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DIAGNOSIS AND
TREATMENT IN
INTERNAL MEDICINE

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DIAGNOSIS AND
TREATMENT
IN INTERNAL
MEDICINE

Edited by
Patrick Davey
Consultant Cardiologist, Northampton General Hospital NHS Trust,
Northampton, UK

David Sprigings
Formerly Consultant Physician, Northampton General Hospital NHS Trust,
Northampton, UK

1
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1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2018
The moral rights of the authors‌have been asserted
First Edition published in 2018
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2018941300
ISBN 978–​0–​19–​956874–​1
Printed and bound in China by
C&C Offset Printing Co., Ltd.
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-​pregnant
adult who is not breast-​feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.

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Preface

Diagnosis and Treatment in Internal Medicine came about through our experience on
the acute medical take. Here, sick patients present in large numbers with a vast range
of problems. What all patients need, as the bedrock of management, is a differential
diagnosis, and the central aim of our book is to help doctors formulate this. We asked
experts in their field to provide succinct and authoritative guidance across the breadth
of internal medicine. The assessment of symptoms or presenting problems is a major
element of the book, but there is also comprehensive coverage of disorders of the
body systems, including psychological aspects and palliative care. Chapters are struc-
tured so that key information can rapidly be found. Doctors need a broad perspective
on health and its promotion, and there are sections addressing nutrition, lifestyle, and
prevention of disease.
This book approaches medicine from the patient’s perspective, through the stories
that patients tell us about their illness, and provides the knowledge that turns these
narratives into diagnoses, treatment, health, and longevity. Throughout, our focus has
been on meeting the needs of doctors in the clinic, in the emergency department, or
on the ward.
Our eternal thanks go out to our contributors. Some 200 outstanding doctors have
produced admirably compact and lucid chapters. Throughout the lengthy gestation of
the book, we have been ably supported by the staff at Oxford University Press, who
have encouraged us and orchestrated the project. All praise should be directed to the
authors, and any mistakes are ours. Please do let us have your suggestions for improve-
ments (you can contact us at [email protected] and [email protected]).
Patrick Davey
David Sprigings

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Contents

Normal values xiii

Abbreviations xv
Contributors xxiii

PART 1 THE APPROACH TO THE PATIENT

1 Diagnostic reasoning 2 5 The psychological examination 18

2 Dealing with uncertainty 8 6 Confidentiality 22
3 Taking the history 12 7 Consent 24
4 The physical examination 15

PART 2 ASSESSMENT OF SYMPTOMS AND PRESENTING PROBLEMS

8 Palpitation 28 37 Anaemia 104

9 Acute chest pain 31 38 Bruising and bleeding 106
10 Chronic chest pain 37 39 Transient loss of consciousness 109
11 Hypotension 43 40 Coma 112
12 Acute breathlessness 47 41 Delirium (acute confusional state) 116
13 Chronic breathlessness 51 42 Seizures 120
14 Peripheral oedema 56 43 Difficulty speaking (including dysphasia and
15 Murmur 58 dysarthria) 123
16 Cough 61 44 Weakness 126
17 Wheeze 63 45 Tremor and other abnormal movements 131
18 Haemoptysis 65 46 Gait disorders 134
19 Pleural effusion 67 47 Sensory loss 137
20 Chylothorax 70 48 Headache 142
21 Difficulty swallowing 71 49 Loss of vision 146
22 Haematemesis 73 50 The red eye 150
23 Acute abdominal pain 75 51 Hearing loss 153
24 Chronic abdominal pain 78 52 Facial pain 155
25 Dyspepsia 81 53 Dizziness 157
26 Abdominal mass 83 54 Disorders of sleep 159
27 Constipation 85 55 Haematuria 161
28 Acute diarrhoea 87 56 Oliguria and anuria 163
29 Chronic diarrhoea 89 57 Polyuria 165
30 Rectal bleeding 91 58 Dysuria 167
31 Jaundice 93 59 Urinary incontinence 170
32 Ascites 95 60 Faecal incontinence 173
33 Chylous ascites 98 61 Vaginal discharge 175
34 Swelling in the neck 99 62 Joint pain 178
35 Splenomegaly and other disorders of the 63 Muscle pain 181
spleen 101 64 Low back pain 183
36 Lymphadenopathy 103 65 Painful leg 187

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 66 Leg ulcers 191 76 Fever 216
67 Limb ischaemia 193 77 Hyperthermia 218
68 Rashes 195 78 Hypothermia 221
69 Blistering rashes 197 79 Fatigue 224
70 Photosensitive rashes 200 80 Unintentional weight loss 226
71 Itching 203 81 Obesity: differential diagnosis 228
72 Lumps and bumps 205 82 Self-​harm 231
73 Falls 209 83 Alcohol intoxication 234
74 Immobility (‘Off legs’) 212 84 Intravenous drug use 239
75 Suspected anaphylaxis 214

PART 3 CARDIOVASCULAR DISORDERS

85 Normal function of the cardiovascular 105 Raynaud’s phenomenon 325

system 244 106 Heart muscle disease (cardiomyopathy) 327
86 Risk factors for cardiovascular disease 248 107 Tumours and the heart 332
87 Diagnosis and investigation in suspected heart 108 Cardiac infection 335
disease 252
109 Pericardial disease 340
88 Congenital heart disease in adults 263
110 Extrasystoles 342
89 Chronic stable angina 271
111 Sinus tachycardia 345
90 Acute coronary syndromes 275
112 Focal (ectopic) atrial tachycardia 348
91 Acute heart failure 280
113 Multifocal atrial tachycardia 351
Contents

92 Chronic heart failure 283

114 Atrioventricular nodal re-entrant
93 Aortic stenosis 287 tachycardia 354
94 Aortic regurgitation 290 115 Atrioventricular re-​entrant tachycardia 357
95 Mitral regurgitation 292 116 Atrial fibrillation 361
96 Miscellaneous valvar pathology: Mitral 117 Atrial flutter 366
stenosis, pulmonary stenosis, and tricuspid
regurgitation 295 118 Ventricular tachyarrhythmias: Ventricular
tachycardia and ventricular fibrillation 369
97 Percutaneous coronary intervention 299
119 Bradyarrhythmias 379
98 Heart surgery 302
120 Sudden cardiac death 384
99 Circulatory support therapy 306
121 Cardiac device therapy 395
100 Pulmonary hypertension 308
122 Drug-​induced cardiovascular disease 401
101 Venous thrombosis and pulmonary
embolism 312 123 Psychological management of coronary heart
disease 403
102 Aortic aneurysm 318
124 Treatment of terminal cardiovascular
103 Aortic dissection 320 disease 405
104 Peripheral arterial disease 322

PART 4 RESPIRATORY DISORDERS

125 Normal respiratory function 410 131 Pneumothorax 436

126 Diagnosis in suspected respiratory disease 412 132 Cystic fibrosis 439
127 Investigation in respiratory disease 415 133 Asthma 441
128 Upper respiratory tract infections, including 134 Chronic obstructive pulmonary disease 445
influenza 425 135 Respiratory failure 449
129 Pneumonia 427 136 Obstructive sleep apnoea 454
130 Tuberculosis 431 137 Bronchiectasis 456

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138 Sarcoidosis and other granulomatous lung 142 Occupational lung disease 472
disease 458 143 Pleural infection and malignancy 475
139 Interstitial lung disease 460 144 Drug-​induced lung disease 477
140 Pulmonary vasculitis 464 145 Psychology in respiratory disease, including
141 Lung cancer (including management of an dysfunctional breathing 480
isolated lung lesion) 467 146 Terminal care in respiratory illness 482

PART 5 INTENSIVE CARE MEDICINE

147 Critical illness 486 151 ICU treatment of acute kidney injury 496
148 Role of the intensive care unit 488 152 ICU treatment of sepsis and septic shock 498
149 ICU treatment of respiratory failure 490 153 Terminal care in the intensive care unit 501
150 ICU treatment of cardiovascular failure 493 154 Brain death 503

PART 6 DISORDERS OF THE KIDNEY AND URINARY TRACT, AND ELECTROLYTE

AND METABOLIC DISORDERS

155 Normal renal function 506 169 Inherited renal diseases 556
156 Diagnosis in suspected renal disease 509 170 The kidney in systemic disease 558
157 Investigation in renal disease 512 171 Renal vascular disease 561
158 Urinary tract infection 518 172 Management of terminal care in renal
159 Glomerulonephritis 521 disease 563
160 Interstitial renal disease 527 173 Disorders of plasma potassium 565

Contents
161 Nephrotic syndrome 529 174 Disorders of plasma sodium 568
162 Acute kidney injury 533 175 Disorders of plasma calcium 570
163 Chronic kidney disease 536 176 Disorders of plasma phosphate 573
164 Diabetic renal disease 540 177 Disorders of plasma magnesium 575
165 Urinary tract obstruction 543 178 Disorders of acid–​base balance 577
166 Renal calculi 546 179 Porphyria 580
167 Renal and bladder cancer 549 180 Aminoacidopathies, urea cycle disorders, and
organic acidurias 582
168 Renal replacement therapy 552
181 Amyloidosis 584

PART 7 DIABETES MELLITUS AND ENDOCRINE DISORDERS

182 Normal function of the endocrine system 588 188 Adrenal disease 612
183 Diagnosis and investigation in endocrine 189 Cushing syndrome 617
disorders 593 190 Short stature 619
184 Diabetes mellitus 596 191 Infertility 621
185 Hypoglycaemia 601 192 Pituitary disorders: Prolactinomas, acromegaly,
186 Thyroid disease 603 and pituitary apoplexy 625
187 Primary hyperparathyroidism 610

PART 8 GASTROINTESTINAL DISORDERS

193 Normal gastrointestinal function 632 195 Investigation in gastrointestinal disease 637
194 Diagnosis in suspected gastrointestinal 196 Immunology and genetics in gastrointestinal and
disease 635 hepatic medicine 641

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 197 Gastrointestinal infections 644 202 Malabsorption 660
198 Benign oesophageal disease 648 203 Inflammatory bowel disease 663
199 Peptic ulcer disease 651 204 Gastrointestinal tumours 667
200 Gall bladder disease 653 205 Functional gastrointestinal diseases 674
201 Pancreatic disease 656 206 Psychiatry in gastrointestinal medicine 676

PART 9 DISORDERS OF THE LIVER

207 Normal hepatic function 680 213 Autoimmune hepatitis 709

208 Investigation in liver disease 686 214 Genetic liver disease 713
209 Acute liver failure 690 215 Drug-​induced liver disease 718
210 Chronic liver failure 693 216 Miscellaneous liver diseases 721
211 Alcoholic liver disease 697 217 The liver in systemic disease 726
212 Viral hepatitis 700 218 Liver cancer 731

PART 10 NEUROLOGICAL DISORDERS

219 Normal neurological function 736 232 Motor neuron disease 794
220 Diagnosis in suspected neurological disease 739 233 Spinal cord disease 796
221 Investigation in neurological disease 742 234 Neuropathy 800
222 Demographics of neurological disease 752 235 Myopathy 804
Contents

223 Neurogenetic disease 755 236 Vasculitis in neurology 807

224 Neurocutaneous syndromes 760 237 Neurological tumours 812
225 Congenital neurological disorders 762 238 Non-​metastatic neurological manifestations of
226 Epilepsy 764 malignancy 815
227 Stroke 767 239 Neurosurgery 817
228 Dementia 777 240 Drug-​induced neurological disease 821
229 Neurological infection 781 241 Functional and dissociative disorders in
neurology 825
230 Disorders of movement 787
242 Palliative care in neurological disease 828
231 Multiple sclerosis 791

PART 11 DISORDERS OF THE SKIN

243 Normal skin function 832 254 Nail disorders 863

244 Approach to diagnosing skin disease 836 255 Mucosal disease 865
245 Investigation in skin disease 839 256 Genital disease 868
246 Skin infection and infestation 842 257 Polymorphic light eruption and actinic
247 Cutaneous vasculitis 845 prurigo 870
248 Acne 847 258 Disorders of pigmentation 872
249 Psoriasis 850 259 Skin cancer 874
250 Eczema 853 260 Skin markers of internal medicine 882
251 Urticaria 855 261 Drug-​induced skin disease 886
252 Bullous disorders 857 262 Psychocutaneous medicine 889
253 Hair disorders 860

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PART 12 DISORDERS OF THE MUSCULOSKELETAL SYSTEM

263 Normal function of the musculoskeletal 269 Systemic lupus erythematosus 918
system 892 270 Crystal arthropathy 921
264 Diagnosis in suspected rheumatological 271 Infection of joints and bones 925
disease 894
272 Vasculitis 927
265 Investigation in rheumatological disease 900
273 Osteomalacia 932
266 Osteoarthritis 906
274 Paget’s disease of bone 933
267 Rheumatoid arthritis 910
275 Osteoporosis and fragility fracture 935
268 Seronegative spondyloarthropathy 914
276 Genetic bone and joint disease 938

PART 13 HAEMATOLOGICAL DISORDERS

277 Normal blood function 944 285 Prothrombotic conditions 984

278 Diagnosis and investigation in haematology 951 286 Acute leukaemia 989
279 Deficiency anaemias 955 287 Chronic leukaemia 992
280 Haemolytic anaemia 958 288 Myelodysplasia 995
281 Normal platelet function 967 289 Lymphoma 996
282 Platelet disorders 970 290 Multiple myeloma and related conditions 999
283 Normal haemostatic function 975 291 Myeloproliferative disorders 1002
284 Bleeding disorders 979 292 Terminal care in haematological disease 1005

Contents
PART 14 DISORDERS OF THE IMMUNE SYSTEM

293 Functions of the immune system 1008 298 Combined T-​and B-​cell
294 Clinical features and diagnosis of immunological immunodeficiencies 1028
disease 1013 299 Complement deficiencies 1031
295 Neutrophil abnormalities 1017 300 Hypersensitivity diseases 1034
296 Human immunodeficiency virus infection 1020 301 Immunological support 1038
297 Antibody deficiencies 1025 302 Immunosuppressive therapy and therapeutic
monoclonal antibodies 1040

PART 15 INFECTIOUS DISEASES

303 Defences against infection 1044 312 Spirochaetal infection (non-syphilis) 1079
304 Nature and demographics: Epidemiology of 313 Syphilis 1082
infective organisms 1048 314 Rickettsial infection 1084
305 Diagnosis in suspected infective disease: 315 Fungal infection 1086
The history and examination 1051
316 Protozoal infection: Gut organisms 1091
306 Investigation in infection 1058
317 Protozoal infection: Malaria 1094
307 Treatment of infection 1061
318 Worm infection (including hydatid
308 Viral infection 1064 disease) 1098
309 Sepsis 1068 319 Prion disease 1101
310 Bacterial infection 1071 320 Sexually transmitted disease
311 Mycobacterial infection other than (gonorrhoea) 1103
tuberculosis 1075

