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1 001 Pearls of Life Changing Wisdom Insight on Identity Truth and Success Elizabeth Venstra
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Library of Congress Cataloging-in-Publication Data
Names: Hopcroft, Keith, editor.
Title: Instant wisdom for GPs : pearls from all the specialities / [edited by] Keith Hopcroft.
Description: Boca Raton : CRC Press/Taylor & Francis Group, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2017033146 (print) | LCCN 2017033902 (ebook) | ISBN 9781315116808 (ebook) | ISBN 9781138196209 (pbk. : alk. paper) | ISBN 9781138296923 (hardback : alk. paper)
Subjects: | MESH: General Practice | General Practitioners | Health Knowledge, Attitudes, Practice
LC record available at https://lccn.loc.gov/2017033146
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PREFACE
I’m fairly confident that, if anyone was dispensing Instant Wisdom on writing a book, they would say that no one ever reads a Preface. On that basis, I’ll keep this brief.
The idea for this project has been kicking around in my brain for years. Partly because I’ve always loved those wise nuggets you occasionally pick up from a particularly good lecture or article. And partly because of the event that spawned Pearl #20 in the ‘General Practice’ chapter. Essentially, the book is an attempt to distil and collate gems of wisdom about medicine – derived from study, evidence, teaching and, especially, years of experience – that we all possess and which we might remember/reveal if we were held upside down and shaken long enough.
Of course, true wisdom can’t be instilled by digesting a book. But something quite close perhaps can be, and it was an attractive enough notion for me to have a go.
The logical way to structure the book is by speciality. As it will be of most interest to generalists – trainees, young GPs and established old timers like me who still genuinely learn something every day – I sincerely hope it comes across as true enlightenment rather than unrealistic specialist dogma. If it errs towards the latter, then I’ve failed in my editing duties. The fact that I’ve contrived the ‘General Practice’ chapter to be twice as long as all the others is some sort of insurance policy for this, plus it reflects the fact that, of course, general practice is the most difficult and wide-ranging speciality of all.
As for how you read the book, that’s up to you. Dip in and out, or plough through methodically, as the fancy takes you. But I do hope it is read – and that, as a result, you feel that bit wiser, and your patients feel that bit better.
ACKNOWLEDGMENTS
Frankly, I’ve lost track of all the people I should thank, there have been so many. But special mentions to Richard Davenport, Nick Summerton, Shaba Nabi and Alistair Moulds. Hats off to CRC Press/Taylor & Francis for taking the idea, and me, seriously. Obviously, a massive thank you to all the authors for turning around such high quality work within my deadline, with only a few needing the cattle-prod treatment (they know who they are). And, lastly, I’d like to thank, and dedicate the book, to all GPs and their staff – and especially those at Laindon Medical Group – because it’s their wisdom, and their hard work, that keeps the NHS afloat.
CONTRIBUTORS
s . Hasan Arshad
Department of Allergy and Clinical Immunology
University of Southampton and
Consultant Allergist
University Hospital Southampton
Southampton, United Kingdom and Director
The David Hide Asthma and Allergy Research Centre
Isle of Wight, United Kingdom
David s . Baldwin
Clinical and Experimental Sciences
Faculty of Medicine
University of Southampton
Southampton, United Kingdom
e lizabeth Ball
Queen Mary University of London
London, United Kingdom
Andrew Bath
ENT Consultant
Norfolk and Norwich University Hospital
Norwich, United Kingdom
tak Chin
Consultant Allergist
University Hospital Southampton
Southampton, United Kingdom
tahseen A. Chowdhury
Consultant Physician
Department of Diabetes
The Royal London Hospital Barts Health NHS Trust
London, United Kingdom
Phil Clelland
Orthopaedic Consultant
Wrightington Hospital Wigan, United Kingdom and
Registrar Sports and Exercise Medicine
NW Deanery, United Kingdom
stephanie Cooper
Speech Therapist
Norfolk and Norwich University Hospital
Norwich, United Kingdom
Richard Davenport
Consultant Neurologist
Western General Hospital and Royal Infirmary of Edinburgh and
Honorary Senior Lecturer
University of Edinburgh Edinburgh, United Kingdom
Ian e ardley
Consultant Urologist
Leeds Teaching Hospital Trust
Leeds, United Kingdom
e lizabeth Griffiths
Consultant Allergist
University Hospital Southampton
Southampton, United Kingdom
Matthew Harries
The Dermatology Centre
University of Manchester
Manchester, United Kingdom and
Salford Royal NHS Foundation Trust
Salford, United Kingdom
Dylan Harris
Palliative Care Department
Cwm Taf University Health Board
Wales, United Kingdom
Peter Heinz
Consultant in Acute and General Paediatrics
Addenbrooke’s Hospital
Cambridge, United Kingdom
Keith Hopcroft
General Practitioner at Laindon
Medical Group
Basildon, United Kingdom
Andy Hughes
Consultant Community Haematologist
Basildon and Thurrock University
Hospitals NHS Foundation Trust
Essex, United Kingdom
Aroon Lal
Consultant Nephrologist
Basildon and Thurrock University Hospital
