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MEDICAL
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MEDICAL

Sixth Edition

MARY P. HARWARD, MD, FACP

Internal Medicine and Geriatrics
Orange, California
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

MEDICAL SECRETS, SIXTH EDITION ISBN: 978-0-323-47872-4

Copyright © 2019 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 ar-
rangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found
at our website: www.elsevier.com/permissions.

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

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
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Library of Congress Cataloging-in-Publication Data

Names: Harward, Mary P., editor.

Title: Medical secrets / [edited by] Mary P. Harward.
Description: Sixth edition. | Philadelphia, PA : Elsevier Inc., [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2017058627 | ISBN 9780323478724 (pbk. : alk. paper)
Subjects: | MESH: Internal Medicine | Examination Questions
Classification: LCC RC58 | NLM WB 18.2 | DDC 616.0076--dc23 LC record available at
https://lccn.loc.gov/2017058627

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Printed in the United States.

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To our patients who have shared with us the secrets of
their health and illness.
This page intentionally left blank

     
CONTRIBUTORS

William L. Allen, M. Div, JD Teresa G. Hayes, MD, PhD

Associate Professor Associate Professor
Department of Community Health and Family Medicine Department of Internal Medicine
Program in Bioethics, Law, and Medical Hematology-Oncology Section
Professionalism Baylor College of Medicine
University of Florida College of Medicine Chief
Gainesville, Florida Hematology-Oncology Section
Michael E. DeBakey VA Medical Center
Katherine Vogel Anderson, PharmD, BCACP Houston, Texas
Associate Professor
University of Florida College of Pharmacy and Medicine Nisreen Husain, MD
Gainesville, Florida Director
GI Motility
Rhonda A. Cole, MD, FACG Department of Gastroenterology
Associate Section Chief Baylor College of Medicine
Department of Gastroenterology Houston, Texas
Associate Professor
Department of Internal Medicine Ankita Kadakia, MD
Baylor College of Medicine Assistant Professor of Clinical Medicine
Houston, Texas Division of Infectious Diseases
University of California San Diego Medical
Kathryn H. Dao, MD, FACP, FACR Center – Owen Clinic
Associate Director of Clinical Rheumatology San Diego, California
Baylor Research Institute
Dallas, Texas Henrique Elias Kallas, MD, CMD
Assistant Professor
Nathan A. Gray, MD Departments of Medicine and Aging
Assistant Professor of Medicine University of Florida College of Medicine
Division of General Internal Medicine Gainesville, Florida
Duke University School of Medicine
Durham, North Carolina Alexander S. Kim, MD
Assistant Professor of Medicine
Gabriel Habib, Sr., MS, MD, FACC, FCCP, FAHA Associate Program Director
Professor of Medicine and Cardiology Allergy/Immunology Fellowship Program
Baylor College of Medicine University of California, San Diego
Director of Education and Associate Chief San Diego, California
Section of Cardiology
Michael E. DeBakey VA Medical Center Roger Kornu, MD, FACR
Houston, Texas Affiliated Physician
University of California, Irvine
Eloise M. Harman, MD Irvine, California
Staff Physician and MICU Director
Malcom Randall VA Medical Center R. Anjali Kumbla, MD
Professor Emeritus of Medicine Department of Hematology/Oncology
University of Florida College of Medicine The Southeast Permanente Medical Group
Gainesville, Florida Athens, Georgia
Mary P. Harward, MD, FACP Daniel Lee, MD
Internal Medicine and Geriatrics Clinical Professor of Medicine
Orange, California Division of Infectious Diseases
University of California San Diego Medical
Timothy R.S. Harward, MD, FACS Center—Owen Clinic
Vascular and Interventional Specialists of Orange San Diego, California
County
Orange, California

vii
 viii CONTRIBUTORS

Harrinarine Madhosingh, MD, FACP, FIDSA Eric I. Rosenberg, MD, MSPH, FACP
Attending Physician Associate Professor and Chief
Infectious Disease Division of General Internal Medicine
Central Florida Infectious Disease Specialists Department of Medicine
Assistant Professor University of Florida College of Medicine
Department of Medicine Associate Chief Medical Officer
University of Central Florida University of Florida Health Shands Hospitals
Orlando, Florida Gainesville, Florida
Ara Metjian, MD Abbas Shahmohammadi, MD
Assistant Professor Assistant Professor
Division of Hematology Division of Pulmonary and Critical Care Medicine
Department of Medicine Department of Medicine
Duke University School of Medicine University of Florida College of Medicine
Durham, North Carolina Gainesville, Florida
John Meuleman, MD Damian Silbermins, MD
Geriatric Research, Education, and Clinical Huntington Internal Medicine Group
Center Huntington, West Virginia
University of Florida College of Medicine
Gainesville, Florida Amy M. Sitapati, MD
Clinical Professor of Medicine
Jeffrey M. Miller, MD Chief Medical Information Officer of Population Health
Chief University of California San Diego Health
Division of Hematology/Oncology San Diego, California
Program Director
Hematology/Oncology Fellowship David B. Sommer, MD, MPH
Olive View—UCLA Medical Center Neurology, Movement Disorders
Cedars Sinai Medical Center Reliant Medical Group
Kaiser Sunset Worcester, Massachusetts
Associate Clinical Professor of Medicine Susan E. Spratt, MD
David Geffen School of Medicine at UCLA Associate Professor
Olive View UCLA Medical Center Division of Endocrinology
Los Angeles, California Department of Medicine
Yamini Natarajan, MD Duke University School of Medicine
Assistant Professor Durham, North Carolina
Department of Gastroenterology Adriano R. Tonelli, MD
Baylor College of Medicine Assistant Professor
Michael E. DeBakey VA Medical Center Division of Pulmonary, Allergy, and
Houston, Texas Critical Care Medicine
Catalina Orozco, MD Case Western Reserve University School of Medicine
Rheumatology Associates Cleveland, Ohio
Dallas Texas Whitney W. Woodmansee, MD
Rahul K. Patel, MD, FACP, FACR Endocrinology
Medical Director Mayo Clinic—Jacksonville
PRA Health Sciences Jacksonville, Florida
Dallas, Texas Jason A. Webb, MD, FAPA
Sharma S. Prabhakar, MD, MBA, FACP, FASN Director of Education
Professor and Chief Duke Center for Palliative Care
Division of Nephrology Assistant Professor
Vice-Chair Department of Medicine
Department of Medicine Department of Psychiatry and Behavioral Sciences
Texas Tech University Health Sciences Center Duke University School of Medicine
Lubbock, Texas Durham, North Carolina

Nila S. Radhakrishnan, MD
Assistant Professor and Chief
Division of Hospital Medicine
Department of Medicine
University of Florida College of Medicine
Gainesville, Florida
PREFACE

Most of my post-training professional life has been concurrent with the six editions of this book, and I have
seen astounding scientific and therapeutic changes with each new update of Medical Secrets. The chapters
in the sixth edition reflect the many major changes in medical science, prevention, and therapy that have
occurred since the book was first published in 1991. For instance, in the first edition the mortality rate from
Acquired Immunodeficiency Syndrome (AIDS) was cited as 75% at 3 years, and treatment of AIDS as a
chronic disease was not discussed. The sixth edition now notes the 36.9 million people living with Human
Immunodeficiency Virus (HIV) and AIDS and includes questions on preventive treatments. Elsewhere, the
Gastroenterology chapter contrasts the lack of even screening tests for hepatitis C in 1991 with questions
on contemporary effective methods for hepatitis C treatment in 2018. Similar contrasts can be found in
all the chapters. Also noteworthy are the chapters added to later editions on Medical Ethics and Palliative
Medicine, acknowledging the increased presence of these disciplines in everyday medical practice.
The contributor list has also significantly changed since the first edition with new contributors to this
edition adding their fresh perspectives. In addition, Drs. Cole, Habib, and Prabhaker deserve special recog-
nition for faithfully updating their chapters from the first through the sixth editions.
I hope the students using this book will appreciate and acknowledge the perspectives in the previous
editions, yet sense how quickly medicine adapts to new discoveries. Many of the quotes at the beginning of
the chapters reflect the historical context of the disciplines and hopefully may prompt the reader to inves-
tigate the original sources. Perhaps some of the students reading the text today will be future contributors
and remember how medicine was practiced “back during the time of the sixth edition.”