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 PART 16 CANCERS

321 Cancers related to infection 1106 326 Prostate cancer 1118

322 Principles of oncogenesis 1109 327 Breast cancer 1122
323 Presentations in suspected cancer 1111 328 Ovarian and testicular cancer 1126
324 Diagnosis and staging of cancer 1113 329 Symptom control in cancer 1128
325 Treatment of cancer 1115 330 Dying from cancer 1131

PART 17 DIETARY, LIFESTYLE, AND ENVIRONMENTAL FACTORS

AFFECTING HEALTH

331 Normal nutritional function 1134 337 Physical activity and its role in disease
332 Starvation and malnutrition 1136 prevention 1155
333 Vitamin deficiencies 1139 338 Smoking 1158
334 Nutritional support in the critically ill 1144 339 Alcohol 1160
335 Poor diets 1147 340 Environmental radiation 1164
336 Obesity: epidemiology, prevention and 341 Air pollution 1166
management 1150 342 Non-​prescription drugs 1168

PART 18 PREVENTION OF DISEASE

343 Prevention of cardiovascular disease 1172 347 Prevention of neurological disease 1183
Contents

344 Prevention of respiratory disease 1176 348 Prevention of cerebrovascular disease 1187
345 Prevention of kidney disease 1179 349 Prevention of infection 1189
346 Prevention of gastrointestinal disease 1181 350 Prevention of cancer 1192

PART 19 SCREENING FOR DISEASE

351 Screening for cardiovascular disease 1196 354 Screening for gastrointestinal disease 1206
352 Screening for respiratory disease 1202 355 Screening for neurological disease 1209
353 Screening for kidney disease 1205 356 Screening for cancer 1211

Index 1215

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Normal values

Common haematology values

Haemoglobin men: 130–​180 g/​l
women: 115–​160 g/​l
Mean cell volume, MCV 76–​96 fl
Platelets 150–​400 × 109/​l
White cells (total) 4–​11 × 109/​l
• neutrophils 40%–​75%
• lymphocytes 20%–​45%
• eosinophils 1%–​6%
Blood gases
pH 7.35–​7.45
PaO2 >10.6 kPa (75–​100 mm Hg)
PaCO2 4.7–​6 kPa (35–​45 mm Hg)
Base excess ±2 mmol/​l
U&ES (urea and electrolytes)
Sodium 135–​145 mmol/​l
Potassium 3.5–​5 mmol/​l
Creatinine 70–​120 μmol/​l
Urea 2.5–​6.7 mmol/​l
eGFR >90
LFTs (liver function tests)
Bilirubin 3–​17 μmol/​l
Alanine aminotransferase, ALT 5–​35 IU/​l
Aspartate transaminase, AST 5–​35 IU/​l
Alkaline phosphatase, ALP 30–​150 IU/​l (non-​pregnant adults)
Albumin 35–​50 g/​l
Protein (total) 60–​80 g/​l
Cardiac enzymes
Troponin T <0.1 μg/​l
Creatine kinase 25–​195 IU/​l
Lactate dehydrogenase, LDH 70–​250 IU/​l
Lipids and other biochemical values
Cholesterol <5 mmol/​l desired
Triglycerides 0.5–​1.9 mmol/​l
Amylase 0–​180 Somogyi U/​dl
C-​reactive protein, CRP <10 mg/​l
Calcium (total) 2.12–​2.65 mmol/​l
Glucose, fasting 3.5–​5.5 mmol/​l
Prostate-​specific antigen, PSA 0–​4 ng/​ml
T4 (total thyroxine) 70–​140 mmol/​l
Thyroid-​stimulating hormone, TSH 0.5–​5.7 mU/​l
Abbreviations: eGFR, estimated glomerular filtration rate; PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood.
Reproduced from M Longmore and IB Wilkinson et al., Oxford Handbook of Clinical Medicine, Ninth Edition, 2014, with permission from Oxford University Press

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Abbreviations

γGT gamma-​glutamyl transferase ALL acute lymphocytic leukaemia

5-​ASA 5-​aminosalicylic acid ALP alkaline phosphatase
6MP 6-​mercaptopurine ALS amyotrophic lateral sclerosis
AA AA protein-​related renal amyloidosis ALT alanine aminotransferase
AAA abdominal aortic aneurysm AMA anti-​mitochondrial antibody
AAFB acid-​and alcohol-​fast bacteria AMD age-​related macular degeneration
AASV antineutrophil cytoplasmic antibody-​associated AMI acute myocardial infarction
systemic vasculitis AML acute myeloid leukaemia
Ab antibody AMP adenosine monophosphate
ABC Airway, Breathing, and Circulation ANA antinuclear antibody
ABCDE Airway, Breathing, Circulation, Disability, and ANC absolute neutrophil count
Exposure ANCA antineutrophil cytoplasmic antibody
ABG arterial blood gas ANS alcohol nurse specialist
ABP arterial blood pressure anti-​dsDNA anti-​double-​stranded DNA antibody
ABPA allergic bronchopulmonary aspergillosis anti-​HBc antibody to the hepatitis B core antigen
ABPI ankle–​brachial pressure index anti-​HBe antibody to the hepatitis B e antigen
ABPM ambulatory blood-​pressure monitoring anti-​HBs antibody to the hepatitis B surface antigen
AC air conduction anti-​LKM anti-​liver kidney microsomal type 1 antibody
ACD anaemia of chronic disorders anti-​LPA anti-​liver–​pancreas antigen antibody
ACE angiotensin-​converting enzyme anti-​SLA anti-​soluble liver antigen antibody
ACE-​I angiotensin-​converting-​enzyme inhibitor anti-​SMA smooth muscle antibody
ACPA anti-​citrullinated protein/​peptide antibody anti-​TNF anti-​tumour necrosis factor
ACR albumin–​creatinine ratio ANZDATA Australia and New Zealand Dialysis and Transplant
ACS acute coronary syndrome Registry
ACT activated clotting time APACHE Acute Physiology and Chronic Health Evaluation
ACTH adrenocorticotropic hormone APC activated protein C
AD autosomal dominant APKD adult polycystic kidney disease
ADA adenosine deaminase APS antiphospholipid syndrome
ADC apparent diffusion coefficient APTT activated partial thromboplastin time
ADH antidiuretic hormone APTTr activated partial thromboplastin time ratio
ADP adenosine diphosphate AR autosomal recessive
ADT androgen deprivation therapy ARB angiotensin II receptor blocker
AEIPF acute exacerbation of idiopathic pulmonary fibrosis ARDS acute respiratory distress syndrome
AF atrial fibrillation ARF acute renal failure
AFB acid-​fast bacilli ARPKD autosomal recessive polycystic kidney disease
AH atrium–​His ARR aldosterone:renin activity ratio
AHF acute heart failure ARSAC Administration of Radioactive Substances Advisory
AHI apnoea hypopnoea index Committee
AI adrenal insufficiency ART antiretroviral therapy
AIDS acquired immune deficiency syndrome ARVC arrhythmogenic right ventricular cardiomyopathy
AIH autoimmune hepatitis ARVC/​D arrhythmogenic right ventricular cardiomyopathy/​
AIN anal intra-​epithelial neoplasia dysplasia
AION anterior ischaemic optic neuropathy AS ankylosing spondylitis
AIP autoimmune pancreatitis ASAS Assessment of SpondyloArthritis International
AIVR accelerated idioventricular rhythm Society
AJCC American Joint Committee on Cancer ASD atrial septal defect
AKI acute kidney injury AST aspartate aminotransferase
AL amyloid light chain AT antithrombin
ALA amoebic liver abscess ATG antithymocyte globulin
ALD alcoholic liver disease ATL adult T-​cell leukaemia
ALERT Acute Life-​threatening Events Recognition and ATN acute tubulointerstitial nephritis
Treatment ATP adenosine triphosphate
ALF acute liver failure AUDIT Alcohol Use Disorders Identification Test

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 AV atrioventricular CCF congestive cardiac failure
aVF augmented voltage unipolar left foot lead CCP cyclic citrullinated peptide
AVIR accelerated idioventricular rhythm CCS Canadian Cardiovascular Society
aVL augmented voltage unipolar left arm lead CD Crohn’s disease
AVN atrioventricular node CDC Centers for Disease Control
AVNRT atrioventricular nodal re-​entrant tachycardia CDI cranial diabetes insipidus
AVP arginine vasopressin CF counting fingers
AVPU Alert, Voice, Pain, or Unresponsive CGD chronic granulomatous disease
AVRT atrioventricular re-​entrant tachycardia CHD coronary heart disease
AVSD atrioventricular septal defect CHF congestive heart failure
AZA azathioprine CI confidence interval
BAE bronchial artery angiography and embolization CIDP chronic inflammatory demyelinating
BAL bronchoalveolar lavage polyradiculoneuropathy
BC bone conduction CIPO chronic idiopathic pseudo-​obstruction
BCC basal cell carcinoma CIS carcinoma in situ
BCLC Barcelona Clinic Liver Cancer CJD Creutzfeldt–​Jakob disease
BCNIE blood culture-​negative infective endocarditis CK creatine kinase
BCP basic calcium phosphates CKD chronic kidney disease
BCR B-​cell receptor CLL chronic lymphoid leukaemia
BCT broad-​complex tachycardia CMAP compound muscle action potential
BD brain death CMC carpometacarpal
BDD body dysmorphic disorder CML chronic myeloid leukaemia
BI bacterial index CMRI cardiac magnetic resonance imaging
BIMA bilateral internal mammary artery CMT Charcot–​Marie–​Tooth disease
BIPAP bi-​level positive airway pressure CMV cytomegalovirus
BIPSS bilateral inferior petrosal sinus sampling CNS central nervous system
BMD bone mineral density COCP combined oral contraceptive pill
Abbreviations

BMI body mass index COP cryptogenic organizing pneumonia

BMRC British Medical Research Council COPD chronic obstructive pulmonary disease
BMT bone marrow transplantation CPAP continuous positive airways pressure
BNP brain natriuretic peptide CPB cardiopulmonary bypass
BO Barrett’s oesophagus CPEX cardiopulmonary exercise testing
BP blood pressure CPP combined physical and psychological programme
BPH benign prostatic hypertrophy CPPD calcium pyrophosphate dihydrate deposition
bpm beats per minute CrAG cryptococcal antigen
BPPV benign paroxysmal positional vertigo CRAO central retinal artery occlusion
BRAO branch retinal artery occlusion CRF clinical risk factor for parental hip fracture
BRF bone risk factor CRH corticotrophin-​releasing hormone
BrS Brugada syndrome CRP C-​reactive protein
BRVO branch retinal vein occlusion CRT cardiac resynchronization therapy
BSA body surface area CRVO central retinal vein occlusion
BSD brainstem death CS corticosteroid
BSE bovine spongiform encephalopathy CSF cerebrospinal fluid
BSG British Society of Gastroenterology CSH carotid sinus hypersensitivity
BTS British Thoracic Society CSM carotid sinus massage
CABG coronary artery bypass graft surgery CT computed tomography
CAD coronary artery disease CTA computed tomography angiography
CADASIL cerebral autosomal dominant arteriopathy with CTD connective tissues disease
subcortical infarcts and leucoencephalopathy CTEPH chronic thromboembolic pulmonary hypertension
CAH congenital adrenal hyperplasia CTPA computed tomography pulmonary angiography
CAM Confusion Assessment Method CVA cerebral vascular accident
cANCA cytoplasmic antineutrophil cytoplasmic antibody CVD cardiovascular disease
CAP community-​acquired pneumonia CVID common variable immunodeficiency
CaSR calcium-​sensing receptor CVP central venous pressure
CBCD chronic bullous disease of childhood CVPT catecholaminergic polymorphic ventricular
CBD common bile duct tachycardia
CBG cortisol-​binding globulin CWS cotton-​wool spot
CBT cognitive behavioural therapy CXR chest X-​ray
CBZ carbimazole CYC cyclophosphamide
CCB calcium-​channel blocker DA dermatitis artefacta

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DADS distal acquired demyelinating symmetrical ET essential tremor
DAH diffuse alveolar haemorrhage EUA examination under anaesthesia
DAS Disease Activity Score EUS endoscopic ultrasound
DAT drug action team FAP familial amyloid polyneuropathy
DBS deep brain stimulation FAST Face Arm Speech Test
DCM dilated cardiomyopathy FBC full blood count
DEXA dual-​energy X-​ray absorptiometry FDA Food and Drug Administration
DF Maddrey discriminant function FDG fluorodeoxyglucose
DHEA dehydroepiandrosterone FDP fibrinogen degradation products
DHEAS dehydroepiandrosterone sulphate FEV1 forced expiratory volume in 1 second
DI diabetes incipidus FFA free fatty acid
DIC disseminated intravascular coagulopathy FFR fractional flow reserve
DILD drug-​induced lung disease FFS five-​factor score
DILS diffuse infiltrative lymphocytosis syndrome FHH familial hypocalciuric hypercalcaemia
DIP distal interphalangeal FI faecal incontinence
DIS dissemination in space FiO2 inspired fraction of oxygen
DIT dissemination in time; FISH fluorescent in situ hybridization
DLCO diffusing capacity of the lung for carbon monoxide FLAIR fluid attenuated inversion recovery
DLE discoid lupus erythematosus FLI fatty liver index
DM diabetes mellitus FNAC fine-​needle aspiration cytology
DMARD disease-​modifying anti-​rheumatic drug FOB faecal occult blood
DOT directly observed therapy FSGS focal segmental glomerulosclerosis
DPP-​4 dipeptidyl peptidase-​4 FSH follicle-​stimulating hormone
DRE digital rectal examination FTD frontotemporal dementia
dsDNA double-​stranded DNA FUO fever of unknown origin
DSE dobutamine stress echocardiography FVC forced vital capacity
DST dexamethasone suppression test FVL factor V Leiden