Basildon, United Kingdom and
Honorary Senior Clinical Lecturer
UCL Medical School
University College London
London, United Kingdom
John Leach
Consultant Neurosurgeon
Manchester, United Kingdom and
Orthopaedic Consultant
Wrightington Hospital
Wigan, United Kingdom
Jessica Manson
Rheumatology Consultant
University College London
Hospitals NHS Foundation Trust
London, United Kingdom
Jerome Ment
Consultant Cardiologist
Heart of England Foundation Trust
United Kingdom
stephen J. Middleton
Consultant Gastroenterologist
Addenbrooke’s Hospital
Cambridge University
Cambridge, United Kingdom and
Honorary Professor of Gastroenterology
Plymouth University School of Medicine
Plymouth, United Kingdom
neal navani
Consultant in Thoracic Medicine
University College London Hospital
London, United Kingdom
John Phillips
ENT Consultant
Norfolk and Norwich University Hospital
Norwich, United Kingdom
omar Rafiq
Consultant Ophthalmologist
Rotherham NHS Foundation Trust
Rotherham, United Kingdom
Michael Rayment
Consultant in Sexual Health and HIV Medicine
Chelsea and Westminster NHS Foundation Trust and
Honorary Senior Clinical Lecturer
Imperial College London
London, United Kingdom
n.F.W. Redwood
Consultant General and Vascular Surgeon
Queen Elizabeth Hospital
King’s Lynn, United Kingdom
Adam Rosenthal
Consultant Gynaecologist
University College Hospital
University College Hospitals NHS Foundation Trust
London, United Kingdom
David Rutkowski
The Dermatology Centre
University of Manchester
Manchester, United Kingdom and
Salford Royal NHS Foundation Trust
Salford, United Kingdom
Zak shakanti
The Dermatology Centre
University of Manchester
Manchester, United Kingdom and
Salford Royal NHS Foundation Trust
Salford, United Kingdom
Karol sikora
Chief Medical Officer
Proton Partners International
Wales, United Kingdom and
Department of Cancer Medicine
Imperial College School of Medicine and
Consultant Oncologist
Hammersmith Hospital
London, United Kingdom
Rudy sinha-Ray
Specialist Registrar in Thoracic Medicine
University College London Hospital
London, United Kingdom
Peter tassone
ENT Consultant
Norfolk and Norwich University Hospital
Norwich, United Kingdom
Mark P.J. Vanderpump
Consultant Physician and Endocrinologist
The Physicians’ Clinic
London, United Kingdom
Charlotte Wing
Rheumatology Specialist Registrar
Whittington Hospital
London, United Kingdom
James Woodard
Consultant Geriatrician
Derby Teaching Hospitals NHS Foundation Trust
United Kingdom
ALLERGY
Tak Chin, Elizabeth Griffiths and S. Hasan Arshad
Ten Pearls of wisdom
1. A high total Ig e does not necessarily indicate allergic disease and a normal total Ig e does not exclude allergy
Immunoglobulin E (IgE) is the antibody that mediates allergic reactions; however, measuring total IgE is not useful in the management of allergic diseases. Total IgE in the circulation includes IgE antibodies directed against allergens (allergen-specific IgE) and infective agents, plus some is of unknown specificity. Hence, total IgE can be high in the absence of allergic disease. On the other hand, a patient may have specific IgE against an allergen (e.g., cat) while the total IgE may not exceed the normal range. For allergy diagnosis, it is better to measure allergen-specific IgE (e.g., using RAST) against an allergen suspected from the history.
2. ‘Chronic urticaria and/or angioedema’ is usually non-allergic
Urticaria and angioedema are relatively common, although often transient, conditions. Urticaria is also known as hives or nettle rash, and angioedema appears as diffuse swelling. Acute urticaria and/or angioedema (one off episodes) could result from an allergic reaction (such as to foods or drugs), or from infection. However, some patients present with recurrent episodes of urticaria and/or angioedema, not associated with any specific or consistent trigger (although note the Pearl regarding patients on ACE inhibitors). These patients are usually suffering from idiopathic or spontaneous urticaria and/or angioedema, which is not due to allergy. Chronic urticaria and/or angioedema involve skin and/or mucous membrane, and only rarely progress to anaphylaxis. These patients require reassurance and treatment with (high dose, if needed) antihistamines.
3. only a small proportion of adverse reactions to drugs are due to drug allergy
Adverse reactions to drugs can be expected (related to their pharmacological effects) and unexpected. For pharmacological adverse effects, consider dose
adjustment or use of an alternative medication. The ‘unexpected’ reactions could be due to allergy, intolerance or idiosyncrasy. An allergic reaction has an immunological basis, although that may not be easy to establish. Hence, for practical purposes, any drug reaction with clinical features of allergy (such as rash or anaphylaxis) can be regarded as allergic. There is usually no simple test to diagnose drug allergy, and drug provocation tests are often required to establish the diagnosis. These are cumbersome and carry significant risk. Therefore, if possible, consideration should be given to using a suitable alternative before referral for drug allergy testing. If no suitable alternative is available, however, patients should be referred for testing and if drug allergy is confirmed, desensitisation is possible, which would allow safe use of the drug.