Mary P. Harward, MD, FACP

Orange, California

ix
This page intentionally left blank

     
CONTENTS

TOP 100 SECRETS 1

CHAPTER 1 MEDICAL ETHICS 5
William L. Allen, M Div, JD

CHAPTER 2 GENERAL MEDICINE AND AMBULATORY CARE 11

Mary P. Harward, MD, FACP

CHAPTER 3 MEDICAL CONSULTATION 40

Eric I. Rosenberg, MD, MSPH, FACP, Nila S. Radhakrishnan, MD, and Katherine Vogel Anderson, PharmD, BCACP

CHAPTER 4 CARDIOLOGY 54
Gabriel Habib, Sr., MS, MD, FACC, FCCP, FAHA

CHAPTER 5 VASCULAR MEDICINE 98

Timothy R.S. Harward, MD, FACS

CHAPTER 6 PULMONARY MEDICINE 109

Abbas Shahmohammadi, MD, Adriano R. Tonelli, MD, and Eloise M. Harman, MD

CHAPTER 7 GASTROENTEROLOGY 140

Rhonda A. Cole, MD, FACG, Nisreen Husain, MD, and Yamini Natarajan, MD

CHAPTER 8 NEPHROLOGY 170

Sharma S. Prabhakar, MD, MBA, FACP, FASN

CHAPTER 9 ACID-BASE AND ELECTROLYTE DISORDERS 197

Sharma S. Prabhakar, MD, MBA, FACP, FASN

CHAPTER 10 RHEUMATOLOGY 220

Roger Kornu, MD, FACR, Kathryn H. Dao, MD, FACP, FACR, Catalina Orozco, MD, and Rahul K. Patel, MD,
FACP, FACR

CHAPTER 11 ALLERGY AND IMMUNOLOGY 258

Alexander S. Kim, MD

CHAPTER 12 INFECTIOUS DISEASES 302

Harrinarine Madhosingh, MD, FACP, FIDSA

CHAPTER 13 A CQUIRED IMMUNODEFICIENCY SYNDROME AND HUMAN IMMUNODEFICIENCY

VIRUS INFECTION 333
Daniel Lee, MD, Ankita Kadakia, MD, and Amy M. Sitapati, MD

CHAPTER 14 HEMATOLOGY 357

Damian Silbermins, MD, and Ara Metjian, MD

CHAPTER 15 ONCOLOGY 399

R. Anjali Kumbla, MD, Jeffrey M. Miller, MD, and Teresa G. Hayes, MD, PhD

CHAPTER 16 ENDOCRINOLOGY 431

Susan E. Spratt, MD, and Whitney W. Woodmansee, MD

xi
 xii CONTENTS

CHAPTER 17 NEUROLOGY 472

David B. Sommer, MD, MPH

CHAPTER 18 GERIATRICS 497

John Meuleman, MD, and Henrique Elias Kallas, MD, CMD

CHAPTER 19 PALLIATIVE MEDICINE 515

Jason A. Webb, MD, FAPA, and Nathan A. Gray, MD
  
TOP 100 SECRETS
These secrets are 100 of the top board alerts. They summarize the most important concepts,
principles, and salient details of internal medicine.

1. Informed consent is not merely a signature on a form but a process by which the patient and
physician discuss and deliberate the indications, risks, and benefits of a test, therapy, or procedure
and the patient’s outcome goals.
2. Patients should participate in informed consent, even if they have impaired memory or communi-
cation skills, whenever they have sufficient decision-making capacity.
3. Decision-making capacity is determined by assessing the patient’s ability to (1) comprehend the
indications, risks, and benefits of the intervention; (2) understand the significance of the underlying
medical condition; (3) deliberate the provided information; and (4) communicate a decision.
4. Many states now have specific physician-signed order forms to indicate a patient’s end-of-life
preferences for resuscitation and intensity of care.
5. All adults need one dose of tetanus, diphtheria, pertussis (Tdap) vaccine in place of one booster
dose of tetanus-diphtheria (Td) vaccine to improve adult immunity to pertussis (whooping cough).
6. Zoster vaccine is indicated for adults ≥ 60 years old even if they have had an episode of herpes
zoster infection.
7. Adolescent girls and boys should begin human papillomavirus (HPV) vaccine at age 11–12 to
prevent HPV infection and reduce cervical cancer risk. Those who start at a later age can “catch
up” through age 21 (men) or age 26 (women).
8. High-risk patients and those 65 years and older should receive two types of pneumococcal
vaccine: pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine
(PCV23) at least 12 months apart.
9. Antibiotic prophylaxis before dental procedures is recommended only for patients with (1) signifi-
cant congenital heart disease; (2) previous history of endocarditis; (3) cardiac transplantation; and
(4) prosthetic valve.
10. “Routine” preoperative testing is not helpful to reduce surgical risk. Laboratory and procedural
tests should be ordered to address the acuity or stability of a medical problem or to investigate an
abnormal symptom or physical sign identified during the consultation.
11. Preoperative consultation should include identification of risk factors for postoperative venous
thromboembolism and appropriate treatment.
12. Patients undergoing major surgery who are at risk of adrenal suppression may need glucocorti-
coid therapy in the perioperative period. Some patients, though, may just need close monitoring
postoperatively for signs of adrenal insufficiency.
13. “Tight” control of diabetes with target blood sugar of 80–110 mg/dL may not be beneficial
postoperatively.
14. Metformin should be held and renal function closely monitored for patients undergoing surgery or
imaging procedures involving contrast agents.
15. Asking the patient about personal and family history of bleeding episodes associated with minor
procedures or injury is as effective in identifying bleeding diatheses as measuring coagulation
studies.
16. Noninvasive stress testing has the best predictive value for detecting coronary artery disease
(CAD) in patients with an intermediate (30–80%) pretest likelihood of CAD and is of limited value in
patients with very low (<30%) or very high (>80%) likelihood of CAD.
17. Routine use of daily low-dose aspirin (81–325 mg) can reduce the likelihood of cardiovascular
disease in high-risk patients with known CAD, diabetes, stroke, or peripheral or carotid vascular
disease.
18. Routine daily low-dose aspirin use is associated with an increased risk of gastrointestinal bleeding,
which can be reduced through the use of proton pump inhibitors.
19. Right ventricular infarction should also be considered in any patient with signs and symptoms of
inferior wall myocardial infarction.