Abbreviations
DU duodenal ulcer FXTAS fragile X-​associated tremor/​ataxia syndrome
DVLA Driver and Vehicle Licensing Agency G1 Genotype 1
DVP diastolic blood pressure G2 Genotype 2
DVT deep-​vein thrombosis G3 Genotype 3
DWI diffusion-​weighted imaging G6PD glucose-​6-​phosphate dehydrogenase
EBUS-​TBNA endobronchial ultrasound-​guided transbronchial GA general anaesthesia
needle aspiration GABA gamma-​aminobutyric acid
EBV Epstein–​Barr virus GAD glutamic acid decarboxylase
ECG electrocardiogram GAD65 glutamic acid decarboxylase autoantibody
Echo echocardiography GALT gut-​associated lymphoid tissue
ECOG Eastern Cooperative Oncology Group GAS Group A streptococcus
EDTA ethylenediamine tetra-​acetic acid GBM glomerular basement membrane
EEG electroencephalogram GBS Guillain–​Barré syndrome
EGDT early goal-​directed therapy GCA giant cell arteritis
eGFR estimated glomerular function rate GCS Glasgow Coma Scale
EHEC enterohaemorrhagic Escherichia coli GFR glomerular filtration rate
EIA enzyme immunoassay GGO ground-​glass opacity
ELISA enzyme-​linked immunosorbent assay GH growth hormone
EMG electromyography GI gastrointestinal
ENA extractable nuclear antigen antibody GIST gastrointestinal stromal tumour
ENT ear, nose, and throat GMC General Medical Council
EOTR end-​of-​treatment response GN glomerulonephritis
EPAP expiratory positive airway pressure GnRH gonadotropin-​releasing hormone
EPO erythropoietin GOLD Global Initiative for Chronic Obstructive Lung
EPP erythropoietic protoporphyria Disease
ePPi extracellular pyrophosphate GORD gastro-​oesophageal reflux disease
EPR electronic patient record GOS Glasgow Outcome Score
EPS electrophysiological study GP general practitioner
ERCP endoscopic retrograde cholangiopancreatography GPA granulomatosis with polyangiitis
EROA effective regurgitant orifice area GPI glycosyl-​phosphatidylinositol
ESC European Society of Cardiology GRA glucocorticoid-​responsive aldosteronism
ESR erythrocyte sedimentation rate GU gastric ulcer
ESRD end-​stage renal disease GUM genito-​urinary medicine

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 GvHD graft-​vs-​host disease IBD inflammatory bowel disease
HAART highly active antiretroviral therapy IBS irritable bowel syndrome
HAP hospital-​acquired pneumonia IC intermittent claudication
HAS human albumin solution ICA islet cell autoantibody
HAV hepatitis A virus ICa,L L-​type calcium current
Hb A adult haemoglobin ICD implantable cardioverter defibrillator
Hb A1c haemoglobin A1c (glycosylated haemoglobin) ICH intracranial haemorrhage
Hb F fetal haemoglobin ICP intracranial pressure
Hb haemoglobin ICU intensive care unit
HBc hepatitis B core protein ID infectious disease
HBeAg hepatitis B e antigen IDL intermediate-​density lipoprotein
HBPM home blood-​pressure monitoring IDU intravenous drug users
HBsAg hepatitis B surface antigen IE infective endocarditis
HBV hepatitis B virus IFD invasive fungal disease
HCC hepatocellular carcinoma IFN interferon
HCM hypertrophic cardiomyopathy IFN-​alpha interferon alpha
HCV hepatitis C virus IgA immunoglobulin A
HD Huntington’s disease IgE immunoglobulin E
HDL high-​density lipoprotein IgG immunoglobulin G
HDU high-​dependency units IgM immunoglobulin M
HDV hepatitis D virus IGRA interferon gamma release assays
HER2 human epidermal growth factor receptor 2 IHD ischaemic heart disease
HEV hepatitis E virus IK1 inward rectifier potassium current
HF heart failure IKr rapidly activating component of the delayed rectifier
HFmrEF heart failure with mid-​range ejection fraction potassium current
HFpEF heart failure with preserved ejection fraction IKs slowly activating component of the delayed rectifier
HFrEF heart failure with reduced ejection fraction potassium channel
Abbreviations

HHT hereditary haemorrhagic telangiectasia IL interleukin

HHV6 human herpes virus 6 IL-​6 interleukin 6
HHV7 human herpes virus 7 ILD interstitial lung disease
HHV8 human herpes virus 8 IM intramuscular
HIFU high-​intensity focused ultrasound IMD inherited metabolic disease
HIGM hyperimmunoglobulin M IMIg intramuscular immunoglobulin
HIT heparin-​induced thrombocytopenia IMPACT Ill Medical Patients’ Acute Care and Treatment
HIV human immunodeficiency virus INa sodium current
HLA human leukocyte antigen INa,K sodium–​potassium pump current
HM hand movements INCX sodium-​calcium exchanger current
HMW high molecular weight INR international normalized ratio
HNPCC hereditary non-​polyposis colorectal cancer IPAP inspiratory positive airway pressure
HNPP hereditary neuropathy with liability to pressure palsies IPD idiopathic Parkinson’s disease
HPA hypothalamic–​pituitary–​adrenal IPF idiopathic pulmonary fibrosis
HPIV human parainfluenza virus IPG implantable pulse generator
HPV human papilloma virus IPI International Prognostic Index
HRA Human Rights Act 1998 IPJ interphalangeal joint
HRCT high-​resolution computed tomography IRIS immune reconstitution inflammatory syndrome
HRS hepatorenal syndrome IRRT intermittent renal replacement therapy
HS hereditary spherocytosis IRT immunoreactive trypsinogen
HSCT haemopoietic stem cell transplantation ISS International Staging System
HSP Henoch–​Schönlein purpura IST inappropriate sinus tachycardia
HSV herpes simplex virus ITP immune thrombocytopenia
HTLV1 human T-​lymphotrophic virus 1 ITT insulin tolerance test
HUS haemolytic–​uraemic syndrome ITU intensive therapy unit
HUV hypocomplementaemic urticarial vasculitis IUD intrauterine device
HV His–​ventricle IV intravenous
IA2 islet antigen 2 autoantibody IVC inferior vena cava
IAA insulin autoantibody IVDU intravenous drug use
IABP intra-​aortic balloon pump IVF in vitro fertilization
IAH intra-​abdominal hypertension IVIg intravenous immunoglobulin
IAP intra-​abdominal pressure IVUS intravascular ultrasound
IBA identification and brief advice JVP jugular venous pulse

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KCO carbon monoxide transfer coefficient MDS myelodysplasia
KDIGO Kidney Disease: Improving Global Outcomes MDT multidisciplinary team
KEEP Kidney Early Evaluation Program MELAS mitochondrial encephalomyopathy with lactic
KS Kaposi’s sarcoma acidosis and stroke-​like episodes
KSHV Kaposi’s sarcoma-​associated herpesvirus MELD Model for End-​Stage Liver Disease
LACS lacunar stroke MEN multiple endocrine neoplasia
LAD left anterior descending MERRF myoclonic epilepsy with ragged red fibres
LAE left atrial enlargement MG myasthenia gravis
LAVAT local anaesthetic video-​assisted thoracoscopy MGUS monoclonal gammopathy of unknown significance
LBBB left bundle branch block MHC major histocompatibility complex
LBC liquid-​based cytology MHRA Medicines and Healthcare Products
LBD Lewy body dementia Regulatory Agency
LBP low back pain MI myocardial infarction
LCIS lobular carcinoma in situ MIC minimum inhibitory concentration
LCSD left cervicothoracic sympathetic denervation MM malignant melanoma
LCX left circumflex artery MMA methylmalonic acidaemia
LDCT low-​dose computed tomography MMR measles, mumps, rubella
LDH lactate dehydrogenase MMSE Mini-​Mental State Examination
LDL low-​density lipoprotein MND motor neuron disease
LEMS Lambert–​Eaton myasthenia syndrome MOAI monoamine oxidase inhibitor
LET linear-​energy transfer MODY maturity-​onset diabetes of the young
LFT liver function test MOF multi-​organ failure
LH luteinizing hormone MPO myeloperoxidase
LIMA left internal mammary artery MPS myocardial perfusion scan
LMN lower motor neuron MR mitral regurgitation
LMWH low-​molecular-​weight heparin MRA magnetic resonance angiography
LN lymph node MRA magnetic resonance angiography

Abbreviations
LOS lower oesophageal sphincter MRC Medical Research Council
LP lumbar puncture MRCP magnetic resonance cholangiopancreatography
LPA Lasting Power of Attorney MRI magnetic resonance imaging
LPP lichen planopilaris MRSA meticillin-​resistant Staphylococcus aureus
LQTS long-​QT syndrome MRV magnetic resonance venography
LR likelihood ratio MS multiple sclerosis
LSMDT local skin cancer multidisciplinary team MSE mental state examination
LT leukotriene MSF Mediterranean spotted fever
LTBI latent infection with Mycobacterium tuberculosis MSM men who have sex with men
LTNP long-​term non-​progressor MSU monosodium urate
LV left ventricular MSUD maple syrup urine disease
LVAD left ventricular assist device MTP metatarsophalangeal
LVEF left ventricular ejection fraction MTX methotrexate
LVESD left ventricular end-​systolic diameter MUP minimum unit price
LVH left ventricular hypertrophy MuSK muscle-​specific kinase
LVNC left ventricular non-​compaction MUST Malnutrition Universal Screening Tool
LVOT left ventricular outflow tract NAAT nucleic acid amplification test
LVRS lung volume reduction surgery NAC N-​acetylcysteine
MAC Mycobacterium avium complex NAD nicotinamide adenine dinucleotide
MALT mucosa-​associated lymphoid tissue NADPH nicotinamide adenine dinucleotide phosphate
MAP mean arterial pressure NAFLD non-​alcoholic fatty liver disease
MAT multifocal atrial tachycardia NAPQI N-​acetyl-​p-​benzoquinone imine
MBL mannan-​binding-​lectin NASH non-​alcoholic steatohepatitis
MCA middle cerebral artery NCRN National Cancer Research Network
MCandS microscopy, culture, and sensitivities NCS nerve conduction study
MCBT mindfulness-​based cognitive therapy NEWS National Early Warning Score
MCH mean cell haemoglobin NFD nephrogenic fibrosing dermopathy
MCHC mean cell haemoglobin concentration NGT nasogastric tube
MCI mild cognitive impairment NHL non-​Hodgkin’s lymphoma
MCP metacarpophalangeal NICE National Institute for Health and Care Excellence
MCV mean corpuscular volume NIHL noise-​induced hearing loss
MDM multidisciplinary meeting NIHSS National Institutes of Health Stroke Scale
MDR multidrug-​resistant NIPPV nasal intermittent positive pressure ventilation

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 NIV non-​invasive ventilation PET positron emission tomography
NK natural killer PEX plasma exchange
NMO neuromyelitis optica PFT pulmonary function testing
NMS neuroleptic malignant syndrome PG prostaglandin
NP nosocomial pneumonia PH pulmonary hypertension
NPL no perception of light PHT pressure half-​time
NRH nodular regenerative hyperplasia PI pancreatic insufficiency
NRT nicotine replacement therapy PIP proximal interphalangeal
NS nephrotic syndrome PISA proximal isovelocity surface area
NSAID non-​steroidal anti-​inflammatory drug PJP Pneumocystis jiroveci pneumonia
NSCLC non-​small cell lung carcinoma PJRT persistent junctional reciprocating tachycardia
NSLBP non-​specific low back pain PK pyruvate kinase
NSTEMI non-​ST-​elevation myocardial infarction PKU phenylketonuria
NSVT non-​sustained ventricular tachycardia PL perception of light
NTA National Treatment Authority PLAX parasternal long-​axis view
NTG glyceryl trinitrate (nitroglycerin) PLE polymorphic light eruption
NTM non-​tuberculous mycobacteria PLMS periodic leg movements during sleep
NT-​pro-​BNP N-​terminal brain natriuretic peptide PLS primary lateral sclerosis
NYHA New York Heart Association PML progressive multifocal leucoencephalopathy
OA osteoarthritis PML progressive multifocal leukoencephalopathy
OAC oral anticoagulation PMN polymorphonuclear
OCP oral contraceptive pill PMT pacemaker-​mediated tachycardia
OCSP Oxfordshire Community Stroke Project PNH paroxysmal nocturnal haemoglobinuria
ODI oxygen desaturation index PNS peripheral nervous system
OGD oesophagogastroduodenoscopy POF premature ovarian failure
OHS obesity hypoventilation syndrome POI premature ovarian insufficiency
OLM ocular larva migrans POTS postural tachycardia syndrome
Abbreviations

ONJ osteonecrosis of the jaw PPH primary pulmonary hypertension

OPSI overwhelming post-​splenectomy infection PPI proton-​pump inhibitor
OSA obstructive sleep apnoea PPM permanent pacemaker
PABA para-​aminobenzoic acid PPMS primary progressive multiple sclerosis
PACNS primary angiitis of the central nervous system PPV polysaccharide pneumococcal vaccine
PaCO2 partial pressure of carbon dioxide in arterial blood pred. predicted
PAH pulmonary arterial hypertension PRES posterior reversible encephalopathy syndrome
PAI primary adrenal insufficiency PRR pattern recognition receptors
PAMP pathogen-​associated molecular patterns PS performance status
pANCA perinuclear antineutrophil cytoplasmic antibody PSA prostate-​specific antigen
PAO2 partial pressure of alveolar oxygen PsA psoriatic arthritis
PaO2 partial pressure of oxygen in arterial blood PSAX parasternal short-​axis view
PAT Paddington Alcohol Test PSC primary sclerosing cholangitis
PBC primary biliary cholangitis PSP primary spontaneous pneumothorax
PC20 the provocative concentration required to cause a PT prothrombin time
20% fall in the forced expiratory volume in 1 second PTA pure tone audiogram
PCI percutaneous coronary intervention PTCA percutaneous transluminal coronary angioplasty
PCO2 partial pressure of carbon dioxide PTH parathyroid hormone
PCOS polycystic ovary syndrome PTU propylthiouracil
PCP pneumocystis pneumonia PUD peptic ulcer disease
PCR polymerase chain reaction PUJ pelvic–​ureteric junction
PCT porphyria cutanea tarda PUO pyrexia of unknown origin
PCV pneumococcal conjugate vaccine PUVA psoralen plus ultraviolet light A
PD Parkinson’s disease PVC premature ventricular complex
PDA patent ductus arteriosus PVE prosthetic valve endocarditis
PE pulmonary embolus PVL Panton–​Valentine leukocidin
PEA pulseless electrical activity PVT portal vein thrombosis
PEEP positive end-​expiratory pressure RA rheumatoid arthritis
PEFR peak expiratory flow rate RAPD relative afferent pupillary defect
PEG percutaneous endoscopic gastrostomy RAS reticular activating system
PEG-​IFNα pegylated interferon alpha RAST radioallergosorbent testing
PEI percutaneous ethanol injection RBBB right bundle branch block
PEM protein-​energy malnutrition RBC red blood cell