4. Avoid indiscriminate penicillin prescribing in children if possible – the child may end up with a lifelong erroneous label of penicillin allergy
Penicillin and its derivatives belong to the beta-lactam group of antibiotics that share a beta-lactam ring structure, which also include cephalosporins. Approximately 10% of the population reports an allergy to penicillin, but only 1% are confirmed following formal testing. Many of these patients were given penicillin group of antibiotics during childhood for a viral illness with the viral exanthem wrongly labelled as penicillin allergic rash. They are subsequently advised to avoid penicillins resulting in more costly and less safe alternative antibiotics given throughout their life unnecessarily. This emphasises the need to try to avoid antibiotic prescribing in childhood viral illnesses.
5. All patients with an anaphylaxis of unknown cause should be referred to an allergy clinic
Most anaphylaxis guidelines recommend that all patients with a new or unexpected anaphylactic episode should be referred to an allergy specialist to investigate possible triggers, in order to minimise the risk of future reactions and to provide a management plan. This is done with a detailed history, allergy skin prick, and/or intradermal testing, blood tests and, if required, provocation tests to identify the allergic cause and institute preventive measures. If food is involved, referral to a specialist dietitian is helpful. Contact information for patient support groups (such as Anaphylaxis UK) may be helpful.
6. Pollen-food allergy syndrome/oral allergy syndrome is often unrecognised or misdiagnosed
This is an increasingly common phenomenon seen in adults with hay fever. It is caused by cross-reacting proteins found in pollen, which are similar to proteins found in raw fruits, vegetables or tree nuts. As a result, the body
mistakes the food proteins for pollen proteins and so the immune system reacts to them.
The foods most likely to cause pollen-food allergy syndrome in birch pollen allergy (the most common form) are raw apple, kiwi fruit, peach, cherry, other stone fruits, hazelnut and almond. The reactions are usually limited to oral itching, tingling or swelling only (hence it is also called oral allergy syndrome), which occurs within minutes of eating the cross-reactive foods. There is usually no systemic involvement or cardiovascular compromise. Another typical feature of pollen-food allergy syndrome is that patients are usually able to tolerate the cooked, processed or tinned forms of the raw foods which cause problems (as heating and processing breaks down the causative proteins).
7. Consider AC e -i nduced angioedema in those taking the relevant drug who suffer with intermittent oral angioedema – even if they have been on the treatment for years
Check medication lists for ACE inhibitors in patients presenting with angioedema that only affects the lips, tongue or face. There is no associated urticaria nor other features of anaphylaxis.
The mechanism of ACE-induced angioedema is not allergic. While it is an easy diagnosis to pick up when ACE inhibitors have just been started, ACEinduced angioedema more often occurs after many years of uneventful use. As a result, many patients have recurrent episodes of orofacial angioedema before the diagnosis is made. Angiotensin-II receptor antagonists, such as losartan, are considered safe to use in these patients.
8. Consider referral of certain patients with wasp or bee sting anaphylaxis for insect venom immunotherapy (which is available on the n Hs)
Patients who have anaphylaxis to wasp or bee stings can be desensitised with immunotherapy, which is usually given as a 3-year course of injections. This is a very effective treatment and is successful in preventing systemic reactions in approximately 95%–100% of wasp venom allergy patients and approximately 80% of bee venom allergy patients. Those at high risk of future stings (such as gardeners or bee keepers) should be considered for immunotherapy.
9. Adult-onset eczema is rarely due to food allergy
While studies have shown that certain foods such as cow’s milk and egg can exacerbate eczema in more than 50% of children of preschool age, similar reactions to ‘classical’ food allergens are not common in adults. Food allergy should certainly be considered in infants with severe eczema. Allergy skin prick test and/or oral food challenge may help to identify the cause; however, finding
a ‘causative’ food for eczema in adulthood is very rare. Unnecessary dietary restrictions that are not based on proper diagnosis may lead to malnutrition and additional psychological stress.
10. skin prick testing and patch testing are very different – know which to use and when
These are very different tests. Skin prick testing is helpful for Type I IgE-mediated allergic reactions (e.g., foods and aeroallergens), whereas patch testing is helpful for Type IV delayed-type hypersensitivity reactions (e.g., fragrances, chemicals and metals). Skin prick testing can be performed in 15 minutes while patch testing is usually done over the course of 5 days (patches applied at day 1 with further appointments on day 3 and 5 to read the results). Patch testing is usually done to investigate contact allergy by dermatologists rather than allergists.