1
2 TOP 100 SECRETS

20. D iabetes is considered an equivalent of known CAD, and treatment and prevention guidelines for
diabetic patients are similar to those for patients with CAD.
21. Patients with congestive heart failure (CHF) and left ventricular ejection fraction (LVEF) < 35% with
class II or III New York Heart Association (NYHA) symptoms should be considered for implantable
cardiac defibrillator.
22. Consider aortic dissection in the differential diagnosis of all patients presenting with acute chest or
upper back pain.
23. Increasing size of an abdominal aortic aneurysm (AAA) increases the risk of rupture. Patients with
AAA greater than 5 cm or aneurysmal symptoms should have endovascular or surgical repair.
Smaller aneurysms should be followed closely every 6 to 12 months by computed tomography (CT)
scan.
24. Patients presenting with pulselessness, pallor, pain, paralysis, and paresthesia of a limb likely have
acute limb ischemia due to an embolus and require emergent evaluation for thrombolytic therapy
or revascularization.
25. Patients with symptoms of transient ischemic attack are at high risk of stroke and require urgent
evaluation for carotid artery disease and treatment that may include antiplatelet agents, carotid
endarterectomy, statin drugs, antihypertensive agents, and anticoagulation.
26. All patients with peripheral arterial disease and cerebrovascular disease should stop smoking.
27. Asthma, chronic obstructive pulmonary disease (COPD), CHF, vocal cord dysfunction, and upper
airway cough syndrome (UACS) can all cause wheezing.
28. Inhaled corticosteroid therapy should be considered for asthmatic patients with symptoms that
occur with more than intermittent frequency.
29. Pulmonary embolism cannot be diagnosed by history, physical examination, and chest radiograph
alone. Additional testing such as d-dimer level, spiral chest CT scan, angiography, or a combination
of these tests will be needed to effectively rule in or rule out the disease.
30. Sarcoidosis is a multisystem disorder that frequently presents with pulmonary findings of abnor-
mal chest radiograph, cough, dyspnea, or chest pain.
31. Hepatitis C virus infection can lead to cirrhosis, hepatocellular carcinoma, and severe liver disease
requiring liver transplantation. Routine screening for infection is helpful for certain high-risk groups
including those born in the United States between 1945 and 1965.
32. Travelers to areas with endemic hepatitis A infection should receive hepatitis A vaccine.
33. Celiac sprue should be considered in patients with unexplained iron-deficiency anemia or
osteoporosis.
34. In the United States, gallstones are common among American Indians and Mexican Americans.
35. Esophageal manometry may be needed to complete the evaluation of patients with noncardiac
chest pain that may be due to esophageal motility disorders.
36. The estimated glomerular filtration rate (eGFR) is now routinely reported when chemistry panels
are ordered and can provide a useful estimate of renal function.
37. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use should be
evaluated for all diabetics, even those with normotension, for their renoprotective effects.
38. Diabetes is the most common cause of chronic kidney disease (CKD) in the United States, followed
by hypertension.
39. When erythrocyte-stimulating agents are used for the treatment of anemia associated with CKD
and end-stage renal disease, the hemoglobin level should not be normalized but maintained at
11–12 g/dL.
40. Almost 80% of patients with nephrolithiasis have calcium-containing stones.
41. Hyponatremia can commonly occur after transurethral resection of the prostate.
42. Thrombocytosis, leukocytosis, and specimen hemolysis can falsely elevate serum potassium
levels.
43. Intravenous calcium should be given immediately for patients with acute hyperkalemia and elec-
trocardiographic changes.
44. Hypoalbuminemia lowers the serum total calcium level but does not affect the ionized calcium.
45. Hypokalemia, hypophosphatemia, and hypomagnesemia are common findings in alcoholics who
require hospitalization.
46. Lupus mortality rate is bimodal in distribution. It peaks in patients who die early from the disease
or infection and again in patients who die later in life from cardiovascular diseases.
47. Inflammatory arthritis is characterized by morning stiffness, improvement with exercise, and
involvement of small joints (although large joints may also be involved).
 TOP 100 SECRETS 3

48. P atients with autoimmune disorders who smoke should be counseled to quit because tobacco has
recently been linked to precipitation of symptoms and poorer prognosis.
49. Most rheumatologic diseases are diagnosed via clinical criteria based on thorough history, physical
examination, and selective laboratory testing and imaging.
50. Early diagnosis of an inflammatory arthritis leads to intervention and improved clinical outcomes
because there are many disease-modifying therapies available.
51. The most common immunoglobulin (Ig) deficiency is IgA deficiency, which can cause a false-
positive pregnancy test.
52. Intranasal steroids are the single most effective drug for treatment of allergic rhinitis. Deconges-
tion with topical adrenergic agents may be needed initially to allow corticosteroids access to the
deeper nasal mucosa.
53. ACE inhibitors can cause dry cough and angioedema.
54. Beta blockers should be avoided whenever possible in patients with asthma because they may
accentuate the severity of anaphylaxis, prolong its cardiovascular and pulmonary manifesta-
tions, and greatly decrease the effectiveness of epinephrine and albuterol in reversing the
life-threatening manifestations of anaphylaxis.
55. Patients with persistent fever of unknown origin should first be evaluated for infections, malignan-
cies, and autoimmune diseases.
56. Viruses are the most common causes of acute sinusitis; therefore, antibiotics are ineffective,
unless symptoms are persistent (>10 days) or relapse after improvement.
57. Rocky Mountain spotted fever (RMSF) occurs through North and Central America with concentra-
tion in the southeastern and south central U.S. states with increasing incidence in Arizona (on
Indian reservations). Empiric therapy for RMSF should be considered within 5 days of symptom
onset for patients with febrile illnesses and a history of a tick bite who have been in these regions
in the spring or summer (May to September).
58. Asplenic patients (either anatomic or functional) are susceptible to infections with encapsulated
organisms (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis) and
should receive appropriate vaccinations for these organisms in addition to up-to-date childhood
vaccinations. Needed vaccinations should be administered 14 days before elective splenectomy, if
possible.
59. Allergic bronchopulmonary aspergillosis (ABPA) occurs in asthmatics and is evident by recurrent
wheezing, eosinophilia, transient infiltrates on chest radiograph, and positive serum antibodies to
Aspergillus.
60. Chagas disease, caused by Trypanosoma cruzi, can cause cardiomyopathy, cardiac arrhythmias,
and thromboembolism.
61. Human immunodeficiency virus (HIV) infection is preventable and treatable but not curable.
62. Routine HIV testing should be considered for all patients aged 13–65 years.
63. A fourth-generation Ag/Ab combination enzyme immunoassay (EIA) is needed for diagnosis of
acute primary HIV infection.
64. HIV-infected patients with undetectable viral loads can still transmit HIV.
65. HIV-infected patients with tuberculosis are more likely to have atypical symptoms and present with
extrapulmonary disease.
66. All patients with HIV infection should be tested for syphilis, and all patients diagnosed with syphilis
(and any other sexually transmitted disease) should be tested for HIV.
67. The presence of thrush (oropharyngeal candidiasis) indicates significant immunosuppression in an
HIV-infected patient.
68. Transferrin saturation and ferritin are effective screening tests for hemochromatosis.
69. Methylmalonic acid can be helpful in the diagnosis of vitamin B12 deficiency in patients with low
normal vitamin B12 levels.
70. Patients with chronic hemolysis should receive folate replacement (1 mg/day).
71. Chronic lymphocytic leukemia is the most common leukemia in adults and is often found in those
older than 70 years.
72. Patients with antiphospholipid syndrome have an antiphospholipid antibody and the clinical occur-
rence of arterial or venous thromboses or both, recurrent pregnancy losses, or thrombocytopenia.
73. Solid tumor staging often uses American Joint Commission on Cancer (AJCC) TNM staging
(T = tumor size and areas of invasion; N = regional nodal status; and M = distant metastases).
74. Each type of cancer is driven by different mutations and abnormal checkpoints for which many
new, targeted immunotherapeutics have been developed.
4 TOP 100 SECRETS