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RBV ribavirin SPECT single-​photon emission computed tomography
RCC red-​cell count SQTS short-​QT syndrome
RCM restrictive cardiomyopathy SRH stigmata of recent haemorrhage
RCT randomized control trial SSP secondary spontaneous pneumothorax
RDT rapid diagnostic test SSRI selective serotonin reuptake inhibitor
REM rapid-​eye-​movement ssRNA single-​stranded RNA
RF rheumatoid factor SSSS staphylococcal scalded skin syndrome
RFA radiofrequency ablation STD sexually transmitted disease
RIP Riyadh Intensive Care Programme STEMI ST-​elevation myocardial infarction
RIPA ristocetin-​induced platelet aggregation STI sexually transmitted infection
RNP ribonucleoprotein STIR short T1 inversion recovery
RNS repetitive nerve stimulation SUA serum uric acid
ROSIER Recognition of Stroke In the Emergency Room SUDEP sudden unexpected death in epilepsy
RPGN rapidly progressive glomerulonephritis SUNCT short-​lasting neuralgiform headache with
RR relative risk conjunctival injection and tearing
RRT renal replacement therapy SV40 simian virus 40
RS reactive site SVC superior vena cava
RSV respiratory syncytial virus SVR sustained virologic response
RTA road traffic accident SVT supraventricular tachycardia
RUQ right upper quadrant SWEDD subjects without evidence of dopaminergic deficits
RV right ventricular T3 triiodothyronine
RVAD right ventricular assist device T4 thyroxine
RVOT right ventricular outflow tract TAA thoracic aortic aneurysm
RVOTO right ventricular outflow tract obstruction TACE trans-​arterial chemo-​embolization
SAA serum amyloid A protein TB tuberculosis
SAAG serum–​ascites albumin gradient TBG thyroxine-​binding globulin
SAB Staphylococcus aureus bacteraemia TBNA transbronchial needle aspiration

Abbreviations
SAECG signal-​averaged electrocardiogram TCA tricyclic antidepressant
SAH subarachnoid haemorrhage TCR T-​cell receptor
SAI secondary adrenal insufficiency TdP torsades de pointes
SALT speech and language therapists TE thromboembolism
SaO2 arterial oxygen saturation TFPI tissue factor pathway inhibitor
SAPS Simplified Acute Physiology Score TFT thyroid function test
SARS severe acute respiratory syndrome TGA transposition of the great arteries
SBP systolic blood pressure Th T helper
SCA sudden cardiac arrest Th2 T-​helper type 2
SCC squamous cell carcinoma TIA transient ischaemic attack
SCD sudden cardiac death TIN tubulointerstitial nephritis
SCID severe combined immune deficiency TINU tubulointerstitial disease with uveitis
SCLC small cell lung carcinoma TIPS transjugular intra-​hepatic portosystemic shunt
SCLE subacute cutaneous lupus erythematosus TK tyrosine kinase
ScvO2 central venous oxygen saturation TKI tyrosine kinase inhibitor
SD standard deviation TLC total lung capacity
SF synovial fluid TLCO transfer factor for carbon monoxide
SHBG sex hormone-​binding globulin TLoC transient loss of consciousness
SIADH syndrome of inappropriate antidiuretic hormone TLR Toll-​like receptor
excretion TLS tumour lysis syndrome
SIRS systemic inflammatory response syndrome TM tympanic membrane
SIV simian immunodeficiency virus TNFα tumour necrosis factor alpha
SLE systemic lupus erythematosus TNM tumour, node, and metastases
SLNB sentinel lymph node biopsy TOE transoesophageal echocardiography
SMA smooth muscle antibody TPMT thiopurine methyltransferase
SMART Specific, Measurable, Achievable, Realistic, TPO thyroid peroxidase
and Timed TPR total peripheral resistance
SMR standard mortality ratio TRH thyrotropin-​releasing hormone
SNHL sensorineural hearing loss TRUS trans-​rectal ultrasound
SNRT sinus node re-​entrant tachycardia TSE transmissible spongiform encephalopathy
SOD sphincter of Oddi dysfunction TSH thyroid-​stimulating hormone
SOFA Sequential Organ Failure Assessment TT thrombin time
SOV single-​organ vasculitis TTE transthoracic echocardiography

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 TTP thrombotic thrombocytopenic purpura VC vital capacity
TURBT trans-​urethral resection of bladder tumour VCD vocal cord dysfunction
TURP trans-​urethral resection of the prostate VCLAD very long-​chain acyl-​coenzyme A dehydrogenase
TWI T-​wave inversion deficiency
UA undifferentiated arthritis VDRL Venereal Disease Research Laboratory
U&E urea and electrolytes VEGF vascular endothelial growth factor
UC ulcerative colitis VF ventricular fibrillation
UCD urea cycle disorder VGCC voltage-​gated calcium channel
UDCA ursodeoxycholic acid VGKC voltage-​gated potassium channel complex
UGIH upper gastrointestinal haemorrhage VKA vitamin K antagonist
UKPDS UK Prospective Diabetes Study VLDL very-​low-​density lipoprotein
UKRR UK Research Reserve VLM visceral larva migrans
ULN upper limit of normal VOC volatile organic compound
ULT urate-​lowering therapy VPC premature ventricular complex
UMN upper motor neuron VQ ventilation–​perfusion
UNSCEAR United Nations Scientific Committee on the Effects VSD ventricular septal defect
of Atomic Radiation VT ventricular tachycardia
URTI upper respiratory tract infection VTE venous thromboembolism
USRDS United States Renal Data System VUJ vesicoureteric junction
USS ultrasound scan VZV varicella zoster virus
UTI urinary tract infection WBC white blood cell
UUN urinary urea nitrogen WCC white-​cell count
UV ultraviolet WG Wegener’s granulomatosis (granulomatosis with
UVA ultraviolet light A polyangiitis)
UVB ultraviolet light B WG–​MPA Wegener’s granulomatosis–​microscopic polyangiitis
VA effective alveolar volume WHO World Health Organization
VaD vascular dementia WPW Wolff–​Parkinson–​White syndrome
Abbreviations

VAD ventricular assist devices XO xanthine oxidase

VAP ventilator-​associated pneumonia XP xeroderma pigmentosum
VATS video-​assisted thoracoscopic surgery

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Contributors

Richard Abbott Peter G. Bain

Consultant Neurologist, Leicester Royal Infirmary, Leicester, UK Reader and Honorary Consultant in Clinical Neurology, Charing
Cross Hospital, London, UK
Yasir Abu-​Omar
Consultant Cardiothoracic and Transplant Surgeon, Papworth Amitava Banerjee
Hospital, Papworth Everard, UK Senior Clinical Lecturer in Clinical Data Science and Honorary
Consultant Cardiologist, University College London, London, UK
Bhavyang Acharya
Consultant in Palliative Medicine, Cynthia Spencer Phil Barber
Hospice, Northamptonshire Healthcare NHS Foundation Consultant Respiratory Physician, University Hospital of South
Trust, Northampton, UK Manchester, Manchester, UK

David Adlam Simon Barry

Senior Lecturer in Acute and Interventional Cardiology and Consultant in Respiratory Medicine, University Hospital Llandough,
Honorary Consultant Cardiologist, University of Leicester, Penarth, UK
Leicester, UK
Dirk Bäumer
Joshua Agbetile Consultant Neurologist, Peterborough and Stamford Hospitals NHS
Consultant Respiratory Physician, Homerton University Hospital, Foundation Trust, Peterborough, UK
London, UK
Mike Beadsworth
Daniel Ajzensztejn Consultant in Infectious Diseases and General Medicine,
Consultant Clinical Oncologist, Oxford University Hospitals NHS Royal Liverpool University Hospital, Liverpool, UK
Foundation Trust, Oxford, UK
Nick Beeching
Raza Alikhan Senior Lecturer and Honorary Consultant in Infectious Diseases,
Consultant Haematologist, University Hospital of Wales, Liverpool School of Tropical Medicine and Royal Liverpool
Cardiff, UK University Hospital, Liverpool, UK

Rob Andrews Tony Bentley

Associate Professor of Diabetes University of Exeter, Exeter, UK Consultant Microbiologist, Northampton General Hospital NHS
Trust, Northampton, UK
Tim Anstiss
Member, British Psychological Society, and Fellow, Royal Society Anthony Bewley
of Arts Consultant Dermatologist, Barts Health NHS Trust, London, UK,
and Honorary Senior Lecturer, University of London, London, UK
Charles M. G. Archer
Specialist Registrar in Dermatology, Churchill Hospital Oxford, UK Kailash P. Bhatia
Professor of Clinical Neurology, University College London,
Clive B. Archer London, UK, and Honorary Consultant Neurologist, National
Consultant Dermatologist, Guy’s and St Thomas’ NHS Foundation Hospital for Neurology and Neurosurgery, London, UK
Trust, London, UK
Malini Bhole
Richard Armstrong Consultant Immunologist, The Dudley Group NHS Foundation
Consultant Neurologist, Royal Berkshire NHS Foundation Trust, Trust, Dudley, UK
Reading, UK, and Oxford University Hospitals NHS Foundation
Trust, Oxford, UK Benjamin Bloch
Consultant Orthopaedic Surgeon, Nottingham University Hospitals
Kaleab Asrress NHS Trust, Nottingham, UK
St Thomas’ Hospital, London, King’s College London; Royal North
Shore Hospital, University of Sydney, Australia James Bonnington
Consultant Intensivist, Nottingham University Hospital NHS Trust,
Stephen Aston Nottingham, UK
National Institute for Health Research Academic Clinical Lecturer
in Infectious Diseases, University of Liverpool, Liverpool, UK Ian Bowler
Consultant and Deputy Clinical Lead in Microbiology, John Radcliffe
Mona Bafadhel Hospital, Oxford, UK
Consultant Respiratory Physician, Oxford University Hospitals NHS
Foundation Trust, and Senior Clinical Researcher, University of Marilyn Bradley
Oxford, Oxford, UK Consultant Physician in Genitourinary Medicine, Royal Liverpool and
Broadgreen University Hospitals NHS Trust, Liverpool, UK
Fahd Baig
Clinical Research Fellow, University of Oxford, Oxford, UK Rowland J. Bright-​Thomas
Consultant Respiratory Physician, University Hospital of South
Manchester, Manchester, UK

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 Elaine Buchanan Lucy Cottle
Consultant Physiotherapist, Oxford University Hospitals NHS Consultant Physician in Infectious Diseases, Leeds Teaching
Foundation Trust, Oxford, UK Hospitals NHS Trust, Leeds, UK

Chris Bunch Anthony Cox

Consultant Physician and Clinical Haematologist, John Radcliffe Senior Lecturer in Clinical Pharmacy and Drug Safety, University of
Hospital, Oxford, UK Birmingham, Birmingham, UK

Sarah Cader Sonya Craig

Consultant Neurologist, Basingstoke and North Hampshire Consultant Respiratory and Sleep Physician, Aintree University
Hospital, Basingstoke, UK Hospital, Liverpool, UK

Caroline Cardy Anjali Crawshaw

Consultant Rheumatologist, Worcestershire Royal Hospital, Consultant Respiratory Physician, Queen Elizabeth Hospital,
Worcester, UK University Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
Alan Carson
Consultant Neuropsychiatrist, NHS Lothian, Edinburgh, UK, and Paul Cullinan
Reader, University of Edinburgh, Edinburgh, UK Professor of Occupational and Environmental Respiratory Disease,
National Heart and Lung Institute, Imperial College, London, UK
Matteo Cella
Lecturer in Clinical Psychology, King’s College London, Nicola Curry
London, UK Consultant Haematologist, Churchill Hospital, Oxford, UK

Aron Chakera David Cutter

Consultant Nephrologist, Sir Charles Gairdner Hospital, Perth, Consultant Clinical Oncologist, Oxford University Hospitals NHS
Australia Foundation Trust, Oxford, UK

Trudie Chalder Adam Darowski

Professor of Cognitive Behavioural Psychotherapy, King’s College Consultant Physician, John Radcliffe Hospital, Oxford, UK, and
London, London, UK Honorary Senior Lecturer, Oxford University, Oxford, UK

John Chambers Parthajit Das

Contributors

Professor of Clinical Cardiology and Consultant Cardiologist, Guy’s Consultant Rheumatologist, Kettering General Hospital NHS
and St Thomas’ NHS Foundation Trust, London UK Foundation Trust, Kettering, UK

Hannah Chapman Patrick Davey

Specialist Registrar in Clinical Oncology, Mount Vernon Cancer Consultant Cardiologist, Northampton General Hospital NHS
Centre, Northwood, UK Trust, Northampton, UK

Mas Chaponda Emily Davies

Consultant in Infectious Diseases and General Medicine, Royal Consultant Dermatologist, Gloucestershire Royal Hospital,
Liverpool University Hospital, Liverpool, UK Gloucester, UK

Mimi Chen Geraint Davies

Consultant Endocrinologist, St.George’s University Hospitals Reader in Infection Pharmacology and Consultant in Infectious
Foundation NHS Trust, London, UK Diseases, University of Liverpool, Liverpool, UK

Nigel Clayton Paul Davies

Senior Chief Clinical Physiologist, Wythenshawe Hospital, Consultant Neurologist, Northampton General Hospital NHS Trust,
Manchester, UK Northampton, UK

Sian Coggle Sam Dawkins

Consultant in Infectious Diseases and Acute Internal Medicine, Specialist Registrar in Cardiology, John Radcliffe Hospital, Oxford, UK
Cambridge University Hospitals NHS Foundation Trust,
David de Berker
Cambridge, UK
Consultant Dermatologist and Honorary Senior Lecturer, University
Graham Collins Hospitals Bristol NHS Foundation Trust, Bristol, UK
Clinician Scientist, Imperial College, London, UK
Aminda De Silva
Cris S. Constantinescu Consultant Gastroenterologist, Royal Berkshire NHS Foundation
Professor of Neurology and Consultant Neurologist, Nottingham Trust, Reading UK
University Hospital NHS Trust, Nottingham, UK
Sarah Deacon
Graham Cooke Consultant Respiratory Physician, Worcestershire Royal Hospital,
Reader Infectious Diseases, Imperial College, London, UK Worcester, UK

Susan Cooper Miguel Debono

Consultant Dermatologist and Honorary Senior Clinical Lecturer, Consultant Endocrinologist and Honorary Senior Lecturer, Royal
Oxford University Hospitals NHS Foundation Trust, Oxford, UK Hallamshire Hospital, Sheffield, UK