Obscure or overlooked diagnoses
1. Food-dependent exercise-induced anaphylaxis
Exercise is a known physical factor that can trigger anaphylaxis. In some patients, food can act as a cofactor – this is known as ‘food-dependent exercise-induced anaphylaxis’. Food can be ingested safely by itself, but the association with exercise is crucial for the onset of symptoms. This is seen more often in adults than in children. Common foods implicated are wheat, peanut and shellfish. The most frequently reported exercise associated with food-dependent exercise-induced anaphylaxis is jogging/running. A provocation test is required if there is doubt regarding the diagnosis. Management includes avoidance of eating the suspected food 4 hours before exercise and carrying an adrenaline auto-injector.
2. Baboon syndrome (symmetrical drug-related intertriginous and flexural exanthema [sDR IF e])
This is a reaction that results in a distinctive erythematous rash affecting the skin folds. When it predominantly affects the buttocks and natal cleft, it resembles the red bottom of a baboon (hence its name). The neck, armpits, flexures and other skin folds may also be affected symmetrically. It is usually caused by systemic exposure to drugs (such as beta-lactam antibiotics).
3. Aquagenic urticaria
This is not technically an allergy to water, but rather a very rare form of physical urticaria (now classified as inducible urticaria), where hives develop immediately on contact with water regardless of temperature. It is not IgE-mediated.
It typically presents in early teenagers and tends to affect young women. Reactions tend to occur with activities such as bathing, swimming or walking in the rain.
4. s eminal plasma allergy
This is a rare condition affecting women that causes allergic reactions to semen. It is caused by developing a specific IgE antibody response to proteins in seminal fluid (rather than the spermatozoa). Reactions usually occur after unprotected intercourse and vary from localised pain to generalised systemic reactions (including anaphylaxis).
Easily confused
1. Allergic urticaria and Idiopathic urticaria
Allergic urticaria
▪ Consistent trigger
▪ Immediate reaction within 5–15 minutes of exposure to trigger
▪ Present only on exposure to allergen
Idiopathic urticaria
▪ No consistent trigger
▪ No consistent timing with reaction to suspected trigger
▪ If present most days for more than 6 weeks then an allergen is unlikely
2. Food allergy and Food intolerance/irritable bowel syndrome
Food allergy
▪ Is immunologically mediated
▪ Reactions are acute (within minutes of ingestion)
▪ Common suspected foods are milk, egg, nuts, seafood and fruits
▪ Strict avoidance is required
Prescribing points
Food intolerance/irritable bowel syndrome
▪ Food can be a non-immunological trigger
▪ Reactions can be delayed after ingestion of suspected food
▪ Clinical manifestations are generally confined to gastrointestinal tract
▪ Not fatal
▪ Is more common in adults
▪ Common suspected foods are grains
▪ Avoidance need not be strict
1. High dose antihistamines are generally safe
Non-sedating antihistamines are the mainstay of treatment for chronic urticaria, and up to four times the recommended dose can be used. However,
at high doses, many non-sedating antihistamines can manifest sedating properties. Fexofenadine is better tolerated in terms of sedating effects even at higher doses. Antihistamines should be avoided in pregnancy if possible; however, no teratogenic effects have been reported, and there is considerable clinical experience of safety with cetirizine and loratidine during pregnancy.
2. start hay fever medications about one month before the start of the pollen season
Hay fever medications are most effective if they are started a few weeks before pollen is released. Starting hay fever medications in this way (as opposed to when allergy symptoms have developed and allergic inflammation has already become established) reduces or even prevents release of histamine and other allergic mediators, which results in less severe symptoms. Trees typically release pollen from March to May; with grasses, typically, the key time is May to August.
3. Make sure that emollients are applied correctly
Patients should be told to wash their hands before applying emollients to reduce the risk of infection. They should avoid using fingers to scoop up emollient from the tub – they should instead use a clean spoon to scoop the emollient to be applied on to a plate. This should be applied in the direction of hair growth and allowed to be absorbed for 30 minutes. Rubbing up and down or in a circular motion should be avoided, as this may clog up the hair follicles and irritate the skin.
4. treatment of anaphylaxis is with intramuscular adrenaline
Anaphylaxis, defined as a systemic, life-threatening allergic reaction, should be treated immediately with intramuscular administration of adrenaline (conveniently available as adrenaline auto-injectors). For adults and older children, the dose is 500 micrograms. The dose for younger children depends on their body weight. Intravenous or intramuscular antihistamine and corticosteroids are additional secondary treatments. High flow oxygen and inhaled or nebulised bronchodilators may be administered if there is evidence of bronchoconstriction. Once stable, patients should be transferred to the hospital as delayed reactions do occur occasionally.
CARDIOLOGY
Jerome Ment
Ten Pearls of wisdom
1. The key factor with anginal pain is the consistent relation to exertion and an easing with rest
Ischaemic symptoms may have many modes of presentation, often specific to an individual patient. Typical angina is often described as a central chest heaviness or tightness with exertion, but cardiac ischaemia can manifest as pain from anywhere from the jaw to the umbilicus, or even the back. The most important feature is the clear relationship with exercise – and the fact that it usually remains consistent in nature for an individual patient.