75. D ifferential diagnosis when evaluating possible malignancy should always ensure an accurate
treatment plan and may require multiple biopsies and other procedures prior to diagnosis.
76. Tobacco and alcohol use are significant risk factors for head and neck cancers.
77. The treatment plan for a malignancy is often chemotherapy but may include surgical oncology,
radiation oncology, and palliative medicine.
78. The best initial screening test for evaluation of thyroid status in most patients is the thyroid-
stimulating hormone (TSH). The exceptions are patients with pituitary and hypothalamic dysfunction.
79. Patients with type 1 and type 2 diabetes mellitus (DM) should be screened at regular intervals for
the microvascular complications of retinopathy, neuropathy, and nephropathy.
80. Closely examine the feet of diabetic patients regularly, looking for ulcerations, significant callous
formation, injury, and joint deformities that could lead to ulceration. Check dorsalis pedis and
posterior tibial pulses to detect reduced blood flow and sensation with a monofilament.
81. Erectile dysfunction and decreased libido in men and amenorrhea and infertility in women are the
most common symptoms of hypogonadism.
82. Hyperparathyroidism is the most common cause of hypercalcemia.
83. Ataxia can be localized to the cerebellum.
84. Gait dysfunction, urinary dysfunction, and memory impairment are symptoms of normal-
pressure hydrocephalus.
85. In the appropriate setting, thrombolysis can markedly improve the outcome of stroke. Prompt
initiation of thrombolytic therapy is essential.
86. The sudden onset of a severe headache may indicate an intracranial hemorrhage.
87. Optic neuritis can be an early sign of multiple sclerosis.
88. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia,
particularly for older adults.
89. Older adults are particularly susceptible to the anticholinergic effects of multiple medications,
including over-the-counter antihistamines.
90. Anemia is not a normal part of aging, and hemoglobin abnormalities should be investigated.
91. Decisions regarding screening for malignancies in the elderly should be based not on the age
alone but on the patient’s life expectancy, functional status, and personal goals.
92. Systolic murmurs in the elderly may be due to aortic stenosis or aortic sclerosis.
93. Delirium in hospitalized patients is associated with an increased mortality risk.
94. When delirium occurs, the underlying cause should be thoroughly evaluated and treated.
95. Pneumonia is the most common infectious cause of death in the elderly.
96. Patients with life-limiting or serious illness can be referred for palliative care at any point in their
illness process, regardless of prognosis.
97. A stimulant laxative should always be prescribed whenever opiates are prescribed for chronic pain
management to manage opiate-induced constipation.
98. Patients can discontinue hospice care if their symptoms improve or their end-of-life goals change.
99. Opiates are the first line treatment for severe dyspnea at the end of life.
100. Opioid analgesics are available in many forms including tablets to swallow or for buccal applica-
tion, oral solutions, lozenges for transmucosal absorption, transdermal patches, rectal supposito-
ries, and subcutaneous, intravenous, or intramuscular injection administration.
 CHAPTER 1
MEDICAL ETHICS
William L. Allen, M Div, JD

I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or
wrong them.
Attributed to Hippocrates
4th-Century Greek Physician
  

ETHICAL PRINCIPLES AND CONCEPTS

1. Define the following terms in relation to the patient and physician-patient
relationship: beneficence, nonmaleficence, autonomy, and justice.
•  Beneficence: The concept that the physician will contribute to the welfare of the patient through
the recommended medical interventions
•  Nonmaleficence: An obligation for the physician not to inflict harm upon the patient
•  Autonomy: The obligation of the physician to honor the patient’s right to accept or refuse a
recommended treatment, based on respect for persons
•  Justice: The obligation of the physician to avoid treating patients differently by providing
better care or privileges to favored patients or by discriminating against less favored patients,
especially on grounds of race, ethnicity, sex, sexual orientation, religion, creed, socioeconomic
status, or disability
2. What is fiduciary duty?
An obligation of trust imposed upon physicians requiring them to place their patients’ best interests
ahead of their own interests and, as the patient’s advocate, to protect patients from exploitation or
neglect of others in the health care system.
3. What is conflict of interest?
A situation in which one or more of a professional’s duties to a client or patient potentially conflicts
with the professional’s self-interests or when a professional’s roles or duties to more than one patient
or organization are in tension or conflict.
4. How should conflicts of interest be addressed?
• Avoided, if possible
• Disclosed to institutional officials or to patients affected
• Managed by disinterested parties outside the conflicted roles or relationships
5. What is conscientious objection?
Refusal to participate in or perform a procedure, prescription, or test grounded on a person’s sincere
and deeply held belief that it is morally wrong.

6. What is a conscience clause?

A provision in law or policy that allows providers with conscientious objections to decline participation
in activities to which they have moral objections, under certain conditions and limitations. The scope
of the allowance should only protect the provider’s conscience, not deny a patient legitimate care.

7. Describe futility.
The doctrine that physicians are not required to provide treatment if there will be no medical benefit
from it. It has become a very controversial term in recent times, in part because of inconsistency
in definition and usage. In the narrowest definition, “futility” may refer to physiologic futility or the
inability of a treatment or intervention to support bodily functions such as circulation or respiration
or reverse the ultimate decline and cessation of these functions. More often, though, futility refers
to the very low likelihood of an intervention succeeding in restoring physiologic function or health.
5
 6 MEDICAL ETHICS

Patients and physicians may disagree about the level of probability that could be considered
futile, though. Most health care institutions will establish policies for guidance in resolving such
disagreements.

INFORMED CONSENT
8. How should one request “consent” from a patient?
Consent is not a transitive verb. Sometimes a medical student or resident is instructed to “go
consent the patient,” implying that consent is an act that a health professional performs upon a
passive recipient who has no role in the action other than passive acceptance. A health professional
seeking consent from a patient should be asking the patient for either an affirmative endorsement of
an offered intervention or a decision to decline the proposed intervention.
9. What is consent or mere consent?
Consent alone, without a sufficiently robust level of information to justify the adjective “informed.”
Although “mere consent” may avoid a finding of battery (which is defined as harmful or offensive
physical contact with a person without that person’s consent), it is usually insufficient permission for
the physician to proceed with a procedure or treatment.
10. What is informed consent?
Consent from a patient that is preceded by and based on the patient’s understanding of the proposed
intervention at a level that enables the patient to make a meaningful decision about endorsement or
refusal of the proposed intervention.
11. What are the necessary conditions for valid informed consent?
• Disclosure of relevant medical information by health care providers
• Comprehension of relevant medical information by patient (or authorized representative)
• Voluntariness (absence of coercion by medical personnel or institutional pressure)
12. What topics should always be addressed in the discussion regarding informed
consent (or informed refusal)?
• Risks and benefits of the recommended intervention (examination, test, or treatment)
• Reasonable alternatives to the proposed intervention and the risks and benefits of such alternatives
   • The option of no intervention and the risks and benefits of no intervention

K EY POIN T S: IN F ORM ED C O N S E N T
1. Informed consent involves more than a signature on a document.
2. Before beginning the informed consent process, the physician should assess the patient’s capacity
to understand the information provided.
3. The physician should make the effort to present the information in a way the patient can compre-
hend and not just assume the patient is “incompetent” because of difficulty in understanding a
complex medical issue.
4. The patient’s goals and values are also considered in the informed consent process.

