations and contacts are major in-
fluences on the spread of many infectious diseases
ranging from Mycoplasma pneumonia to influenza.
Many infectious illnesses are passed from one fam-
ily member to others in a household, and families
are important vectors in times of epidemics.
7. Outcomes in acute and chronic illness
Multiple studies have demonstrated different out-
comes in acute and chronic illness based on the
degree of social supports available in families.
Similarly, family dysfunction can be a major con-
tributor to illness and adverse health outcomes in
many individuals.
Continued
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of How to know
the wild flowers
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

Title: How to know the wild flowers

a guide to the names, haunts, and habits of our
common wild flowers

Author: Frances Theodora Parsons

Illustrator: Marion Satterlee

Release date: November 6, 2023 [eBook #72056]

Language: English

Original publication: New York: Charles Scribner's Sons, 1893

Credits: Richard Tonsing and The Online Distributed

Proofreading Team at https://www.pgdp.net (This file
was produced from images generously made available
by The Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK HOW TO

KNOW THE WILD FLOWERS ***
Transcriber’s Note:
New original cover art included with this eBook is
granted to the public domain.
 HOW TO KNOW THE WILD
FLOWERS
A Guide
TO THE NAMES, HAUNTS, AND HABITS OF
OUR COMMON WILD FLOWERS

BY

MRS. WILLIAM STARR DANA

ILLUSTRATED BY

MARION SATTERLEE

“The first conscious thought about wild flowers was to find out their names—the first

conscious pleasure—and then I began to see so many that I had not previously noticed. Once

you wish to identify them, there is nothing escapes, down to the little white chickweed of the

path and the moss of the wall.”

—Richard Jefferies

NEW YORK

CHARLES SCRIBNER’S SONS

1893
 Copyright, 1893, by
CHARLES SCRIBNER’S SONS

TROW DIRECTORY
PRINTING AND BOOKBINDING COMPANY
NEW YORK
 CONTENTS

PAGE
Preface, vii
How to Use the Book, ix
Introductory Chapter, 1
Explanation of Terms, 8
Notable Plant Families, 13
Flower Descriptions:
I. White, 22
II. Yellow, 113
III. Pink, 173
IV. Red, 213
V. Blue and Purple, 229
VI. Miscellaneous, 276
Index to Latin Names, 287
„ to English Names, 292
„ of Technical Terms, 298

One of these days some one will give us a hand-book of our wild
flowers, by the aid of which we shall all be able to name those we
gather in our walks without the trouble of analyzing them. In this
book we shall have a list of all our flowers arranged according to
color, as white flowers, blue flowers, yellow flowers, pink flowers,
etc., with place of growth and time of blooming.

John Burroughs.
 PREFACE

The pleasure of a walk in the woods and fields is enhanced a

hundredfold by some little knowledge of the flowers which we meet
at every turn. Their names alone serve as a clew to their entire
histories, giving us that sense of companionship with our
surroundings which is so necessary to the full enjoyment of outdoor
life. But if we have never studied botany it has been no easy matter to
learn these names, for we find that the very people who have always
lived among the flowers are often ignorant of even their common
titles, and frequently increase our eventual confusion by naming
them incorrectly. While it is more than probable that any attempt to
attain our end by means of some “Key,” which positively bristles with
technical terms and outlandish titles, has only led us to replace the
volume in despair, sighing with Emerson, that these scholars
Love not the flower they pluck, and know it not,
And all their botany is Latin names!

So we have ventured to hope that such a book as this will not be

altogether unwelcome, and that our readers will find that even a
bowing acquaintance with the flowers repays one generously for the
effort expended in its achievement. Such an acquaintance serves to
transmute the tedium of a railway journey into the excitement of a
tour of discovery. It causes the monotony of a drive through an
ordinarily uninteresting country to be forgotten in the diversion of
noting the wayside flowers, and counting a hundred different species
where formerly less than a dozen would have been detected. It
invests each boggy meadow and bit of rocky woodland with almost
irresistible charm. Surely Sir John Lubbock is right in maintaining
that “those who love Nature can never be dull,” provided that love be
expressed by an intelligent interest rather than by a purely
sentimental rapture.