2. Beware that patients may have more than one type of chest pain
It is not unusual for a patient to describe atypical chest pain – often easily explained as musculoskeletal – which can mask the more typical manifestations of angina – unless these are carefully elicited. So, in patients with appropriate risk factors, ask about exertional symptoms and changes in exercise capacity, even if the history is initially suggestive of musculoskeletal pain. Conversely, patients with known ischaemic heart disease may experience non-cardiac chest pain. After an infarct, patients often become very aware of their heart and chest, and may describe ‘twinges’ of short-lived, localised, often left-sided chest pain unrelated to activity. Early reassurance can be invaluable in settling these symptoms before they escalate and raise concerns.
3. Cardiac ischaemia may manifest as breathlessness rather than pain
Some patients with cardiac ischaemia will report breathlessness as the sole symptom. While this is most often described in patients with diabetes, it can occur in non-diabetics too. The breathlessness is exertional, particularly on inclines or stairs, eases quickly with rest and is often worse in cold weather. Typically, there is an absence of accompanying respiratory symptoms such as a productive cough or wheeze. On more detailed enquiry, patients will sometimes describe short-lived chest tightness with exercise, but the dominant symptom is the sensation of breathlessness.
4. Don’t be misled by the ‘walk through phenomenon’
Some patients with angina experience a ‘warm up’ or ‘walk through’ phenomenon, which can confuse the unwary clinician. While these patients begin to experience their typical angina on exertion, over time some discover that if they can continue for a little longer, their symptoms dissipate, allowing them to ‘walk through’ the symptom. This phenomenon, usually ascribed to ischaemic preconditioning – an adaptive response whereby repeated short periods of ischaemia protect the heart against a subsequent ischaemic insult – is considered protective to some degree, but needs to be recognised as part of the spectrum of angina symptoms.
5. Automated eCG i nterpretation is not always correct
Modern ECG machines can provide automated interpretation to aid the clinician. Unfortunately, this can be misleading and often plain wrong, raising anxiety in both patient and doctor. The most common example is the ‘consider previous inferior infarct’ report – in fact, T wave inversion and small Q waves in one or two inferior leads are often normal. Other common examples include movement artefact interpreted as atrial fibrillation, and QT interval prolongation where the U wave and not the T wave has been measured. It is worth double checking, or getting a cardiologist to review the ECG, if the automated interpretation is out of step with the clinical picture.
6. significant palpitations are usually sustained, exertional and/or accompanied by other symptoms
The symptom of palpitations is one of the most common reasons for referral to cardiology, yet most of these patients can be reassured that their symptoms are harmless. They will typically describe short-lived flutters, often at rest or in bed at night, accompanied by ‘missed beats’ typical of benign isolated ectopic beats. More significant symptoms are suggested by sustained palpitations with a ‘heart racing’ phenomenon, particularly if exertional and accompanied by dizziness or chest pain. Ask about a family history of sudden cardiac death or premature heart attacks. If present, this warrants early referral and investigation.
7. Heart failure is very difficult to diagnose clinically
Systolic heart failure is an important and life limiting diagnosis that can now be effectively treated, if not cured; however, clinical diagnosis can be fraught with difficulty. In one study, cardiologists were only able to correctly diagnose it at the bedside in 40% of cases. Ankle swelling, breathlessness and lung crepitations are poor discriminators. More specific markers are a displaced apex beat, a raised venous pressure and the presence of a systolic murmur at the apex. BNP, while often used as a screening tool, lacks specificity. An abnormal ECG, particularly in the presence of left bundle branch block or atrial fibrillation, should raise the level of suspicion further. An echocardiogram remains the gold standard test and may also offer insights into the underlying aetiology.
8. Cardiac problems aren’t always caused by coronary atheroma
A number of cardiac conditions can present with one or more of the three cardinal cardiac symptoms: chest pain, breathlessness and syncope. The elderly patient, in particular, should be examined carefully for aortic stenosis. The typical murmur requires prompt referral and investigation. Delays, or inappropriate investigation or treatment – such as exercise testing or sublingual nitrates – can have potentially fatal outcomes. In the younger patient, take a family history and ask about sudden cardiac death or cardiomyopathies. An ECG revealing left ventricular hypertrophy or widespread T wave inversion should also alert the clinician to an underlying and important cardiomyopathy.
9. Know the possible reasons for resistant hypertension – and consider spironolactone
Resistant hypertension can be extremely challenging. Addressing nonpharmacological factors may help. Obesity and high salt intake are recognised as contributors, but less well known are the effects of alcohol and dietary indiscretions such as liquorice and excess caffeine. Drug therapy is often more effective and better tolerated if used in combination and at mid-range doses, although compliance should always be confirmed before any adjustments. An underlying cause remains uncommon but should be sought in younger patients (under 40 years old), in drugresistant hypertension despite three agents, or where clinical findings or baseline bloods tests are suggestive. If all else fails, consider the addition of spironolactone.