13. What are the different standards for the scope of disclosure in informed consent?
• Full disclosure: Disclosure of everything the physician knows. This standard is impractical, if not
impossible, and is not legally or ethically required.
• Reasonable person (sometimes called “prudent person standard”): Patient-centered standard of
disclosure of the information necessary for a reasonable person to make a meaningful decision
about whether to accept or to refuse medical testing or treatment. This standard is the legal
minimum in some states.
• Professional practice (also called “customary practice”): Physician-centered standard of disclo-
sure of the information typically practiced by other practitioners in similar contexts. Sometimes
the professional practice standard is the legal minimum in states that do not acknowledge the
reasonable person standard.
• Subjective standard: Disclosure of information a particular patient may want or need beyond
what a reasonable person may want to know. This is not a legally required minimum but is ethi-
cally desirable if the physician can determine what additional information the particular patient
might find important.
Another random document with
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The sergeant-major produced a piece of paper. “Show me to the
rooms up-stairs,” he said and walked toward the stairway.
“Why do you wish to see them?” asked Aunt Martha, somewhat
alarmed and bewildered.
The soldier made no reply but mounted the steps. Don followed him
closely. After a brief inspection of the rooms they came down, and
the soldier wrote something on the slip of paper. “You’ll have two
men to billet,” he said. “So you’d better fix up that big room at the
front.”
“I’ll do nothing of the sort,” Aunt Martha said indignantly.
The man’s red face became redder than ever; he started to say
something, then checked himself and laughed. “Two men,” he
repeated and strode toward the door and slammed it behind him.
“O Donald!” cried Aunt Martha. “If your uncle were only here!”
Don clenched his fists. “Two Redcoats to live with us all winter!” he
exclaimed. “That’s what it means, Aunt Martha.”
“Oh, dear,” said his aunt and sat down by the window. “Two—two
Redcoats to track in mud and dirt and scratch and tear things with
their heavy shoes——”
“Now, don’t worry, Aunt Martha,” Don interrupted her. “Maybe it won’t
be so bad, having them here. And maybe before long General
Washington will have his army ready to drive all of them out of the
town.”
Aunt Martha soon recovered her spirits and set about making ready
for the two unwelcome guests. “I suppose if they insist on having the
big front room, we’ll have to give it to them,” she said. “I don’t see
any other way out of it.”
“Who Lives Here Beside Yourself, Young Sire?”
Nevertheless, she spent most of the day in cleaning the spare
bedroom, and when Don looked at it that afternoon he could not help
smiling. “You’ve made it the best-looking room in the house,” he said.
“Maybe they’ll prefer it to the big room.”
“That’s just what I had in mind,” his aunt replied and smiled.
“Oh, say!” exclaimed Don, and his face suddenly became pale. “All
that stuff in the cellar—what if they should discover it!”
Aunt Martha shared her nephew’s agitation, and she bit her lips in
perplexity. “I haven’t thought of that,” she said. “We’ll just have to run
our chances and see that the door is kept locked always.”
“We’d surely find ourselves in hot water if they happened to learn
that it’s there,” said Don. “Oh, how I hate ’em all!” he cried
impulsively.
The next morning when the two soldiers came with all their
equipment Don and his aunt got a surprise that for Don at least was
not altogether unpleasant. One of the Redcoats was Private Harry
Hawkins!
He nodded and smiled at Don as he and his comrade entered the
house and were shown up-stairs.
The man who was with him, a short, dark-haired fellow, stopped at
the door of Aunt Martha’s room. “This is it, Hawkins,” he said. “The
big room on the front, the sergeant-major said, and a fine room it is.
We’re in luck, you and I.”
Hawkins looked at Aunt Martha and, observing the troubled
expression in her eyes, said, “Is this the room you want us to
occupy?”
“No, it isn’t,” she replied. “That’s my room, and the one across the
hall is my nephew’s. Next to his is the room I’d hoped you would
occupy—since it seems you’ve got to occupy a room of some sort.”
“That’s the room we’ll have, then,” said Hawkins promptly and
carried his equipment into it.
But his companion did not follow him; he stood looking into the big
room.
“Come on, Snell,” said Hawkins, laughing. “The other room is plenty
big enough. Anyone would think you were six feet, five, instead of
five feet, six.”
Grumbling, the fellow turned away reluctantly and entered the room
that Aunt Martha had made ready for them.
Both Don and his aunt gave Hawkins a look of thanks and then went
down-stairs. For some time they sat in silence and listened to the
scuffling of feet on the floor above them. Then Don said in a low
voice: “It might have been worse, mightn’t it?”
His aunt nodded. “I suppose it might,” she admitted. “One of them
seems a gentlemanly fellow.”
Fortunately, Hawkins and Snell were in the house very little during
the daytime. They would rise early and hurry off to eat mess with
their company; then they might return for a few minutes only to hurry
out to the parade grounds. Usually they were away somewhere
during the afternoon and evening. On the whole they were not much
bother; it was the mere fact that Aunt Martha had to have them that
irritated her most.
Jud’s mother also had suffered. Jud told Don about it one evening at
Aunt Martha’s. “We’ve got only one,” he said, “but he’s a sergeant-
major—big and fat and red-faced and uglier than a mud fence!”
“With blue eyes and a red nose?” asked Don.
“Yes, little mean eyes that somehow make me think of buttermilk.”
“Probably it’s the sergeant-major who came to us,” said Don.
“Probably it is,” added his aunt dryly. “I don’t see how there could be
two men quite so ugly as he.”
“Well, he’s a billeting sergeant,” said Jud, “and his name is Bluster.”
“Huh,” said Don. “He’s well named.”
“Just listen to that wind outside,” said Aunt Martha; “that’s blustery
enough too!”
The wind had been blustery and sharp for several days, and almost
before the boys realized it winter had set in in dead earnest. And
with the cold came increased suffering. Fuel was scarce, and the
army had hard work getting it. But they did get it, nevertheless, and
the way they went about it added another grievance to the long list
that the townsfolk held against them. Buildings were torn down—
usually they were the poorest structures, but not always—fences
disappeared overnight, and gates that had creaked on their hinges
one day were missing the next morning.
In December the town presented its most deplorable aspect. Hostile
cannon glowered in position on hill and thoroughfare, and insolent
soldiers such as Sergeant-Major Bluster and Private Snell sat about
hearthstones where once happy families had been wont to gather.
Food as well as fuel was extremely scarce, and prices were so high
that more than one person was driven to steal. Faneuil Hall had
been turned into a playhouse for the amusement of the Redcoats,
and in it the fine spirit of the people, their intense desire for peace
and liberty and fair treatment, were turned into ridicule. Even when
snow fell and covered the suffering town in a soft white blanket, and
few soldiers were on the streets to jostle and mock pedestrians, the
guns on Beacon Hill boomed forth as if to remind them that Howe
and the King’s troops still held sway.
Hundreds of persons, too poor longer to support themselves, had
obtained Howe’s permission to depart in boats to Point Shirley,
whence they made their way into the country—homeless, penniless
and miserable. But still Aunt Martha’s will would not allow her to
yield. “No—no,” she declared more than once, “I’ll not go! The good
Lord knows how I long to be with David, but I know that he is being
well cared for. Glen gave me his word, and he is a man I’d trust to
the ends of the earth.”
Mrs. Lancaster, who happened to be calling, only shook her head.
“Yes, I know you think I’m stubborn,” Don’s aunt continued. “Perhaps
I am, but I intend to remain right here in my own home, and that’s an
end of it.”
One day in January, Don and Jud went to Aunt Martha with a request
that Don be permitted, as Jud said, to “go some place” the following
evening.
“Where do you want to go, Don?” she asked.
“Down to Faneuil Hall,” Don said quickly. “There’s something or other
going on there, and we’d like to see it.”
“There’ll be music,” added Jud.
“British music,” said Aunt Martha.
“Well, yes, but it may sound all right.”
Aunt Martha frowned.
“Oh, say, Aunt Martha,” exclaimed Don, laughing, “we won’t become
Tories—honest. It’s mighty dull here these days, and we want to see
what’s going on. It’s all right, isn’t it?”
If Aunt Martha was stubborn she seldom showed it where her
nephew was concerned, and this time was no exception to the rule.
She yielded to him—whereas the whole force of General Howe only
made her the more resolute!
“Good for you, Aunt Martha,” said Jud—he had got into the habit of
calling her “aunt,” and she seemed rather pleased with him for doing
it.
“I picked up some information to-day,” he added. “Our privateers
have been doing some great things on the high seas. They’ve
captured hundreds of the King’s vessels.”
“I’ve heard of Captain Manly,” said Aunt Martha.
“Well, there are lots besides Captain Manly,” Jud replied. “And
another thing—our men have chosen a flag; it’s called the Union
Flag of the Thirteen Stripes—one stripe for each Colony, you see.
They raised it the first day of the year.”
“My, my, Judson. Where you and Donald learn all these things is a
mystery to me.”
“Well, you see,” replied the resourceful Jud, “if we go to Faneuil Hall
to-morrow night we’ll probably learn more, hey, Don?”
But at that moment Snell and Hawkins entered, and the conversation
ceased.
 CHAPTER XIII
A FARCE IS INTERRUPTED