Patrick Deegan
Metabolic Physician, Addenbrooke’s Hospital, Cambridge, UK

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Alastair Denniston Sherif Gonem
Consultant Ophthalmologist, University Hospitals Birmingham National Institute for Health Research Clinical Lecturer in
NHSFT & Hon Professor, University of Birmingham, Respiratory Medicine, University of Leicester, Leicester, UK
Birmingham, UK
Lynsey Goodwin
Dhananjay Desai Specialist Trainee in Infectious Diseases and General Medicine,
Consultant Respiratory Physician, University Hospital Coventry, Royal Liverpool University Hospital, Liverpool and North
Coventry, UK Manchester General Hospital, Manchester, UK

Michael Doherty Warren Grant

Professor of Rheumatology and Head of Division of Academic Consultant Clinical Oncologist, Cheltenham General Hospital,
Rheumatology, School of Medicine, University of Nottingham, Cheltenham, UK
Nottingham, UK
Tracey Graves
Moutaz El-​Kadri Consultant Neurologist, Addenbrooke’s Hospital, Cambridge, UK,
Consultant Cardiologist and Electrophysiologist, Sheikh Khalifa and Hinchingbrooke Hospital, Huntingdon, UK
Medical City, Abu Dhabi, UAE
Alexander L. Green
Michelle Ellinson Spalding Associate Professor and Consultant Neurosurgeon, John
Freelance Dietitian, London, UK Radcliffe Hospital, Oxford, UK

Christine Elwell Seamus Grundy

Consultant Oncologist, Northampton General Hospital NHS Trust, Consultant Respiratory Physician, Aintree University Hospital,
Northampton, UK Liverpool, UK

Clare England Pranabashis Haldar

Senior Research Associate, University of Bristol, Bristol, UK Senior Clinical Lecturer in Respiratory Medicine, University of
Leicester, Leicester, UK
Ben Esdaile
Consultant Dermatologist, Whittington Hospital, London, UK George Hart
Honorary Research Professor, University of Manchester,
Robin Ferner Manchester, UK
Honorary Professor of Clinical Pharmacology, University of

Contributors
Birmingham, Birmingham, UK Yvonne Hart
Consultant Neurologist, Newcastle Upon Tyne NHS Foundation
Tom Fletcher Trust, Newcastle, UK
Wellcome Trust/​Ministry of Defence Research Training
Fellow and Speciality Registrar in Infectious Diseases, Liverpool Catherine Harwood
School of Tropical Medicine, and Royal Liverpool University Professor in Dermatology and Honorary Consultant Dermatologist,
Hospital, Liverpool, UK Queen Mary University of London, London, UK

Colin Forfar Victoria Haunton

Consultant Cardiologist, Oxford University Hospitals NHS Consultant and Honorary Senior Lecturer in Geriatric Medicine,
Foundation Trust, Oxford, UK University Hospitals of Leicester NHS Trust, Leicester, UK

Martin Fotherby Neil Herring

Consultant Stroke Physician, Leicester Royal Infirmary Leicester, UK Associate Professor of Cardiovascular Physiology, University
of Oxford, Oxford, UK, and Consultant Cardiologist, Oxford
Anthony Frew University Hospitals NHS Trust, Oxford, UK
Professor of Allergy and Respiratory Medicine, Royal Sussex County
Hospital, Brighton, UK William G. Herrington
Honorary Consultant Nephrologist, Churchill Hospital,
Paul Frost Oxford, UK
Consultant in Intensive Care Medicine, University Hospital of
Wales, Cardiff, UK Melvyn Hillsdon
Associate Professor of Exercise and Health Behaviour, University of
Hill Gaston Exeter, Exeter, UK
Emeritus Professor of Rheumatology, University of Cambridge,
Cambridge, UK Stephan Hinze
Consultant Neurologist, Great Western Hospital, Swindon, UK
David J. Gawkrodger
Professor Emeritus in Dermatology, University of Sheffield, Sandeep Hothi
Sheffield, UK Bye Fellow, University of Cambridge, Cambridge, UK, and Specialist
Registrar in Cardiology and General Internal Medicine, Glenfield
Sir Ian Gilmore Hospital, Leicester, UK
Honorary Consultant, Royal Liverpool University Hospital, and
Honorary Professor, University of Liverpool, Liverpool, UK Jonathan A. Hyam
Consultant Brain and Comprehensive Spinal Neurosurgeon,
William Gilmore National Hospital for Neurology and Neurosurgery, London, UK,
Research Fellow, National Drug Research Institute, Curtin and Honorary Senior Lecturer in Neurosurgery, University College
University, Perth, Australia London, London, UK

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 Sarosh Irani Chris Lavy
Honorary Consultant Neurologist and Senior Clinical Fellow, John Professor of Orthopaedic and Tropical Surgery, and Consultant
Radcliffe Hospital, Oxford, UK Orthopaedic and Spine Surgeon, University of Oxford, Oxford, UK

Simon Jackson Richard Lessells

Consultant Urogynaecologist, Oxford University Hospitals NHS Senior Infectious Diseases Specialist, University of KwaZulu-Natal,
Foundation Trust, Oxford, UK Durban, South Africa

Kassim Javaid Andrew Lever

Honorary Consultant Rheumatologist, University of Oxford, Professor of Infectious Diseases, University of Cambridge,
Oxford, UK Cambridge, UK, and Honorary Consultant Physician,
Addenbrooke’s Hospital, Cambridge, UK
Rachel Jeffery
Consultant Rheumatologist, Northampton General Hospital NHS Keir Lewis
Trust, Northampton, UK Professor of Respiratory Medicine, University of Swansea,
Swansea, UK
Andrew A. Jeffrey
Consultant Respiratory Physician and Director of Medical Su-​Yin Lim
Education, Northampton General Hospital NHS Trust, Specialist Registrar in Neurology, Leicester General Hospital,
Northampton, UK, and Honorary Senior Lecturer, University of Leicester, UK
Oxford, Oxford, UK
Mark P. Little
Liberty Jenkins Senior Investigator, National Cancer Institute, Bethesda, MD, USA
Fellow in Neuromuscular Medicine, Stanford University Hospital,
Yoon Loke
Palo Alto, CA, USA
Professor of Medicine and Pharmacology, University of East Anglia,
Andrew M. Jones Norwich, UK
Consultant Respiratory Physician, University Hospital of South
Melanie Lord
Manchester, Manchester, UK
Speech and Language Therapist, Fen House, Ely, UK
Michael Jones
Raashid Luqmani
Clinical Fellow in Cardiology, Oxford University Hospitals NHS
Professor of Rheumatology, University of Oxford, Oxford, UK
Contributors

Foundation Trust, Oxford, UK

Linda Luxon
Nerissa Jordan
Professor Emeritus of Audiovestibular Medicine and Honorary
Consultant Neurologist, Fiona Stanley Hospital, Perth, Australia
Consultant Physician in Neuro-otology, University College London
Elizabeth Justice and University College Hospitals NHS Trust, London, UK
Consultant Rheumatologist, Queen Elizabeth Hospital Birmingham,
Graz Luzzi
Birmingham, UK
Consultant in Genitourinary Medicine, Wycombe General Hospital,
Manish Kalla High Wycombe, UK, and Honorary Senior Clinical Lecturer,
Lecturer in Medicine and Clinical Research Fellow, University of University of Oxford, Oxford, UK
Oxford, Oxford, UK
Robert MacKenzie-​Ross
Alexandra Kent Respiratory Consultant, Royal United Hospital, Bath, UK
Research Fellow, John Radcliffe Hospital, Oxford, UK
Rubeta Matin
Satish Keshav Consultant Dermatologist, Churchill Hospital, Oxford, UK
Gastroenterologist and Honorary Senior Lecturer, John Radcliffe
Jane McGregor
Hospital, Oxford, UK
Consultant Dermatologist, Barts Health NHS Trust, London, UK
Saifudin Khalid
Tess McPherson
Consultant Respiratory Physician, Royal Blackburn Hospital,
Consultant Dermatologist, Churchill Hospital, Oxford, UK
Blackburn, UK
Benedict Michael
Richard Knight
National Institute for Health Research Senior Clinician Scientist
Professor of Clinical Neurology, National CJD Research And
Fellow University of Liverpool, Liverpool, UK, and Post-​Doctoral
Surveillance Unit, Edinburgh, UK
Researcher/​Lecturer, Massachusetts General Hospital/Harvard
Robin Lachmann Medical School Boston, MA, USA
Consultant in Metabolic Medicine, National Hospital for Neurology
Siraj Misbah
and Neurosurgery, London, UK
Consultant Clinical Immunologist, John Radcliffe Hospital, Oxford, UK,
Ajit Lalvani and Honorary Senior Clinical Lecturer, Oxford University, Oxford, UK
Chair of Infectious Diseases, Director of the National Institute of
Amit Mistri
Health Research Health Protection Research Unit, Director of the
Consultant in Stroke Medicine, Leicester Royal Infirmary,
Tuberculosis Research Centre, and Head of Respiratory Infections,
Leicester, UK
National Heart and Lung Institute, Imperial College London,
London, UK Sajjan Mittal
Consultant Haematologist, Northampton General Hospital NHS
Trust, Northampton, UK

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Susan Mollan Joanna Pepke-​Zaba
Consultant Ophthalmologist, University Hospitals Birmingham Consultant Respiratory Physician, Papworth Hospital, Papworth
NHSFT & Clinical Fellow, University of Birmingham, Everard, UK
Birmingham, UK
Erlick A. C. Pereira
Rhiain Morris Senior Lecturer in Neurosurgery, St George’s, University of London,
Clinical Psychologist, Oxfordshire Counselling and Psychology London, UK, and Consultant Neurosurgeon, St George’s Hospital,
Practice, Oxford, UK London, UK

Karen Morrison Jeremy Perkins

Associate Dean for Education and Student Experience, Director Consultant Vascular Surgeon, John Radcliffe Hospital, Oxford, UK
of Medical Education, and Professor of Neurology, University
Joanna Peters
of Southampton, Southampton, UK, and Honorary Consultant
Locum Consultant in Infectious Diseases and Medical Microbiology,
Neurologist, University Hospital Southampton, Southampton, UK
Royal Sussex County Hospital, Brighton, Sussex, UK
Alia Munir
Katrina Pollock
Consultant Endocrinologist, Royal Hallamshire Hospital, Sheffield, UK
National Institute for Health Research Clinical Lecturer in
Louisa Murdin Genitourinary Medicine, Imperial College London, London, UK
Consultant Audiovestibular Physician, Guy’s and St Thomas’ NHS
Jenny Powell
Foundation Trust, London, UK
Consultant Dermatologist, Basingstoke and North Hampshire
Elaine Murphy Hospital, Basingstoke, UK
Consultant in Inherited Metabolic Disease, National Hospital for
Jonathan Price
Neurology and Neurosurgery, London, UK
Clinical Tutor in Psychiatry, University of Oxford, Oxford, UK
Chandramouli Nagarajan
Natalia Price
Consultant Haematologist and Adj. Assistant Professor, DUKE-NUS
Consultant Urogynaecologist, John Radcliffe Hospital, Oxford, UK
Medical School, Singapore General Hospital, Singapore
Susan Price
Pradip Nandi
Consultant in Clinical Genetics, Oxford Regional Genetics Service,
Consultant Rheumatologist, Northampton General Hospital NHS
Oxford, UK

Contributors
Trust, Northampton, UK
Norman Qureshi
Abdul Nasimudeen
Consultant Cardiologist and Electrophysiologist, Imperial College
Consultant Chest Physician, Northampton General Hospital NHS
Healthcare NHS Trust, London, UK
Trust, Northampton, UK
Kazem Rahimi
Pavithra Natarajan
Professor of Medicine, University of Oxford, Oxford, UK
Consultant in Infectious Diseases, North Manchester General
Hospital, Manchester, UK Kim Rajappan
Consultant Cardiologist, John Radcliffe Hospital, Oxford, UK
John Newell-​Price
Professor of Endocrinology and Consultant Endocrinologist, Tommy Rampling
University of Sheffield, Sheffield, UK Academic Clinical Fellow, University College London, London, UK
Jim Newton James Ramsden
Consultant Cardiologist, Oxford University Hospitals NHS Consultant ENT Surgeon, John Radcliffe Hospital, Oxford, UK
Foundation Trust, Oxford, UK
Anna Rathmell
Pippa Newton Medical Manager, Takeda UK Ltd, Wooburn Green, UK, and Lay
Consultant in Infectious Diseases, Manchester University NHS Member, South Central–​Oxford C Research Ethics Committee,
Foundation Trust, Manchester, UK Bristol, UK
Kannan Nithi David Ratliff
Consultant Neurologist and Neurophysiologist, Northampton Consultant Vascular Surgeon, Northampton General Hospital NHS
General Hospital NHS Trust, Northampton, UK Trust, Northampton, UK
Christopher A. O’Callaghan Karim Raza
Professor of Medicine and Honorary Consultant Physician and Professor of Clinical Rheumatology, University of Birmingham,
Nephrologist, University of Oxford, Oxford, UK Birmingham, UK
Liz Orchard Dave Riley
Consultant Cardiologist, John Radcliffe Hospital, Oxford, UK Palliative Medicine Consultant and Clinical Director,
Northamptonshire Healthcare NHS Foundation Trust,
Rakesh Panchal
Northampton, UK
Consultant Respiratory Physician, Glenfield Hospital, Leicester, UK
Simon Rinaldi
Manish Pareek
MRC Clinician Scientist and Honorary Consultant Neurologist,
Senior Clinical Lecturer in Infectious Diseases, University of
University of Oxford, Oxford, UK
Leicester, Leicester, UK, and Honorary Consultant in Infectious
Diseases, Leicester Royal Infirmary, Leicester, UK

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 Joanna Robson Christine Soon
Consultant Senior Lecturer in Rheumatology, University of Consultant Dermatologist, Northampton General Hospital NHS
the West of England, Bristol, UK Trust, Northampton, UK

Kufre Sampson David Sprigings

Consultant Clinical Oncologist, Leicester Royal Infirmary, Formerly Consultant Physician, Northampton General Hospital
Leicester, UK NHS Trust, Northampton, UK

John Saunders Robert Stevens

Consultant Gastroenterologist, Royal United Hospital, Bath, UK Consultant Rheumatologist, Doncaster Royal Infirmary,
Doncaster, UK
Alys Scadding
Consultant in Respiratory Medicine, Glenfield Hospital, Jon Stone
Leicester, UK Consultant Neurologist and Honorary Reader in Neurology,
University of Edinburgh, Edinburgh, UK
Matthew Scarborough
Consultant in Clinical Infection, John Radcliffe Hospital, Oxford, UK Sarah Stoneley
Consultant Geriatrician, Leicester Royal Infirmary, Leicester, UK
Alexander Schmidt
Director, Professor of Musicians’ Medicine, and Consultant Michael Stroud
Neurologist, Kurt Singer Institute for Music Physiology and Consultant Gastroenterologist and Professor of Clinical Nutrition,
Musicians’ Health, Berlin, Germany Southampton University Hospital, Southampton, UK