10. Remember that hyperlipidaemia may have an underlying cause
Lipid profiles are one of the most commonly requested blood tests from general practice. Before reaching for the prescription pad, consider some important possible underlying causes. These include lifestyle factors such as excessive alcohol intake (raised triglycerides), a diet rich in saturated fats (total cholesterol, TG), sedentary lifestyle and cigarette smoking (low HDL) as well as a number of systemic illnesses including hypothyroidism, diabetes mellitus, primary biliary cirrhosis and nephrotic syndrome. Finally, drugs such as antiretroviral agents, retinoids, cyclosporin and corticosteroids may also result in adverse lipid profiles.
Obscure or overlooked diagnoses
1. Infective endocarditis
This usually involves cardiac valves, but may affect other areas such as pacemaker leads. It is rare but potentially life threatening. Patients may present with nonspecific symptoms such as anorexia, weight loss, joint pain, fever and sweats. The chronic nature of these symptoms (weeks) should ring alarm bells. Clinically, a new murmur is the cardinal sign along with splinter haemorrhages. Investigations
reveal microscopic haematuria and a raised white count and CRP. While it can affect anyone, patients most at risk are those with prosthetic valves, those on dialysis, intravenous drug users and patients with known congenital heart disease.
2. syndrome X
This comprises typical angina symptoms with evidence of ischaemia (30% of patients have abnormal myocardial perfusion scans), but with normal epicardial vessels. It is poorly understood, but putative mechanisms include microvascular dysfunction, coronary spasm and abnormal pain gating mechanisms. There is no universally accepted treatment – regimes are often established by trial and error. Treating additional risk factors may help, but the prognosis is good with low rates of adverse cardiac events.
3. takotsubo cardiomyopathy
Takotsubo cardiomyopathy, or broken heart syndrome, is characterised by severe, typical cardiac-sounding chest pain indicative of acute myocardial infarction often accompanied by ECG changes – yet no vessel occlusion is seen on coronary angiogram. The condition is often precipitated by acute emotional stress. The mechanism is unclear: acute severe catecholamine surge, microvascular dysfunction and coronary spasm are possible explanations. Patients need early and prompt admission to support the left ventricle – yet curiously, in almost all instances, there is complete recovery.
4. Long Qt s yndrome
This is a genetic disorder resulting in prolongation of the corrected QT interval with a resultant increased risk of ventricular arrhythmias or sudden cardiac death. There is usually nothing to find on clinical examination. The diagnosis needs to be considered in any patient presenting with syncope, particularly if there is a family history of sudden cardiac death. Patients need urgent referral to specialist cardiac and genetic clinics. Beta-blocker therapy is the mainstay of therapy and should be initiated as soon as the diagnosis is suspected or confirmed. More specialist treatment includes pacemaker or defibrillator implantation.
Orthostatic tachycardia is defined as a rise in heart rate, or a sinus tachycardia (>120 beats/minute), within 10 minutes of standing. It is increasingly recognised as a form of dysautonomia and may present with various non-specific symptoms including fatigue, exercise intolerance, headache (orthostatic migraine), palpitations, lightheadedness or even syncope. Most patients are young women and symptoms may be severe. Formal diagnostic confirmation involves tilt testing, but a simple pulse check on standing is often enough to confirm orthostatic tachycardia. Other causes for dysautnomia – particularly diabetes – need ruling out. Patients should increase their fluid intake to 2 or 3 litres a day along with increased salt in the diet. Drug therapy includes fludrocortisone, beta-blockers and SSRIs.
Easily confused
1. supraventricular tachycardia and Anxiety
History
Examination
SVT
▪ Predominant symptoms are an abrupt onset of palpitations with an awareness of a very rapid heartbeat followed sometimes by anxiety
▪ Usually normal unless examined during SVT. During SVT, heart rate is usually over 150 beats/ minute
Overlapping symptoms/ findings Anxiety
▪ Palpitations
Investigations
▪
ECG confirms SVT if taken during an episode
▪ May be terminated with vagal manoeuvres such as forced Valsalva/carotid sinus massage
▪ Cardiac monitoring during symptoms demonstrates sudden onset rapid tachycardia/SVT
2. Angina vs. Musculoskeletal pain
▪ Tachycardia
▪ Predominant symptom is anxiety, often with hyperventilation and a feeling of panic. An awareness of heartbeat may develop but does not trigger the other symptoms
▪ Usually normal unless during an episode. Tachycardia may be present but heart rates are usually well below 150 beats/minute. Other features such as hyperventilation, anxiety and distress
▪ ECG shows normal/sinus tachycardia during episode
▪ Vagal manoeuvres have no effect
▪ Cardiac monitoring during symptoms demonstrates normal sinus rhythm/sinus tachycardia
▪ BNP significantly elevated in diuretic naive patients
▪ ECG – often abnormal (left bundle branch block, evidence of anterior Q waves and poor R wave progression)
▪ CXR: cardiomegaly and pulmonary congestion
Overlapping symptoms/ findings
▪ Breathlessness
▪ Cough
▪ Crepitations
▪ Peripheral oedema
COPD
▪ Symptoms predominated by productive cough
▪ Peripheral oedema if present is often dependent
▪ Rarely seen in lifelong non-smokers
▪ Oedema rarely pitting unless cor pulmonale established
▪ Normal JVP
▪ Heart sounds soft, no murmurs
▪ Crepitations are coarse and may vary with coughing
▪ Expiratory wheeze common
▪ Spirometry shows characteristic COPD pattern
▪ BNP may be normal or mildly elevated.