Dusk had fallen over the town when Don and Jud, warmly clad in
heavy coats and mufflers, made their way toward Faneuil Hall.
Others were walking in the same direction—mostly officers, who
stepped with the firmness and confidence that marked an officer of
the King. The night was cold and dark, and few lights gleamed as
they once had gleamed, cheerily, in the windows of the shops along
King Street and Merchant’s Row; yet there was cheery conversation.
The boys could hear laughing and congenial talking among the
hurrying throngs.
“I just feel like laughing good and hard to-night,” they heard one man
say.
“Yes, and I too,” another agreed. “There’s been little enough to laugh
at ever since we landed in this town.”
“Well, you’ll laugh to-night, or I’m a Dutchman,” said a third. “There’s
to be a farce called the Blockade of Boston. Funny! I thought I’d
laugh myself sick the first time I heard it rehearsed. I tell you the
officers who wrote it—let’s see; who was it now? Well, never mind;
they certainly wrote a funny play. Just wait till you catch sight of
General Washington!”
Jud scowled in the darkness. “Remember, Don,” he whispered, “we’ll
have to keep a firm hold on our tempers.”
Don laughed. “I’ll keep a firm hold of mine, Jud; but I’m not so sure
about you. You’re hot-headed, you know.”
“Don’t worry about me,” said Jud. “He who laughs last, you know
——”
“But say,” Don interrupted him, “you haven’t told me yet how we’re
going to get inside the place.”
“That’s so,” replied Jud and thrust his elbow knowingly into his
companion’s ribs. “This will get us inside, I think,” and he drew
something small and shiny from his pocket and handed it to Don.
“A silver snuff-box,” said Don, looking at it with some wonder.
“Yes; it’s Sergeant-Major Bluster’s. He couldn’t seem to find it to-day.
Funny, too, ’cause if he’d asked me, I could have told him right
where it was all the time—in my pocket. Do you understand now?”
Don did not understand and said so emphatically.
Jud laughed good-naturedly. “You’re pretty dull sometimes,” he said
frankly. “Just you let me do the talking and we’ll be inside Faneuil
Hall in three shakes.”
“You’ve been doing most of the talking.” Don could not resist the
thrust. “So go ahead and finish.”
“All right; now here we are.”
The boys had reached the hall, which was well lighted and partly
filled with troops. Don and Jud stood to one side of the door and
watched the men as they came singly and in groups and vanished
inside the great building. There were ladies too, most of them young,
and all escorted by gallant officers. Jud kept a sharp lookout toward
the door.
At last Don, a bit impatient at the delay, asked, “How much longer
are we going to wait?”
“Just a few minutes, I think. I’m waiting for fat Bluster—ah, here he
comes, isn’t it?”
“You’re right,” said Don. “Look at the gait, will you?”
Bluster strode pompously to the door, nodded curtly to one of the
soldiers who was on duty there and passed into the hall.
“Come on,” said Don.
“No; just a few minutes longer. Can’t you wait?”
“Say, Jud, you’re a mystery to me to-night,” said Don. “I don’t know
what under the sun you’re trying to do. I don’t think you know,
yourself!”
“Who’s doing all the talking now?” inquired Jud with a grin.
For almost ten minutes the boys waited in the cold. Then Jud led the
way to the door. The soldier on duty at once blocked the passage.
“Scat, you youngsters,” he said.
Jud surely had his temper well in hand that night. “We’re looking for
a sergeant-major,” he said, smiling. “We’ve got to see him, for we
have something important that belongs to him.”
“What is it?”
Jud was embarrassed—at least, he showed every sign of being
embarrassed. “It’s—it’s just a little thing with a lady’s name engraved
on it.”
The soldier laughed. “Do you think you could find him in there?”
“Between the two of us I think we could,” Jud replied promptly.
“Well, be quick about it then.”
The boys were as quick as a flash.
“Young Tories,” the soldier said to a bystander as they entered the
building.
Jud turned abruptly, but Don grasped his arm and pulled him along.
“Don’t be a hothead,” he whispered.
It was only luck that made Jud spy Bluster a few moments later in
the crowded hall. The sergeant-major was sitting on a chair at the
extreme right of the hall. His hat was on the floor beneath the chair,
and he was leaning back with his arms folded across his chest.
More than one Redcoat looked inquiringly at the boys as they walked
round the chairs and benches, and thought no doubt that they were
the sons of some prominent Tory who had brought them with him. As
Jud was passing behind Bluster’s chair he dropped his hat and, in
picking it up, succeeded in laying the ornamental snuff-box on the
hat of the soldier—a circumstance that puzzled the fellow till the end
of his days.
After that the boys found a secluded corner where they stood, in the
shadows, and waited for the play to begin. In front of them were
Redcoats, talking and laughing and smoking. There were a great
many ladies, all of whom had come to laugh at the expense of the
townsfolk of Boston and of the Continental army outside the town.
Fans were moving lightly to and fro, though there was no need of
fans in the cold building; scabbards and buckles were clacking
against the wooden seats; and the lights round the small stage jarred
and flickered as couples moved in front of them to their seats.
Don and Jud said little, but their eyes and ears were alert. At last the
music started, and some time later the curtain on the stage was