Susanne Schneider Kenny Sunmboye

Consultant Neurologist, Ludwig-​Maximilians-​Universität München, Consultant Rheumatologist and UKNIHR CRN East Midlands
München, Germany Musculoskeletal Disorders Specialty Lead, University Hospitals of
Leicester, Leicester, UK
Martin Scott-​Brown
Consultant Oncologist, University Hospital Coventry, Coventry, UK Ravi Suppiah,
Consultant Rheumatologist, Auckland District Health Board,
Aung Sett Auckland, New Zealand
Consultant Stroke Physician, Fairfield General Hospital, Bury, UK
Joanna Szram
Contributors

Shireen Shaffu Consultant Respiratory Physician, Royal Brompton and Harefield

Consultant Rheumatologist, Leicester Royal Infirmary, Leicester, UK NHS Foundation Trust, London, UK
Karen K. K. Sheares David Taggart
Respiratory Consultant, Papworth Hospital, Papworth Everard, Professor of Cardiovascular Surgery, John Radcliffe Hospital,
Cambridge Oxford, UK
Jackie Sherrard Kathy Taghipour
Consultant Physician, Department of Sexual Health, Churchill Consultant Dermatologist, Whittington Health NHS Trust, London, UK
Hospital, Oxford, UK
James Taylor
Cheerag Shirodaria Consultant Rheumatologist, Northampton General Hospital NHS
Honorary Consultant Cardiologist, John Radcliffe Hospital, Oxford, UK Trust, Northampton, UK
Ehoud Shmueli Sherine Thomas
Consultant Gastroenterologist, Northampton General Hospital, Consultant in Infectious Diseases and General Medicine, Barts
NHS Trust, Northampton, UK Health NHS Trust, London, UK
Kevin Shotliff Bryan Timmins
Consultant Diabetologist, Chelsea and Westminster Hospital, Consultant Neuropsychiatrist, Northamptonshire Healthcare NHS
London, UK Trust, Northampton, UK
Salman Siddiqui Jonathan Timperley
Clinical Senior Lecturer , Glenfield Hospital, Leicester, UK Consultant Cardiologist, Northampton General Hospital NHS
Muthu Sivaramakrishnan Trust, Northampton, UK
Consultant Dermatologist, Ninewells Hospital and Medical School, Stacy Todd
Dundee, UK Consultant in Infectious Diseases and General Medicine, Royal
Jacky Smith Liverpool University Hospital, Liverpool, UK
Professor of Respiratory Medicine, University of Manchester, Palak Trivedi
Manchester, UK, and Honorary Consultant, University Hospital of Academic Clinical Lecturer and Specialist Registrar in Hepatology
South Manchester, Manchester, UK and Gastroenterology, University of Birmingham, Birmingham, UK
Roger Smyth Martin R. Turner
Consultant Psychiatrist, Royal Infirmary of Edinburgh, Edinburgh, UK Professor of Clinical Neurology and Neuroscience, John Radcliffe
Tom Solomon Hospital, Oxford, UK
Professor of Neurology, University of Liverpool, Liverpool, UK

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Jaime Vera, Pippa Watson
Clinical Senior Lecturer, Brighton and Sussex Medical School, Consultant Rheumatologist, University Hospital of South
Brighton, UK Manchester, Manchester, UK

Raman Verma Andrew Weir

Specialist Registrar in Respiratory Medicine and Honorary National Consultant Neurologist, Royal Berkshire Hospital, Reading, UK,
Institute for Health Research Lecturer, Glenfield Hospital University, and John Radcliffe Hospital, Oxford, UK
Leicester, UK
Sophie West
Sarah Wakelin Consultant Physician, Freeman Hospital, Newcastle, UK
Consultant Dermatologist and Honorary Senior Lecturer, Imperial
Matt Wise
College Healthcare NHS Trust, London, UK
Physician, University Hospital of Wales, Cardiff, UK
Ben Wakerley
Martyn Wood
Consultant Neurologist, Gloucestershire Royal Hospital,
Consultant in Sexual Health and HIV Medicine, Royal Liverpool
Gloucester, UK
and Broadgreen University Hospitals NHS Trust, Liverpool, UK
Emma Wall
Chee-​Seng Yee
Academic Clinical Lecturer, University College London,
Consultant Rheumatologist, Doncaster Royal Infirmary,
London, UK
Doncaster, UK

Contributors

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Figure 87.8 Myocardial perfusion imaging with single-​photon emission computed tomography (SPECT): An example of inducible hypoperfusion in
the anterior wall and apex. Panels, from left to right, show representative vertical long-​axis (VLA), horizontal long-​axis (HLA), and mid short-​axis (SAX)
slices, with stress above rest. The white arrows show a perfusion defect which is present on the stress slices but which resolves at rest.
Reproduced with permission from Warrell, Cox and Firth, Oxford Textbook of Medicine, fifth edition, Oxford University Press, Oxford, UK, Copyright © 2010

Figure 87.9 CT coronary angiography showing a critical soft plaque stenosis in the left main stem.
Reproduced with permission from Warrell, Cox and Firth, Oxford Textbook of Medicine, fifth edition, Oxford University Press, Oxford, UK, Copyright © 2010

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Figure 87.11 To assess the fractional flow reserve, which is the ratio of the pressures distal to and proximal to a stenosis, a small flexible wire with
two separate pressure sensors is placed across a candidate coronary artery stenosis. Under resting conditions (A), there is only a 10 mm Hg gradient
(ΔP) across the lesion but, under maximal hyperaemia (‘adenosine i.v.’; B), the gradient increases markedly to 33 mm Hg, with a mean distal-​to-​
proximal pressure ratio of 0.56. Thus, in this case, the fractional flow reserve indicates the presence of a functionally significant stenosis, and coronary
angioplasty is indicated; FFR, fractional flow reserve; i.v., intravenous.

Figure 155.1 CT demonstrating the urinary system.

image courtesy of Nigel Cowan

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Figure 155.3 Normal glomerulus and glomerular filtration barrier under light and electron microscopy; note the glomerular basement membrane
(G), with endothelial cells (E) at its upper edge, and the foot processes of the podocytes (P) abutting its lower edge.
image courtesy of Ian Roberts

(A) (B)

Figure 157.1 Microscopic haematuria. (A) Isomorphic red cells. Isomorphic red cells are seen in non-​glomerular haematuria. (B) Dysmorphic red
cells. Dysmorphic red cells are seen in glomerular haematuria, but may also be found in non-​glomerular and tubulointerstitial disease.
Reproduced with permission from Davidson et al, Oxford Textbook of Clinical Nephrology, Third Edition, Oxford University Press, Oxford, UK, Copyright © 2005

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 (A)

(B)

Figure 157.2 (A) Hyaline cast. Hyaline casts are concretions of

Tamm–​Horsfall mucoprotein and may be seen in concentrated urine.
(B) Granular cast. Granular casts are cellular remnants embedded in
hyaline material and are non-​specific for glomerular and tubular disease.
Reproduced with permission from Davidson et al, Oxford Textbook of Clinical
Nephrology, Third Edition, Oxford University Press, Oxford, UK, Copyright © 2005

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 (A) (B)

(C)

Figure 157.3 (A) Red cell cast; inset: haemoglobin cast. Red cell casts are typically seen in glomerulonephritis. (B) Epithelial cell cast. Epithelial cell
casts may be seen in glomerular and tubular disease. (C) White cell cast; individual white cells (arrows) are clearly seen. White cell casts may be seen
in pyelonephritis and tubulointerstitial disease.
Reproduced with permission from Davidson et al, Oxford Textbook of Clinical Nephrology, Third Edition, Oxford University Press, Oxford, UK, Copyright © 2005.

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Figure 158.1 Urinary bacteria (rods).
Reproduced with permission from Davidson et al, Oxford Textbook of Clinical Nephrology,
Third Edition, Oxford University Press, Oxford, UK, Copyright © 2005

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Figure 159.1 Histology of renal biopsy. (A) IgA nephropathy showing mesangial hypercellularity in which there are at least four mesangial cells
in a peripheral mesangial area (periodic acid-​Schiff stain). (B) Postinfectious glomerulonephritis showing endocapillary hypercellularity, in which the
capillary lumina are filled with infiltrating leucocytes (hematoxylin and eosin stain (H&E)). (C) Antiglomerular basement membrane disease, showing
extracapillary proliferation (a cellular crescent), in which there is partial tuft collapse and proliferation of cells within Bowman’s space (H&E and silver).
(D) ANCA-​associated vasculitis, showing necrosis with capillary wall rupture and fibrin exudation (H&E and silver). (E, F) Membranoproliferative
pattern, showing a lobular appearance of the glomerular tuft, with mesangial hypercellularity and thickened capillary walls, with glomerular basement
membrane duplication evident on the silver stain (H&E and silver).
Reproduced with permission from Turner, Oxford Textbook of Clinical Nephrology, Fourth Edition Oxford University Press, Oxford, UK, Copyright © 2015

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Figure 159.2 Immunofluorescence of renal biopsy. (A) Linear glomerular basement membrane (GBM) positivity for IgG in anti-​GBM disease.
(B) Granular capillary wall positivity for IgG in membranous nephropathy. (C) Mesangial positivity for IgA in IgA nephropathy. (D) Mesangial and
capillary wall positivity for C3 in C3 glomerulonephritis. (E) Mesangial and tubular basement membrane positivity for kappa light chains in light chain
deposition disease. (F) Positivity for lambda light chains in tubular casts in light chain cast nephropathy.
Reproduced with permission from Turner, Oxford Textbook of Clinical Nephrology, Fourth Edition Oxford University Press, Oxford, UK, Copyright © 2015

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Figure 160.1 Cast nephropathy.
Reproduced with permission from Turner et al, Oxford Textbook of Clinical Nephrology,
Fourth Edition, Oxford University Press, Oxford, UK, Copyright © 2015

Figure 160.2 Renal biopsy of an acute interstitial nephritis with

oedema and a prominent inflammatory infiltrate of lymphocytes and
eosinophils separating the tubules (image courtesy of Ian Roberts).
Reproduced with permission from Turner et al, Oxford Textbook of Clinical Nephrology,
Fourth Edition, Oxford University Press, Oxford, UK, Copyright © 2015

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Another random document with
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 ‘Neighbour Viot,’ said Maître Picard, ‘I am a public officer, and
cannot allow such rebel talk.’
‘Beware of secret hurt rather than open authority,’ said Glazer.
‘Those words, so publicly expressed, may bring the Aqua Tofana into
your goblet this very night.’
The face of bourgeois Viot fell at the mere hint of impending
danger.
‘You surely do not think so?’ he said.
‘I do not say what I do not think,’ replied the apothecary. ‘If you
have fear, after promulgating these rash sentiments, take some of
my antidote with you: it is of rare virtue.’
‘It cured me,’ said Panurge, ‘after I had swallowed, at my master’s
orders, a quantity of the St. Nicholas manna enough to kill a horse.’
‘But an ass is a different animal, Panurge,’ said Philippe, as he
took up his hat and left the shop.
The humble assistant did not dare to retort, but seeing the Gascon
laughing at him, when Philippe had gone, he aimed a blow at him
with a bleeding-staff, which would have hurt Blacquart sorely had he
not dived down and avoided it. As it was, the staff descended on the
counter and broke a bottle, for which he was severely chidden by his
master.
In the meantime Philippe Glazer, leaving his father’s, crossed the
river by the Petit Pont and took his way towards Notre Dame. The
doors of the cathedral were still open, and he entered the southern
aisle, now dimly lighted by a few votive tapers, which were flaring
and guttering upon their rude iron stands in the currents of air that
swept through the interior. A man, who was evidently waiting to meet
him, emerged from the shadow of one of the pillars as he advanced.
‘M. de Sainte-Croix!’
‘Philippe Glazer!’
‘We are truly met,’ said the student. ‘I received your note this
evening, and you can come to the hospital with me.’
‘You are obliging me,’ said Gaudin; ‘I am anxious respecting the
health of an old servant of mine, now an inmate.’
‘Pshaw! Captain Gaudin,’ replied Philippe, ‘between the Gens de
la Courte Epée there should be no secrets. It is a matter of gallantry,
or I am mistaken; we are freemasons, you know, of a certain sort,
and may trust each other.’
Gaudin laughed and made an evasive reply, as he took Philippe’s
arm; and the two, crossing the square before Notre Dame, entered
the Hôtel Dieu. As they passed the lodge, the porter, recognising
Philippe, gave him a note which had been left for the gentleman who
was expected to accompany him. Gaudin knew the writing, and
hastily opened it. Its contents were as follows:—

‘Do not notice me in the hospital, or suspicion will be

aroused, and I shall not come again. In the Morgue we shall
be free from interruption, and only there. Glazer will conduct
you.
‘Marie.’