▪ ECG – often normal, with large prominent p waves sometimes present if COPD is long standing
▪ CXR: normal heart size, hyperinflated lungs, possible pneumonic change during exacerbations
Prescribing points
1. e ffective use of long-acting nitrates
Long-acting nitrates lose their effectiveness if prescribed inappropriately. Most once daily mononitrate preparations will last approximately 12 hours – but a nitrate-free period is needed to prevent tolerance developing, so twice daily dosing should be avoided.
2. Managing statin intolerance
Intolerance can be a major hurdle to prescribing, with muscle-related problems accounting for two thirds of side effects. This can present early or late (sometimes years after initiation) and some agents – such as fibrates, macrolide antibiotics, calcium channel blockers and grapefruit juice – may exacerbate statin-related myopathy. A little statin is better than none, and very low dose alternate day or even weekly regimes of rosuvasatin 5 mg can sometimes be tolerated and may bring about significant cholesterol reduction, particularly if combined with ezetimibe.
3. using noACs effectively
These have revolutionised anticoagulation therapy for stroke prevention in nonvalvular atrial fibrillation (NVAF); however, there remains confusion over what constitutes NVAF. Valve-related atrial fibrillation, which precludes use of the NOACs, does not include all valvular pathology, but is confined to mechanical prosthetic valves and patients with at least moderate mitral stenosis. NOACs have significant advantages over warfarin including a more consistent effect and a better safety profile, particularly in respect of intracranial haemorrhage.
4. Dual antiplatelet therapy – for whom and how long
The exponential growth of coronary stenting has been accompanied by ever more complex antiplatelet regimes. Implantation of a metal coronary stent requires early and effective antiplatelet therapy to prevent the devastating effects of stent thrombosis – so aspirin is combined with clopidogrel, ticagrelor or prasugrel. This combination is usually continued for 12 months, with discontinuation of the newer agent at that stage and lifelong aspirin as monotherapy thereafter. All too often, patients are left on combination therapy indefinitely as a default, with an accompanying increased risk of haemorrhage with little further clinical benefit. Premature discontinuation to allow for surgery should be discussed with the cardiology team if possible.
CARE OF THE ELDERLY
James Woodard
Ten Pearls of wisdom
1. The absence of typical ut I sy mptoms in older patients means it probably isn’t a ut I
…and isolated confusion is not a typical symptom, so it requires a full evaluation for other causes before a diagnosis of UTI can be made. Typical symptoms include new dysuria, frequency, urgency, suprapubic tenderness, polyuria or haematuria. Bear in mind, too, that the prevalence of asymptomatic bacteriuria –the presence of bacteria in the urinary tract of a patient without typical symptoms of a UTI – increases with age, institutionalisation and the presence of permanent catheters. Asymptomatic bacteriuria is more common than UTIs in older patients and results in the overdiagnosis of UTIs in this age group.
2. Delirium may well point to underlying dementia and so needs follow up
Delirium is an acute state of confusion which fluctuates, results in an altered consciousness level and reduces levels of attention (see also the ‘Easily Confused’ section). In up to 20% of patients, no cause is found, but it is not normal for older patients to become delirious. It should be considered a marker of lowered neurological reserve and is a good predictor for who will go on to develop dementia. One study has suggested that up to 60% of patients presenting to hospital with delirium but no known dementia diagnosis had dementia at 3-month follow up.
3. The majority of older patients in the community are not frail –but know how to spot it
Frailty is a syndrome that is increasingly recognised and used to describe a group of mostly older patients who are vulnerable to medical crisis as a result of minor illness, medication changes or other minimal stimuli. Patients with frailty often have three or more of the following:
a. Slow walking speed
b. Decreased activity levels
c. Muscle weakness (reduced grip strength or difficulty standing from seated position)
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outside which they are not to be seen. This adds very much to the interest of slow travelling, as it keeps you constantly on the watch, and you are rewarded by always seeing something fresh. The trying thing about it is that if you do not buy the thing you want directly you see it, most likely you will never have another chance.