hauled up. There were to be two plays that evening, the first of which
was called “The Busy Body.” The boys watched the actors, all of
whom were Redcoats, and thought the thing rather dull and stupid.
But the audience seemed to enjoy it; there were frequent bursts of
applause and a good deal of laughter.
“Huh,” said Jud as the curtain went down for the last time. “I guess
you have to be a Redcoat or a Tory to like a thing like that.”
“Look,” whispered Don. “Bluster’s found his snuff-box.”
“Sure enough!”
It was all that the boys could do to keep from laughing as they
watched the big sergeant-major. He had found his snuff-box indeed.
In the uncertain light his face was ruddier than ever, and his little
eyes seemed to be popping from his head as he turned first to one
side, then to the other. He looked at the little box; he looked at his
hat; he looked at his cuffs as if the thing might have been hidden
there. Perhaps he thought he had suddenly become a magician.
Then he looked at the ceiling, as if to find the person—or the bird—
that had succeeded in dropping it so that it had landed on his hat
beneath his chair. But even a magician or a bird could not have done
that!
He was still looking at the ceiling when the lights were dimmed, and
the curtain was hauled up again. “The Blockade of Boston,” which
was to be played next, was a farce in which the character who
represented General Washington was supposed to stride awkwardly
upon the stage, wearing a long rusty sword and a wig that was many
sizes too large for him; behind him walked his servant, an uncouth
country boy with a rusty gun. But the audience was not to laugh at
the antics of the two that night.
The curtain had been up only a few moments when the noise of
firing sounded from a distance, and then a red-coated sergeant burst
into the hall and exclaimed:
“The Yankees are attacking our works on Bunker’s Hill!”
Startling as the announcement was, it carried only a ripple of mild
excitement; for no doubt many of the audience supposed that the
sergeant’s words were part of the farce that was to be played. “A
good beginning anyway,” a lieutenant who was sitting in front of the
boys said to his neighbor and laughed heartily.
At that moment a general who was seated close to the stage sprang
to his feet. “Look,” whispered Don. “There’s Howe himself. I didn’t
notice him before.”
“Officers to your posts!” cried the general in a ringing voice.
Then there was excitement enough for anyone. To the two boys it
seemed as if the whole audience rose and started for the doors at
the same instant. Women were screaming and several had already
fainted. Chairs and benches were being overturned—one chair
overturned with Sergeant-Major Bluster in it. Scabbards were
clashing and men were shouting hoarse commands.
“Let’s get out of here!” whispered Jud.
“All right; but wait till the rest have gone; we’d be killed in that mob.”
“What a glorious ending to the ‘Blockade of Boston’!” Jud exulted.
“Couldn’t be better, could it?”
In the excitement some of the lights round the stage were blown out,
and then the place was so dark that you could hardly distinguish
faces.
And in the street it was still darker. The boys were among the last to
leave the hall, and as they stepped outside they could hear the rattle
of small arms and the sound of cheering away to the north.
“It’s an attack on the town,” whispered Jud excitedly. “That’s just
what it is—a big attack!”
But, positive as Jud was, he was wrong, as both boys found out
later. General Putnam had sent a party of perhaps two hundred
Continentals under the command of Major Knowlton to destroy
fourteen houses along Mill Street in Charlestown and to capture the
British guards who were stationed in them. Through a mistake some
of the houses were fired too soon, and the flames gave the alarm to
the enemy on Bunker Hill. But the daring attempt was by no means
unsuccessful. Major Knowlton succeeded in burning eight of the
houses and in capturing five prisoners. Washington himself was well
pleased with the venture.
But the thing that pleased Don and Jud most was the untimely
ending of the night’s entertainment. No one thought of returning to
the hall.
“Here comes Bluster,” said Jud, stepping into a doorway on King
Street to let the Redcoat pass. “I don’t want him to see me.”
When the sergeant-major had passed, the boys made their way
hurriedly to Don’s house in Pudding Lane, which they reached
shortly before eleven o’clock.
“Well,” said Aunt Martha, “did you hear anything of interest at the
hall?”
“Did we?” repeated Don. “You tell what happened, Jud!”
And Jud told her, not omitting the incident of the snuff-box. And when
he had finished, Don thought his aunt laughed more heartily than
she had laughed since the blockade began. “I’m glad you boys
went,” she said. “I’m glad you could see the fine officers discomfited.
They deserve it for the way some of them have acted.”
Jud was suddenly thoughtful. “What in the world will I tell fat Bluster
if he ever asks me about the snuff-box?” he inquired.
“Tell him the truth, Judson,” said Aunt Martha. “But don’t tell him
unless he asks you,” she added with a smile.
“I’ll tell you what to tell him,” said Don. “Tell him that the last time he
used snuff he sneezed and blew the box over the Old South
Meeting-House, and that when it came down it landed right on top of
his hat.”
“Donald!” exclaimed his aunt. “Now you boys scat to bed—quick!”
“That’s the second time we’ve been scatted to-night,” said Jud as he
followed Don up-stairs.
 CHAPTER XIV
A BROKEN LOCK