‘Mass!’ exclaimed Philippe, as Sainte-Croix mentioned the

appointment—‘a strange rendezvous! The lady has a bold mind
within that delicate frame.’
‘Hush!’ said Gaudin, pressing his arm; ‘do not speak so loud.
Show me where the place is and leave me.’
‘Most willingly, if you have courage. One might select a livelier
place, however, than the dead-house of an hospital for a trysting-
place.’
He took his companion by the hand, and they advanced along one
of the arched passages, which the dim lamps barely illuminated, to
the top of a flight of stairs. These they descended, and, passing
along another vaulted way, paused at a door at the extreme end. It
was not fastened. Philippe threw it open, and they entered the
Morgue of the hospital—the receptacle for such as died within the
precincts of the Hôtel Dieu.
It was a dreary room, with bare white walls and a cold stone floor,
lighted by one ghastly lamp that hung against the wall. The frightful
mortality for which the hospital was then remarkable kept it well filled
with its silent inmates. Some of these were placed upon the ground,
enveloped in rough canvas wrappers—the only coffins allowed them
—in the same state as they may now be seen brought to the Clamart
and other dissecting-schools of Paris; others lay ranged side by side
upon large oval marble slabs, capable of accommodating from eight
to ten bodies each, and these had merely coarse sheets, or palls,
thrown over them. Over the stone floor a wooden trellis was placed,
an inch or two in thickness; for the floor was below the level of the
turgid Seine, which flowed immediately on the other side of the wall,
and the reflection of the lamp glimmering through the interstices
showed the water already in the Salle des Cadavres.
As soon as Philippe Glazer had introduced Sainte-Croix to this
dreary place he took his departure, and Gaudin was left alone. The
light waved in the draught of air caused by opening and closing the
door; and as it played over the features of some of the corpses they
appeared to move, from the different shadows, and then to resume
their wonted calm. In the fever of his mind Gaudin would almost
have changed places with them. He had no nervous terror at being
alone in such a dismal locality; his only feeling was one that
approached to envy of their repose. A minute, however, had scarcely
elapsed before the door again opened, and a female, enveloped in a
mantle similar to those worn by the sisters of charity, entered. It was
the Marchioness of Brinvilliers, who now came to commune with her
guilty ally.
They met with perhaps less eagerness than heretofore, albeit they
had not seen each other for several days; but although their passion
had apparently decreased, yet ties more fearful and more enduring
now bound their souls together in the common interest of mutual
guilt. The whole world was contracted to the sphere in which they
both moved; they knew of, cared for nothing beyond it, except those
objects coming within the circle of their dark intent.
After the first greetings had passed, Marie looked cautiously from
the door along the vaulted passage. Satisfied that no one was within
hearing, she closed it, and going to the marble table, partially threw
back the covering from one of the bodies; then grasping Sainte-
Croix’s arm, she drew him towards her, saying in a low voice, but
clear, and to him distinctly audible—
‘It has done its work nobly, and baffled every physician of the Hôtel
Dieu. This one swallowed it in wine, which my own maid, Françoise
Roussel, brought to the hospital. The girl would taste it as she went,
upon the sly, and it well-nigh cost the fool her life. This one shows
what the confiture could do. He lingered long though, and became a
skeleton, as you perceive, before his death.’
Sainte-Croix was aghast at these revelations, although they had
been anticipated. But the demoniac mind of his beautiful companion
drew him still closer towards her; her nature rose grander and
grander in the opinion of his dark soul, from the very fiendishness of
its attributes.
‘I am sure of its work,’ she continued. ‘Unlimited wealth,
unquestioned freedom is in our grasp, so you but second my
intentions. My brothers think they are ruling me as they would a
wayward girl: how terrible will be my retribution!’
‘I have much to tell you, Marie, of my own plans,’ said Gaudin; ‘but
it cannot be here. If those whom you have alluded to fall, others must
go with them. We cannot pause in our career.’
‘There is one that I have marked as the earliest,’ returned the
Marchioness. ‘I know not how it will affect your own feelings; in this
instance I care not.’
Her eyes sparkled with excitement as she spoke, and her rapidity
of utterance became mingled with her hurried but irregular
respiration. An expression passed across her face of mingled
triumph and satisfaction, whilst the fingers of her hand were quickly
working one over the other.
‘And who is that, Marie?’ asked Gaudin, his curiosity aroused by
the manner of the Marchioness.
‘The pale-faced girl, whose acquaintance with yourself I became
so unluckily acquainted with in the Grotto of Thetis—your
Languedocian leman—Louise Gauthier.’
‘She must not be injured!’ exclaimed Sainte-Croix hurriedly.
‘She must die!’ replied the Marchioness, with cold but determined
meaning. ‘She loves you, and you may still care for her. You must be
mine, and mine alone, Gaudin; your affections may not be
participated in by another.’
‘All has finished between us, Marie! You are wrong—utterly wrong
in your suspicions. You surely will not harm a poor girl like Louise?’
‘Gaudin!’ exclaimed his companion, fixing her glance on him with
that intense expression, against the influence of which Sainte-Croix’s
determination could not prevail, ‘when we have fallen—step by step,
hour by hour—and each time irrevocably, to all appearance, until a
fresh abyss, yawning beneath our presence, disclosed a still lower
hell open to receive us—when the sympathies of the world have
turned away from us to cling to fresh objects, in their parasitical
attachment to the freshest and most plausible support, and our
hopes and fears are merged into one blank feeling of careless
determination by utter despair—when all is given up here and
hereafter—in such positions it is not likely that we should pause in
the career marked out to be pursued for any sentiment of justice or
consideration. I am determined.’
There was the silence of some minutes after she had spoken,
broken only by the laboured breathing of either party, or the drip of
water, as, stealing through the walls from the river, it fell upon the
noisome floor. Each, was waiting for the other to speak. Sainte-Croix
was the first to break the pause. He knew that further allusion to
Louise Gauthier would induce fresh recrimination—that Marie would
believe no protestation on his part that the attachment was over—
and that by boldly bearding her, in her present access of jealousy,
the utter destruction of the poor girl would be hastened. He therefore
endeavoured to turn the subject of their conversation into another
channel.
‘Where is your brother?’ he asked. ‘You can act as you please
towards the other person, as you appear to be beyond conviction
from anything I can urge. François is at present the most important
object for our vigilance. Is he in Paris?’
‘He is not,’ replied the Marchioness. ‘Both my brothers are at
Offemont, arranging the distribution of the effects about the estate.
They will remain there for some days, and then depart to Villequoy.
Fortunately François has discharged one of his servants, and is
compelled to look after many of his affairs himself, the
superintendence of which would otherwise fall to his valet.’
‘Is he anxious to supply the place of the domestic?’ inquired
Gaudin eagerly.
‘He is now looking out for some one. But why are you thus
curious?’
‘Because I have a creature in my employ—one who dares
scarcely call his life his own, unless by my permission, who might fill
the post with advantage.’
‘I do not see what we could gain by that,’ observed the
Marchioness.
‘He might wait upon his master at table,’ said Gaudin, ‘and pour
out his drink.’
He regarded his companion with fixed intensity as he threw out the
dark hint contained in his last words.
‘But would there be no suspicion?’ asked Marie.
‘None,’ replied her lover. ‘For his own sake, he would keep the
secret close as the grave. He has a ready wit too, and an unabashed
presence, that would carry him through any dilemma. I ought to
know it.’
‘Hist!’ cried Marie; ‘there is a noise in the passage. We are
overheard.’
‘It is nothing,’ said Sainte-Croix. ‘The night-wind rushing along the
passages has blown-to some of the doors.’
The Marchioness had gone to the entrance of the salle, and
looked along the vaulted way that led to it. A door at the upper end
was distinctly heard to close.
‘I heard retreating footsteps!’ she exclaimed rapidly, as she
returned. ‘There have been some eavesdroppers, I tell you.’
‘Pshaw!’ replied Gaudin; ‘who would come down here? It might be
Philippe Glazer, who brought me into the hospital, and is anxious to
know how much longer our interview is to last.’
‘He does not know me?’ inquired the Marchioness, in a tone that
led up to the answer she desired.
‘He knows nothing, beyond that I have some idle affair with a
religieuse. Pardieu! if every similar gallantry was taken notice of in
Paris, the newsmongers would have enough to do.’
‘However,’ said Marie, ‘it is time that we departed. I must go back
to my dreary home.’
And she uttered the last words in a tone of well-acted
despondency, as she prepared to depart.
‘Stay, Marie!’ cried Gaudin. ‘You have said that your brothers are
at Offemont; who else have you to dread? There is a réunion of all
the best that Paris contains of life and revelry in the Rue des
Mathurins this evening. You will go with me?’
 ‘It would be madness, Gaudin. The city would ring with the scandal
to-morrow morning.’
‘You can mask,’ returned Sainte-Croix, ‘and so will I. I shall be
known to all I care about, and those I can rely on. Marie! you will
come?’
He drew a visor from his cloak as he spoke, and held it towards
the Marchioness. The necessity for sudden concealment in the
affairs of gallantry of the time made such an article part of the
appointments of both sexes.
Marie appeared to waver for an instant; but Gaudin seized her
hands and whispered a few low, but intense and impassioned words
closely in her ear, as though he now mistrusted the very air that,
damp and thickened, clung around them. She pulled the white hood
over her face, and taking his arm, they quitted the dismal chamber in
which this strange interview had taken place.
No notice was taken of them as they left the hospital. The porter
was half-asleep in his huge covered settle, still holding the cord of
the door in his hand, and he pulled it open mechanically as they
passed. On reaching the open space of the Parvis Notre Dame,
Sainte-Croix hailed a voiture de remise—a clumsy, ill-fashioned
thing, but still answering the purpose of those who patronised it,
more especially as there was but a small window on either side, and
that of such inferior glass that the parties within were doubly private.
They crossed the river by the Petit Pont, and proceeded first to the
Rue des Bernardins, where Sainte-Croix’s apartments were situated.
Here the Marchioness left the dress of the sisterhood, in which she
had visited the hospital, and appeared in her own rich garments; the
other having been merely a species of domino with which she had
veiled her usual attire. The coach then went on by the Rue des
Noyers towards the hôtel indicated by Gaudin.
‘This is a wild mad action, Gaudin,’ said the Marchioness. ‘If it
should be discovered, I shall be indeed lost.’
‘There is no chance of recognition,’ replied Sainte-Croix, as he
assisted his companion to fasten on her mask. ‘No one has tracked
us.’
‘I am not so certain of that,’ said Marie. ‘My eyes have deceived
me, or else I have seen, each time we passed a lamp, a figure
following the coach, and crouching against the walls and houses.
See! there it is again!’
As she spoke, she wiped away the condensed breath upon the
windows with her mantle, and called Gaudin’s attention to the street.
‘There!’ she cried; ‘I still see the same figure—tall and dark—
moving after us. I cannot discern the features.’
‘It is but some late passenger,’ said Gaudin, ‘who is keeping near
our carriage for the safety of an escort. You must recollect we are in
the centre of the cut-purse students.’
 The coach turned round the corner of the Rue des Mathurins as
he spoke, crossing the Rue St. Jacques, and halfway along the
street stopped at a porte-cochère, which was lighted up with unusual
brightness. The door was opened, and as Gaudin assisted the
Marchioness to alight, both cast a searching glance along the narrow
street in either direction; but excepting a lackey attached to the Hôtel
de Cluny, where they now got down, not a person was visible.
 CHAPTER XXII.
THE ORGY AT THE HÔTEL DE CLUNY