Ninety-seven of the one hundred and four plates in this book are
from original drawings from nature. Of the remaining seven plates,
six (Nos. LXXX., XCIX., CI., XXII., XLII., LXXXI.), and the
illustration of the complete flower, in the Explanation of Terms, are
adapted with alterations from standard authors, part of the work in
the first three plates mentioned being original. Plate IV. has been
adapted from “American Medicinal Plants,” by kind permission of
the author, Dr. C. F. Millspaugh. The reader should always consult
the “Flower Descriptions” in order to learn the actual dimensions of
the different plants, as it has not always been possible to preserve
their relative sizes in the illustrations. The aim in the drawings has
been to help the reader to identify the flowers described in the text,
and to this end they are presented as simply as possible, with no
attempt at artistic arrangement or grouping.
We desire to express our thanks to Miss Harriet Procter, of
Cincinnati, for her assistance and encouragement. Acknowledgment
of their kind help is also due to Mrs. Seth Doane, of Orleans,
Massachusetts, and to Mr. Eugene P. Bicknell, of Riverdale, New
York. To Dr. N. L. Britton, of Columbia College, we are indebted for
permission to work in the College Herbarium.
New York, March 15, 1893.
 HOW TO USE THE BOOK

Many difficulties have been encountered in the arrangement of

this guide to the flowers. To be really useful such a guide must be of
moderate size, easily carried in the woods and fields; yet there are so
many flowers, and there is so much to say about them, that we have
been obliged to control our selection and descriptions by certain
regulations which we hope will commend themselves to the
intelligence of our readers and secure their indulgence should any
special favorite be conspicuous by its absence.
These regulations may be formulated briefly as follows:
1. Flowers so common as to be generally recognized are omitted,
unless some peculiarity or fact in their history entitles them to
special mention.
Under this, Buttercups, Wild Roses, Thistles, and others are
ruled out.
2. Flowers so inconspicuous as generally to escape notice are
usually omitted.
Here Ragweed, Plantain, and others are excluded.
3. Rare flowers and escapes from gardens are usually omitted.
4. Those flowers are chosen for illustration which seem entitled
to prominence on account of their beauty, interest, or frequent
occurrence.
5. Flowers which have less claim upon the general public than
those chosen for illustration and full description, yet which are
sufficiently common or conspicuous to arouse occasional curiosity,
are necessarily dismissed with as brief a description as seems
compatible with their identification.
In parts of New England, New York, New Jersey, Pennsylvania
and in the vicinity of Washington, I have been enabled to describe
many of our wild flowers from personal observation; and I have
endeavored to increase the usefulness of the book by including as
well those comparatively few flowers not found within the range
mentioned, but commonly encountered at some point this side of
Chicago.
The grouping according to color was suggested by a passage in
one of Mr. Burroughs’s “Talks about Flowers.” It seemed, on careful
consideration, to offer an easier identification than any other
arrangement. One is constantly asked the name of some “little blue
flower,” or some “large pink flower,” noted by the wayside. While
both the size and color of a flower fix themselves in the mind of the
casual observer, the color is the more definitely appreciated
characteristic of the two and serves far better as a clew to its
identification.

When the flowers are brought in from the woods and fields they
should be sorted according to color and then traced to their proper
places in the various sections. As far as possible the flowers have
been arranged according to the seasons’ sequence, the spring flowers
being placed in the first part of each section, the summer flowers
next, and the autumn flowers last.
It has sometimes been difficult to determine the proper position
of a flower—blues, purples, and pinks shading so gradually one into
another as to cause difference of opinion as to the color of a blossom
among the most accurate. So if the object of our search is not found
in the first section consulted, we must turn to that other one which
seems most likely to include it.
It has seemed best to place in the White section those flowers
which are so faintly tinted with other colors as to give a white effect
in the mass, or when seen at a distance. Some flowers are so green as
to seem almost entitled to a section of their own, but if closely
examined the green is found to be so diluted with white as to render
them describable by the term greenish-white. A white flower veined
with pink will also be described in the White section, unless its
general effect should be so pink as to entitle it to a position in the
Pink section. Such a flower again as the Painted Cup is placed in the
Red section because its floral leaves are so red that probably none
but the botanist would appreciate that the actual flowers were yellow.
Flowers which fail to suggest any definite color are relegated to the
Miscellaneous section.