For many days the townsfolk and the soldiers talked of the
performance that the Continental assault on Charlestown had
interrupted. Don and Jud joked about it frequently, but they were
always careful that neither Hawkins nor Snell should overhear them.
If all the Redcoats had been like Hawkins, the good people of Boston
would have had little to complain of. He was always courteous and
considerate; he seemed to spend as little time as possible in the
house and kept to his room even on the coldest nights. The fellow
was undoubtedly a fine soldier and as loyal to his King as any of
them were, and secretly both Don and Jud admired him for it. He
seemed to have a genuine affection for Don, though he rarely spoke
more than a few words at a time to the boy.
Snell, on the other hand, was surly and quick-tempered and an ugly
person to have about the house. He was inquisitive also. Once Aunt
Martha found him trying to unlock the door to the cellar, and though
he desisted at sight of her, the circumstance troubled her. It troubled
Don too, but there was something that troubled him more than that.
Snell had formed an acquaintance with Tom Bullard, and the two
spent much time together.
“I tell you,” Don said to Jud one evening in February, “I don’t like it
one bit, the way those two are together so much. Tom Bullard hates
us like poison—I know that’s why he tried to steal your ma’s chickens
—and I’m sure he’d like nothing better than to make us
uncomfortable somehow.”
“But he can’t do anything, can he? You and your aunt have complied
with all the town regulations, haven’t you?”
Don did not reply at once. “Well, maybe,” he said at last.
But Jud was not easily put off. “What do you mean?” he asked.
“I’ll tell you something sometime,” said Don. “Not now, though.”
Don might not have told his companion his secret at all if it had not
been for an unfortunate event that occurred toward the end of the
month. One Saturday when Aunt Martha had been at the home of a
sick neighbor almost all morning Don entered the house in Pudding
Lane and to his consternation found Snell coming up from the cellar
with an armful of wood. The broken lock lying on the floor told how
the man had entered.
For several moments the two stood confronting each other; Don’s
face was flaming, and his heart was beating a tattoo against his ribs.
Snell, a bit discomfited, soon recovered his poise. “It’s cold in here,”
he said; “I suspected all along that you had wood in the cellar.”
“There’s wood out in the back shed too,” replied Don in a voice that
trembled slightly. “Why didn’t you use that?”
Snell evidently thought no reply was necessary. He crossed the floor
and tossed several sticks upon the fire.
“Why didn’t you use the wood in the shed?” repeated Don in a louder
voice.
Snell looked at the boy tolerantly. “Now see here, young sire,” he
said slowly. “It won’t do for you to ask too many questions. I will say,
though, that if the wood in the shed had not been wet, I might not
have gone to the cellar. Now let that be an end of it. Understand?”
Don was silent and bit his lips. How long had the fellow been down
cellar? Had he seen the merchandise and the powder that belonged
to his uncle? Or had he known that they were there in the first place?
Or had he gone down merely to fetch dry wood? Over and over Don
asked himself the questions without being able to answer them.
He glanced slyly at the Redcoat as he sat in front of the fire, toasting
his fingers. The man was smiling to himself—a faint, inscrutable
smile that told nothing. The fellow might be smiling because he had
discovered the stuff, or he might be smiling merely because of the
discomfiture that he knew he had caused the boy. Don could not tell
which answer was right.
At any rate he was glad that Snell was not in the house when Aunt
Martha entered two hours later. If Snell had been there he would
have learned just exactly what she thought of him and of his
inquisitive visit to the cellar.
Hawkins, however, did enter while Don and his aunt were discussing
the matter. “What is wrong?” he asked, glancing from one to the
other and then at the broken lock, which Don was trying to fix.
“Your comrade,” replied Aunt Martha steadily, “has seen fit to force
his way into the cellar to get wood with which to replenish the fire.
Our fire-wood is in the back shed, and he knows it.”
Hawkins frowned and then, taking the lock from Don’s hands,
examined it.
“There is a great deal of wood in the back shed, as you know,”
continued Don’s aunt, “and I know that it is not all wet as he says it
is.”
“Just so,” said Hawkins and placed the lock on the table. “Just so.”
And he went abruptly to his room.
“There,” said Aunt Martha. “What did I say? They’re all alike, these
Redcoats.”
Later Snell returned, and while Don was helping his aunt to prepare
the supper the two heard the sound of voices from up-stairs. Louder
and louder they became until it was quite plain that the two soldiers
were disagreeing over something.
Suddenly the voices ceased, and the ceiling jarred with a heavy
crash.
“O Donald! What are they doing?”
Steps sounded on the stairs, and a moment later Hawkins, red of
face, entered the room. “I’d like a basin of hot water, if you please,”
he said.
Aunt Martha hastened to get it for him, and presently he returned
with it to the room. He was down again in a few minutes and went
out into the street.
Don and his aunt had finished supper when Hawkins again entered
the house. “Here, my lad,” he said and put a small package into
Don’s hand. “No,” he added, smiling, “it’s something that you can
very well accept. Don’t thank me for it.” And he hurried up-stairs.
Don opened the package; it contained a new lock similar to the one
that Snell had broken.
“Well, I declare!” exclaimed Aunt Martha. “Donald, I believe I
wronged that man.”
When Snell came down-stairs the following morning he made for the
door without delay, but, quick as he was, Aunt Martha observed that
he carried the marks of his encounter with Hawkins; one eye was
partly discolored, and his cheek was swollen.
Later in the morning Don fixed the new lock in place and then hurried
off to find Jud and tell him what had happened.
The day was warm for a day in late February; indeed the winter,
which had begun with severe weather, had proved to be mild after
all. The two boys directed their steps toward Walmer’s wharf at the
foot of Beech Street, where they sat down in the sunlight with their
backs against one of the deserted warehouses.
“We’ll be safe here,” said Don; “no one is likely to overhear what I’ve
got to tell you, Jud.”
Jud leaned forward eagerly, and neither boy observed a third person,
who had followed them at some distance and who now took a
position just within hearing round the corner of the silent warehouse.
“Go on and tell it,” said Jud. “You’ve got me all curious.”
“Well, in our cellar——” began Don, and the hidden figure near the
corner of the building slunk a step nearer. “In our cellar there’s
quantities and quantities of linen and cloth and some powder——”
And Don told of the purchase that his uncle had made before the
blockade.
When he had finished that part of his story Jud whistled softly. “My,
but that’s risky business, keeping it there,” he said. “Just suppose
——”
Don put his hand on his friend’s arm. “Not so loud,” he whispered.
“And, Jud, I know you won’t breathe a word of it to anyone—not
even to your mother.”
“Of course not.”
Don glanced round cautiously. The old wharf apparently was quite
deserted except for themselves. The sun was shining brightly on the
water; the wind, blowing across the rough planks, was rattling the
loose shingles on a small fisherman’s shack beside the big
warehouse.
“Now for some reason,” Don continued, “Snell, the Redcoat, broke
into our cellar yesterday, and that’s why I’m telling you this; I’m afraid
he knows what’s down there, and I want you to help me if you can.”
Jud’s eyes snapped as he listened to his comrade’s story of how
Snell had broken the lock on the cellar door.
As a matter of fact Snell had not known of what was in the cellar; it
was curiosity more than anything else that had prompted him to
break the lock. But it would not be long before he knew just what
was hidden away beneath the little house in Pudding Lane, for
before Don had finished his story the figure that had been listening
so intently at the corner of the warehouse drew back and walked
quickly in the direction of Beech Street. He had not gone far,
however, before he turned on his heel and strode carelessly toward
the wharf.
A few minutes later the boys spied Tom Bullard walking toward them;
his hands were in his pockets, and he seemed wrapped in thought.
“Oh!” he exclaimed as if catching sight of them for the first time.
“Didn’t expect to find anybody here.”
“Huh,” said Jud and turned his back.
Tom walked to the edge of the dock and, smiling to himself, stood for
some time, looking at the sparkling waters. Then he turned and
strode back toward Beech Street.
Don glanced at his companion. “It’s lucky he didn’t hear anything,”
he said.
“If he had,” Jud replied with emphasis, “I’d have pushed him into the
water. What do you suppose he was doing down here anyway?”
“Oh, just snoopin’ around,” replied Don easily. “Since he’s become a
sort of aide to old Ruggles he’s been doing it, you know.”
The boys continued to talk in low tones for some time. It was
pleasant there on the dock in the morning sunlight.
Once Tom Bullard was out of their sight, he started to run. He ran up
Beech Street to Shea’s Lane and from there made his way to
Common Street. Out on the Common some of the companies were
drilling, but Tom did not pause to look at them. He crossed the Mall
and then at a fast walk went here and there among the troops.
It took him almost half an hour to find the person he was looking for,
and when he did find him at last he was so excited that he could
hardly talk. “Snell—Snell,” he began, “I’ve got—something—to—to
——”
“Toot, toot!” said Snell, taking his arm. “Get your breath before you
tell it.”
Tom got his breath, enough of it anyway to tell the Redcoat what he
had overheard at the warehouse. Then Snell was almost as much
excited as Tom was. He rubbed his swollen face thoughtfully.
“Powder in the cellar of that house!” he exclaimed. “Powder and fine
cloth, and I like a fool was down there and didn’t even see it! You’re
sure of it, Bullard?”
“I should say I am,” Tom replied. “Didn’t I hear of it with my own
ears?”
“What are you going to do about it?”
“That’s for the two of us to decide together,” replied Tom. “There’s no
hurry, you know. We want to do it in the best way.”