The Hôtel de Cluny, into the court-yard of which Gaudin led the
Marchioness on alighting from the carriage, is not only a building of
great interest at the present day, but was equally celebrated in the
Middle Ages, and so intimately connected with ancient Paris, even in
the time of the Romans, that a very brief description of it may not be
altogether out of place.
Any one who cares to visit it may arrive at its gates by proceeding
up the Rue de la Harpe from the river, at the Pont St. Michel, and
turning to the left in the Rue des Mathurins. But just before this point
the Palais des Thermes will be passed—the remains of a vast
Roman edifice which once occupied a large area of ground in the
Quartier Latin. Of this building the hall is still in tolerable
preservation; and two stages of subterraneous passages may be
traced to the length of about one hundred feet, where they are
choked up with ruins. There is, however, existing proof that they
formed a perfect communication between the Palais des Thermes
and the Convent des Mathurins, at the other extremity of the street.
Upon the foundations of the Roman building, towards the close of
the fifteenth century, Jacques d’Amboise, one of the nine brothers of
Louis XII.’s minister who bore that name, built the present edifice.
The ground had been purchased more than a century previous by
Pierre de Chaslus, an abbe of the celebrated order of Cluny, a
portion of the Roman palace then being sufficiently perfect to reside
in; and that became the residence of the abbes of Cluny when their
affairs called them to Paris.
The new building was raised upon this site, and with the materials
of the ancient structure, so that at many parts of the hôtel the
graceful architecture of the moyen âge may be seen rising from the
foundation-walls of Roman masonry. This is not, however, the only
part to interest the artist or the antiquary. The entire edifice, built at
an epoch of architectural revolution, is a mixture of the last
inspirations of the Gothic style with the first dawn of the renaissance.
At the commencement of the sixteenth century, the Hôtel de Cluny
was for some time the abode of Mary, the Queen of Louis XII. and
sister of our own Henry VIII. She had been married only three
months when she was left a widow, being then little more than
sixteen.16 Afterwards it was inhabited by a troop of comedians,
although by what means the players were enabled to establish
themselves in a house avowedly the dwelling of the abbes of Cluny,
and of which, whoever lived in it, they never ceased to be the
landlords, is not explained. Subsequently it was made a species of
temporary convent for the reception of Maire Angélique Arnaud, the
abbess of Port-Royal, and a large number of her nuns, whilst a
religious establishment was built for them in the Rue de la Bourbe,
which at the present day forms the Hospice de l’Accouchement of
the same name.
It is now some six or seven years since we went over the Hôtel de
Cluny. The then proprietor, M. du Sommerard, has since died, and
we know not how his decease has affected the admission of
strangers. Certainly it was at that time the most interesting object of
curiosity that Paris afforded. You turned from the narrow, busy Rue
de la Harpe into its quiet court, and modern Paris was for the
moment forgotten in the contemplation of the old and graceful
building, with its picturesque tourelle—its beautifully-ornamented
attic windows, each surrounded by a different pattern of florid Gothic
sculpture—its antique spouts, and chiseled gallery running in front of
the eaves, still showing its exquisite workmanship, in spite of the
clumsy manner in which its trellised length had been patched up with
mortar, and in many places totally concealed—its vanes and gables.
Within, it was rich, indeed, in venerable associations; there were
collected all those articles of rare worth and vertu that made the
hôtel so famous; but these were not to us the principal attractions,
for much was the result of comparatively modern labour. An
atmosphere of antiquity pervaded the interior; you were sensible at
once of that peculiar odour which clings to relics of former times—
that mixture of cathedral interiors, old burly red-edged books, worm-
eaten wainscoting, and damp closets, which is almost grateful,
despite its elements. The sunbeam came through the patched
coloured glass of the old windows, and fell in subdued and varied
tints upon the relics which the rooms enshrined—relics of everyday
life in days long passed away, which it would not mock with the
garish light of present noon, except in the open gallery, and there the
motes appeared to wake into existence in its rays, and dance about,
until with its decline they fell back once more upon the old carvings
and mouldings of the woodwork. In the disposition of the rooms, with
their numberless articles of simple domestic use and homely
furniture, the past was once more recalled; the visitor lived, for the
time, in the bosom of a family long since forgotten, even to its very
name; the solitude was dispelled, and the antique chambers were
once more peopled with their former occupants, gliding noiselessly
about the polished floors, circling round the table, still laid out for
their meal, or kneeling at the chapel altar, as the quivering light fell
on them, piercing the leaves that clustered from the trees of the
adjoining garden about the windows. The day-dream was impressive
and all-absorbing. The feeling, upon once more turning into the busy
hum of the city, was that of dissatisfaction and confusion, like the first
waking from a morning slumber, in which we have been again
communing with those whom we once loved.
Sainte-Croix and Marie entered the principal door of the corps de
logis of the hôtel, and passed up the staircase. He was recognised
and saluted respectfully by the domestics, as one on terms of great
intimacy with the master. The interior of the hôtel was brilliantly
illuminated; and every now and then sounds of the wildest revelry
burst along the corridors, as the heavy rustling curtains that hung
over the doors were thrust on one side. As they neared the principal
room, a man stepped out and met them. His symmetrical figure was
well set off by a magnificent dress; his physiognomy was spirituelle,
without being handsome; his presence was commanding and
prepossessing.
‘My dear Sainte-Croix,’ he exclaimed as he saw Gaudin, ‘you are
welcome. The hours were flying by so rapidly, that I began to think
we should not see you.’
‘Time generally runs away with bright grains, Marquis, whenever
you direct his flight. He must fill his glass from the sands of Pactolus
when he measures your enjoyments.’
‘Will you present me to your fair companion?’ said the host, as he
glanced towards the Marchioness.
‘Henriette,’ said Gaudin, giving a false name to his partner, ‘this is
the Marquis de Lauzun. His mere name conveys with it all those
good qualities which, in one less known, we should mention
distinctly.’
The Marquis bowed, and Marie inclined in return to his salute,
trembling at the same time; for she knew him well, and was fearful of
being discovered. And indeed Lauzun perceived in an instant, by her
deportment, that her manners had more of the court than the
coulisses about them.
‘You have a charming residence, Marquis,’ she observed,
endeavouring to disguise her voice.
‘Say, rather, the abbes of Cluny have,’ replied De Lauzun; ‘for I am
here only as an intruder. But they are too liberal to me. In return for
some poor advantages I persuaded his Majesty to bestow upon their
order, they give up their house to me whenever I require it. Let us
join the company who honour me this evening.’
He threw aside the heavy tapestry as he spoke, and ushered
Sainte-Croix and Marie into the salon. The scene that presented
itself was most exciting—almost bewildering from its gorgeous
revelry. The whole suite of rooms had been thrown open, and was
one blaze of light; the innumerable wax candles, shedding their
brilliancy upon the throng from every available position, clustered in
galaxies of bright twinkling stars round the elaborately-framed and
quaintly-shaped looking-glasses that characterised the domestic
architecture of the time, even in our own days always associated
with splendid elegance and refinement, or diminished in long
perspectives of light along the corridors, and through the other
apartments branching off from the principal room, the comparatively
low ceiling giving them a look of much greater extent than they in
reality possessed.
A joyous crowd had assembled together; all that Paris then knew
of reckless enjoyment and debauchery had collected that evening in
the Hôtel de Cluny. The cavaliers and dames were in equal
numbers; some of the latter were as closely masked as Marie, as
were a few—very few—of the gentleman. Others of the fair visitors
displayed their charms, both of face and bust, to the full, in the same
loose fashion that they would have patronised in the warm season
upon the Pont Neuf and carrefours. And the attractions of these
beauties were of no ordinary character. Handsome beyond
expression the majority indeed were, under the most ordinary
circumstances; but now their full swimming eyes were sparkling with
excitement—a glow of warmth and vivid life flushed their damask
cheeks—the long clusters of perfumed and glossy hair showered
tremblingly upon their rounded shoulders—and, as the light
badinage or wicked repartee fell from their rosy lips, followed by the
joyous peals of their silvery laughter, their mouths displayed pearly
rows of teeth, which fairly dazzled by their brilliancy, and alone
outshone the whiteness of their skin.
The various alcoves, containing beds, fitted up with magnificent
hangings and curtains of rich brocade, shot with gold or embroidered
with the most elaborate devices, were all thrown open, according to
custom, separated only from the rooms by light gilt railings; and
within these various young seigneurs were lounging, playing at dice
or tables, surrounded by a crowd of lookers-on; and the profusion of
broad pieces scattered carelessly about showed that the play was
high and reckless. The extremity of the gallery was veiled by some
fine fabric, and behind this, concealed from the view, a band of
musicians, of a number then seldom collected, was performing the
latest compositions of the court. In the centre a table glittering with
plate and glass was loaded with the choicest refreshments, and the
most ingenious devices in confectionery, surrounding a fountain of
marvellous workmanship, modelled, after the Bassin de Neptune at
Versailles, in dead silver and crystal, playing various kinds of wine,
which fell into separate compartments, whence it was drawn by the
guests into chased silver flagons and goblets of variegated
Bohemian glass. The air was heavy with costly perfumes, whose
vapours wreathed out from antique tripods; and every flower that art
could force into bloom, for the time of year, assisted to form the rich
bouquets that were placed about in all directions.
‘Place, messieurs,’ cried Lauzun gaily, affecting the manners of a
chamberlain, ‘for the Captain Gaudin de Sainte-Croix, who will throw
down his dice as a gage to any adversary who chooses to meet him!’
A number of young men welcomed Gaudin as the others spoke.
He was evidently popular amongst them, possessing in a high
degree that fatal versatility of pleasing which can mask the most
heartless and unprincipled disposition with a semblance of the most
ingenuous gaiety and franchise.
‘I pledge you, Monsieur de Sainte-Croix,’ cried a cavalier, whose
dress was a strange mixture of extreme elegance and the roughest
texture, ‘and will place a hundred louis d’ors against your own.’
‘A match!’ cried Gaudin, throwing his purse on the bed, round
which the party gathered, including Marie, who still kept close to his
side.
‘There are my pieces,’ replied the other; ‘they need no counting.’
And he placed a rude leathern bag by Sainte-Croix’s sparkling
purse.
‘I shall beat you, Chavagnac,’ said Gaudin.
‘You will be clever to do it,’ observed a bystander. ‘The Count de
Chavagnac has ruined us this night.’
‘A new gown of ruby velvet à longues manches, at the next Foire
Sainte Germain, for me, if you win, Chavagnac,’ said one of the
handsomest of the women.
‘You shall have it, Marotte,’ replied the Count.
‘What do you promise me, M. de Sainte-Croix, for old friendship?’
continued Marotte Dupré—for it was she—turning to Gaudin. ‘Let it
be a kiss, if it be nothing else.’
Gaudin looked towards her, and pressed her arm, as he
contracted his forehead, and made a sign of silence. He felt a
sudden shudder pass over the frame of the Marchioness; and when
he turned round, her eyes glared like a fury’s through her mask. She
withdrew her arm and coldly fell back as she whispered—
‘My eyes are being opened anew. Beware!’
Gaudin was for the instant annoyed and returned no answer.
Marotte Dupré had not taken the hint, and continued—
‘You owe me something on the score of your conduct when
Antoine Brinvilliers carried me to the Rue d’Enfer against my will. By
the way, where is his wife, Dubois? You know the secrets of every
woman in our good city.’
 This was addressed to the Abbe Dubois, whose name as a
gallant, either on his own part or that of the King, was pretty well
established.
‘Where she should be—quietly at home,’ replied the abbe.
‘Brinvilliers is on his travels. He is another man since she left him, or
he left her, or they left one another. How is it, M. de Sainte-Croix?—
you ought to know.’
‘By the mass!’ cried Gaudin angrily, ‘my sword can answer the
curiosity of any one better than my tongue.’
‘It is the more innocent weapon of the two in Paris just at present,’
said Marotte. ‘O my reputation!’
Gaudin looked towards Marie. By the quivering of a jewelled
aigrette that formed a portion of her head-dress, he could see that
she was trembling, and her hand tightly clutched part of the rich
curtain that hung beside her.
‘Chut!’ cried Lauzun, observing Sainte-Croix’s kindling temper; ‘to
your play.’
‘Nine!’ said Guadin, throwing his dice, as he caught at the
opportunity of turning the subject.
‘Nine also,’ observed Chavagnac, throwing.
‘Ten!’ exclaimed Guadin. ‘Will you pay me half, or run the chance?’
‘I will play,’ replied Chavagnac, gently shaking the dice-box.
‘Twelve.’
‘Peste!’ cried Gaudin, ‘you have gained them. I thought my dice
knew better than that.’
‘You forgot whose they were to play against,’ said Chavagnac with
a grim smile, taking up the money. ‘Come, I shall be in funds again.
Lauzun’s hospitality has kept me from the high-road. The twelve
hundred pistoles I appropriated from the good people of the Garonne
were nearly gone.’
‘You can still give me the kiss, Gaudin, without being entirely
ruined,’ said Marotte Dupré, as she pouted her red lips towards him.
Sainte-Croix inclined his head towards her. As he did so, Marie
darted forward, and violently drew him back. The action was seen by
all the bystanders. They said nothing, but shrugged their shoulders;
whilst Marotte Dupré looked as if she felt perfectly ready for another
duel with her new and unknown rival.
 ‘Messieurs,’ cried Lauzun, ‘I have a novelty in store for you. I have
picked up a fellow on the Pont Neuf who will sing you couplets about
yourselves by the mile. He is there every afternoon that it is warm
enough for folks to stand and listen.’
‘Let us see him,’ said Dubois, anxious with the rest to turn the
attention of the company. ‘A diable les femmes! There is not a
misery in the world but is connected with them, if you search its
source.’
‘Nor a pleasure,’ replied Lauzun. ‘You ought to know, abbe, if
experience teaches anything.’
‘And monsieur does know,’ said a person who entered just at the
moment. A glance sufficed to show Sainte-Croix that it was Benoit,
who appeared to have reassumed, in part, his ancient mountebank
costume.
‘This is the fellow,’ said Lauzun. ‘Come, friend,’ he continued,
addressing the other, ‘do you see any one here you can sing about?’
‘That do I,’ said Benoit, looking over the crowd; ‘there is the Abbe
Dubois.’
‘Respect the church,’ cried Lauzun laughing. ‘The abbe is beyond
your couplets.’
‘Not at all,’ said Benoit. ‘Mère Ledru left the Quartier Saint-Honoré
but yesterday, entirely to save her daughter from his addresses. Oh!
the abbe is a bon diable, but sly in his pursuits. Hem!’
And clearing his voice he sang these lines, the others repeating
the last lines in chorus—

‘Monsieur l’Abbé, ou allez-vous?

Vous allez vous casser le cou,
Vous allez sans chandelles,
Eh bien!
Pour voir les demoiselles!
Vous m’entendez bien!
C’est bien!
Pour voir les demoiselles!’

‘Silence, rascal!’ cried Dubois, hurling some pieces at Benoit’s

head, who picked them up, put them in his pocket, and was quieted
directly—sooner, indeed, than the laugh against the gallant abbe
which he had raised.
‘Let M. de Sainte-Croix have his turn,’ said Chavagnac. ‘Do you
know him, fool?’
Benoit glanced expressively at Gaudin as he commenced—

‘Monsieur Gaudin de Sainte-Croix,

Whence do you your treasures draw?
Not from dice, nor cards alone,
Nor philosophy’s rare stone,
Biribi!
Why affect such scenes as these,
And neglect your belle Marquise?
Where is she?
Left lamenting, like Louise.
Sacristie!’

Gaudin’s cheek flamed with anger. The company observed that he

was stung deeper than mere badinage could have done; and this
time the laugh was less general than the one which had been raised
against the abbe. He drew Marie’s arm closer within his own, and
with a look of vengeance at Benoit, left the circle; whilst the other
proceeded to launch a couplet against Chavagnac, filled with no very
complimentary allusions to his wild spirit of appropriation.
 CHAPTER XXIII.
SAINTE-CROIX AND MARIE ENCOUNTER AN UNINVITED GUEST

They were each in ill-humour with one another. The apparent

intimacy of Marotte Dupré had aroused all Marie’s jealousy, so
terrible in its very calm; and Gaudin had been annoyed by Benoit’s
allusions. They passed along the room without speaking, nor was it
until they gained an apartment at the end of the suite that a word
was spoken.
It was a small room they entered, with two deeply-stained
windows, and lighted by lamps placed on the outer side of the glass,
producing almost the same effect as though it had been day.
‘I think you must repent having brought me here,’ said the
Marchioness coldly. ‘It was badly contrived on your part not to
forewarn your other favourites, that they might have been more
cautious.’
‘Your suspicions are so utterly without foundation,’ replied Sainte-
Croix, ‘that I shall not take the pains to refute them. At present there
are other matters of deeper import that demand my attention. I
expect, when you learn all, you will give yourself little care about the
continuance of our liaison. We may then know some respite from the
fevered restlessness and uncertainty of our connection. We have
experienced but little peace since we have been acquainted.’
There was a bitterness of tone in his manner of pronouncing the
last sentences that attracted the attention of the Marchioness.
‘What are you alluding to?’ she asked.
‘In a word, Marie, I am ruined. The sum of money I brought here
with me to-night, in the hope of doubling it, is gone. I am deeply
involved: my creditors are pressing me on every side, and I know not
which way to turn to extricate myself.’
‘You judge me too harshly, Sainte-Croix,’ replied the Marchioness.
‘My sweetest revenge would be to assist you when you were utterly
destitute. What must be done? The money left me by my father is in
my brothers’ keeping. Not a sol is spent but I must render them an
account.’
‘But one step is left to be taken,’ said Gaudin. ‘The time has
arrived; they must be removed.’
Marie remained for a time silent, as if waiting for Sainte-Croix
more fully to develop his meaning. At length she spoke—
‘I know not how we can proceed. I cannot tell whether it be my
own fancy or there is in reality ground for suspicion, but my brothers
appear to watch me in every action—every step. I see so little of
them too. They are seldom in the Rue Saint Paul.’
‘We must set other agencies to work,’ said Gaudin. ‘An apparent
stranger would never be suspected.’
‘It is dangerous,’ replied the Marchioness.
‘It is necessary,’ added Sainte-Croix. And after a moment’s pause
he continued: ‘The man Lachaussée, whom you have seen with me,
is mine, body and soul. I can in an instant cause to fall the sword
which hangs over his head. Your brothers’ occupation of Offemont
will require an increase of their establishment: can we not get
Lachaussée into their service? They will then be comparatively in our
hands.’
‘Is he to be trusted?’
‘He is wily as an adder, and as fatal in his attack, to those who
have not charmed him. I will put this scheme in train to-morrow. He
only awaits my word to proceed.’
‘It must be done,’ replied the Marchioness.
And then she uttered a long deep sigh, the relief to her
overcharged heart being accompanied by a low moan of intense
mental pain—not from remorse, but utter despondency, in the
reaction of her spirits, and the apparent blackness of the prospect
before her. The next moment, as if ashamed of the demonstration of
her feelings, she started up from the couch on which they had been
sitting, and prepared to return to the principal room. As she
advanced towards the door, she took a brilliant jewelled chain from
her neck, and placed it in Gaudin’s hands.
‘Whilst we have an opportunity,’ she said, ‘let me give you this
carcanet. It is of some value, and by selling it at the Quai des
Orfevres you can provide for your present superficial expenses.’