With the description of each flower is given—

1. Its common English name—if one exists. This may be looked
upon as its “nickname,” a title attached to it by chance, often
endeared to us by long association, the name by which it may be
known in one part of the country but not necessarily in another, and
about which, consequently, a certain amount of disagreement and
confusion often arises.
2. Its scientific name. This compensates for its frequent lack of
euphony by its other advantages. It is usually composed of two Latin
—or Latinized—words, and is the same in all parts of the world
(which fact explains the necessity of its Latin form). Whatever
confusion may exist as to a flower’s English name, its scientific one is
an accomplished fact—except in those rare cases where an
undescribed species is encountered—and rarely admits of dispute.
The first word of this title indicates the genus of the plant. It is a
substantive, answering to the last or family name of a person, and
shows the relationship of all the plants which bear it. The second
word indicates the species. It is usually an adjective, which betrays
some characteristic of the plant, or it may indicate the part of the
country in which it is found, or the person in whose honor it was
named.
3. The English title of the larger Family to which the plant
belongs. All flowers grouped under this title have in common certain
important features which in many cases are too obscure to be easily
recognized; while in others they are quite obvious. One who wishes
to identify the flowers with some degree of ease should learn to
recognize at sight such Families as present conspicuously
characteristic features.
For fuller definitions, explanations, and descriptions than are
here given, Gray’s text-books and “Manual” should be consulted.
After some few flowers have been compared with the partially
technical description which prefaces each popular one, little
difficulty should be experienced in the use of a botanical key. Many
of the measurements and technical descriptions have been based
upon Gray’s “Manual.” It has been thought best to omit any mention
of species and varieties not included in the latest edition of that
work.
An ordinary magnifying glass (such as can be bought for
seventy-five cents), a sharp penknife, and one or two dissecting-
needles will be found useful in the examination of the smaller
flowers. The use of a note-book, with jottings as to the date, color,
surroundings, etc., of any newly identified flower, is recommended.
This habit impresses on the memory easily forgotten but important
details. Such a book is also valuable for further reference, both for
our own satisfaction when some point which our experience had
already determined has been forgotten, and for the settlement of the
many questions which are sure to arise among flower-lovers as to the
localities in which certain flowers are found, the dates at which they
may be expected to appear and disappear, and various other points
which even the scientific books sometimes fail to decide.
Some of the flowers described are found along every country
highway. It is interesting to note that these wayside flowers may
usually be classed among the foreign population. They have been
brought to us from Europe in ballast and in loads of grain, and
invariably follow in the wake of civilization. Many of our most
beautiful native flowers have been crowded out of the hospitable
roadside by these aggressive, irresistible, and mischievous invaders;
for Mr. Burroughs points out that nearly all of our troublesome
weeds are emigrants from Europe. We must go to the more remote
woods and fields if we wish really to know our native plants. Swamps
especially offer an eagerly sought asylum to our shy and lovely wild
flowers.
LIST OF PLATES
PLATE PAGE
I. Blood-root, Sanguinaria Canadensis, 23
II. Rue Anemone, Anemonella thalictroides, 25
Wood Anemone, Anemone nemorosa, 25
III. Star-flower, Trientalis Americana, 27
Maianthemum
Canadense, 27
IV. May-apple, Podophyllum peltatum, 31
V. Spring Beauty, Claytonia Virginica, 33
VI. Dutchman’s Breeches, Dicentra Cucullaria, 35
VII. Foam-flower, Tiarella cordifolia, 37
VIII. Painted Trillium, Trillium erythrocarpum, 41
IX. Wild Sarsaparilla, Aralia nudicaulis, 43
X. Solomon’s Seal, Polygonatum biflorum, 45
XI. False Solomon’s Seal, Smilacina racemosa, 47
XII. Bellwort, Uvularia perfoliata, 51
„ Oakesia sessilifolia, 51
XIII. White Baneberry, Actæa alba, 53
XIV. Bunch-berry, Cornus Canadensis, 55
XV. Mountain Laurel, Kalmia latifolia, 57
XVI. American Rhododendron maximum,
Rhododendron, 61
XVII. Wood Sorrel, Oxalis Acetosella, 63
XVIII. Shin-leaf, Pyrola elliptica, 67
XIX. Pipsissewa, Chimaphila umbellata, 69
XX. Wintergreen, Gaultheria procumbens, 73
XXI. Indian Pipe, Monotropa uniflora, 75
XXII. Black Cohosh, Cimicifuga racemosa, 79
XXIII. Partridge Vine, Mitchella repens, 81
XXIV. —— —— Dalibarda repens, 85
XXV. Tall Meadow Rue, Thalictrum polygamum, 87
XXVI. Meadow-sweet, Spiræa salicifolia, 89
XXVII. Pokeweed, Phytolacca decandra, 93
XXVIII. Wild Carrot, Daucus Carota, 95
Yarrow, Achillea Millefolium, 95
XXIX. Arrow-head, Sagittaria variabilis, 99
 XXX. Turtle-head, Chelone glabra, 101
XXXI. Traveller’s Joy, Clematis Virginiana, 103
XXXII. Boneset, Eupatorium perfoliatum, 107
XXXIII. Ladies’ Tresses, Spiranthes cernua, 109
XXXIV. Grass of Parnassus, Parnassia Caroliniana, 111
XXXV. Marsh Marigold, Caltha palustris, 115
XXXVI. Yellow Adder’s Tongue, Erythronium
Americanum, 117
XXXVII. Downy Yellow Violet, Viola pubescens, 119
XXXVIII. Shrubby Cinquefoil, Potentilla fructicosa, 121
XXXIX. —— —— Clintonia borealis, 123
XL. Smaller Yellow Lady’s Cypripedium parviflorum,
Slipper, 125
XLI. Indian Cucumber-root, Medeola Virginica, 129
XLII. Winter-cress, Barbarea vulgaris, 131
XLIII. Rattlesnake-weed, Hieracium venosum, 133
XLIV. Bush-honeysuckle, Diervilla trifida, 135
XLV. Meadow Lily, Lilium Canadense, 137
XLVI. Four-leaved Lysimachia quadrifolia,
Loosestrife, 139
XLVII. Yellow Loosestrife, Lysimachia stricta, 141
XLVIII. Yellow Star-grass, Hypoxis erecta, 143
XLIX. Butter-and-eggs, Linaria vulgaris, 147
L. Common St. John’s-wort, Hypericum perforatum, 149
LI. Common Mullein, Verbascum Thapsus, 151
LII. Yellow Fringed Orchis, Habenaria ciliaris, 153
LIII. Pale Jewel-weed, Impatiens pallida, 155
LIV. Evening Primrose, Œnothera biennis, 159
LV. Black-eyed Susan, Rudbeckia hirta, 161
LVI. Elecampane, Inula Helenium, 163
LVII. Wild Sunflower, Helianthemum giganteus, 165
LVIII. Stick-tight, Bidens frondosa, 167
LIX. Smooth False Foxglove, Gerardia quercifolia, 169
LX. Tansy, Tanacetum vulgare, 171
LXI. Trailing Arbutus, Epigæa repens, 175
Twin-flower, Linnæa borealis, 175
LXII. Showy Orchis, Orchis spectabilis, 177
LXIII. Twisted Stalk, Streptopus roseus, 179
 LXIV. Pink Lady’s Slipper, Cypripedium acaule, 181
LXV. Pink Azalea, Rhododendron
nudiflorum, 183
LXVI. Milkwort, Polygala polygama, 187
„ „ sanguinea, 187
LXVII. Spreading Dogbane, Apocynum
androsæmifolium, 189
LXVIII. Purple-flowering Rubus odoratus,
Raspberry, 191
LXIX. Herb Robert, Geranium Robertianum, 195
LXX. Bouncing Bet, Saponaria officinalis, 197
LXXI. Purple Loosestrife, Lythrum Salicaria, 199
LXXII. Meadow-beauty, Rhexia Virginica, 201
LXXIII. Sea Pink, Sabbatia stellaris, 203
LXXIV. —— —— Sabbatia chloroides, 205
LXXV. Rose Mallow, Hibiscus Moscheutos, 207
LXXVI. Fireweed, Epilobium angustifolium, 209
LXXVII. Joe-Pye-weed, Eupatorium purpureum, 211
LXXVIII. Wild Columbine, Aquilegia Canadensis, 215
LXXIX. Wake Robin, Trillium erectum, 217
LXXX. Wood Lily, Lilium Philadelphicum, 221
LXXXI. Butterfly-weed, Asclepias tuberosa, 223
LXXXII. Oswego Tea, Monarda didyma, 225
LXXXIII. Cardinal-flower, Lobelia cardinalis, 227
LXXXIV. Liverwort, Hepatica triloba, 231
LXXXV. Bluets, Houstonia cærulea, 233
LXXXVI. Robin’s Plantain, Erigeron bellidifolius, 237
LXXXVII. Wild Geranium, Geranium maculatum, 239
LXXXVIII. Blue-eyed Grass, Sisyrinchium
angustifolium, 243
LXXXIX. Fleur-de-lis, Iris versicolor, 245
XC. American Brooklime, Veronica Americana, 247
XCI. Monkey-flower, Mimulus ringens, 251
XCII. Blue Vervain, Verbena hastata, 263
XCIII. Self-heal, Brunella vulgaris, 255
XCIV. Blueweed, Echium vulgare, 259
XCV. Great Lobelia, Lobelia syphilitica, 261
XCVI. Indian Tobacco, Lobelia inflata, 263
 XCVII. Beach Pea, Lathyrus maritimus, 265
XCVIII. Chicory, Cichorium Intybus, 267
XCIX. Blazing Star, Liatris scariosa, 271
C. Closed Gentian, Gentiana Andrewsii, 273
CI. Fringed Gentian, Gentiana crinita, 275
CII. Skunk Cabbage, Symplocarpus fœtidus, 277
CIII. Wild Ginger, Asarum Canadense, 279
CIV. Jack-in-the-Pulpit, Arisæma triphyllum, 281

Most young people find botany a dull study. So it is, as taught

from the text-books in the schools; but study it yourself in the fields
and woods, and you will find it a source of perennial delight.

John Burroughs.