It is amusing to watch the harvesting of the peanuts which is now going on. Owing to the clayey nature of the soil, it is impossible to sieve them as in Shantung, so whole families establish themselves in a field, attended by their poultry and pigs, which are picketed out over the surface of the ground. This has been already dug up and cleared by the gatherers, but the family gleans what has been overlooked, and the poultry and pigs again glean what they may have left. Little Chinese children sit in baskets, but at a very tender age they begin to share the toils of their elders. It is astonishing to see the loads of salt, coal, or firewood which some of these tiny creatures manage to carry with a manly energy. There must be a good deal of country life in this district, for there are numbers of nicelooking farms situated on the hilltops (as in the sketch of “Sunlight and Mist”), surrounded by haystacks and vegetable gardens and clumps of the useful bamboo. The bamboo seems to be used for every possible purpose, and many of the implements made from it are as ingenious as they are simple. Take, for instance, the rake; one end of the bamboo rod is split, the ends bent, and a tiny bit of plaiting spreads the prongs out fan shape. A greater variety of baskets, too, is made from bamboos than I have ever seen elsewhere, and they are used for a much larger number of purposes than at home.
As we plodded along the rice-fields one morning, after about an hour’s walk we came to a wayside booth, where our men stopped for their first snack of food, and some particularly fresh-looking eggs tempted us to join their meal. The salesman proceeded to poach them, and would have added sugar if we had not stopped him. Declining chopsticks, I was provided with a nice little pottery spoon, and my friend took possession of a saucer about the size of a penny (commonly used for sauce) for the same purpose. Long strings of mules passed us, carrying taxes in the shape of small basket-loads of bullion, accompanied by a military escort. The leading mules were
gaily decorated with flags, showing that they were on government duty. The road was bad and slippery, and our men soon decided to shorten the day’s journey by one-third, which we declined to allow, having already spared their strength by walking for several hours; we agreed, however, to shorten the stage to a certain extent. The natural result was that we found a horrible inn with only two tiny rooms at our disposal, an inner one being already occupied by several people. We agreed to remain there only on one condition— that these people should be put elsewhere; and we found the three cells were more than filled by ourselves and our staff. There were no windows, but there was plenty of ventilation. The house was like a large barn, the end of which was divided off by a thin partition, in the centre of which was a round door. This part was again subdivided into three cubicles. The outer part of the barn was like a big restaurant, and after a while the many inhabitants rolled themselves up like sausages in the wadded quilts provided by the inn, and bestowed themselves as comfortably as might be on tables or benches, and comparative silence reigned for a few hours. Happily, the rain stopped, for there was quite enough open space in the roof above my head and in the walls for us to study astronomy had it been a clear night. We found it unnecessary to have our pan of charcoal taken out at nights, for there was always a lovely breeze to carry away any fumes there might be.
In this district the beds are made of straw, covered with a bamboo matting, and are not uncomfortable; but we always felt happier when we got a plain wooden bedstead like a large, low table.
We passed a night at an interesting large town called Shun King Fu, and were greatly charmed with the lovely silks we saw being made there, and the silver work. Everywhere the people were busy with the various processes of silk-making. Hand-looms, of course, are used, and we saw the most exquisite golden shades of silk in all stages of manufacture. It is, however, never sold in its natural golden colour, or white (as that is the Chinese mourning), unless some European succeeds in getting hold of a piece in its unfinished state. Some of the natural dyes are wonderfully brilliant, but unfortunately none of them seemed to be fast colours. The red and yellow
vegetable dyes and indigo are grown in the province of Szechwan, but, sad to say, aniline dyes have been introduced, and are becoming more and more common.
The missionaries who were entertaining us kindly sent out to a silk merchant to bring pieces for us to select from, as it is not very usual for ladies to go out shopping in this city. When we had chosen what we wanted, the silk had to be weighed, instead of measured, to ascertain what the price was. The merchant, who brought lovely embroidery silks for sale, had neat little scales in a case with which to weigh the skeins. A long discussion as to the price ensued, as it had gone up since our hosts bought similar silks a month before, and no valid reason could be produced for the change. Of course the system of bargaining is universal, and we were thankful to have some one to tell us what the price ought to have been and to do the bargaining for us. Next the silversmith was summoned, and he brought a trayful of various silver ornaments, ready to be inlaid with kingfishers’ feathers. This is an art peculiar to China; in fact, no one but a Chinaman would have the patience requisite for doing it. The effect is that of the most brilliant, iridescent, blue-green enamel, and usually beads or red-coloured glass or coral are introduced instead of jewels. It is particularly effective when combined with jade. This jewelry was also sold by weight, and we had to leave our purchases to be “feathered” and sent after us, as everything of that sort is only made to order. Brides frequently wear a sort of crown made of silver and kingfishers’ feathers, which looks extremely effective. There are some fine examples of this work in the Chinese Section of the South Kensington Museum.
We were told that we must make an early start next day, as it was a very long stage—between thirty and thirty-five miles—so we were up betimes, and ready at six o’clock. Luck was decidedly against us. First one of the coolies said he was ill and could not go, so another had to be got, which delayed us nearly an hour. The morning was very grey, and a cold drizzle soon set in. My chairbearers fell down even before we got outside the city, and the road became more and more sticky every moment. The men hate cold water, and had to walk round every puddle, which took up a great
deal of time. The ground is composed of a particularly sticky clay, which is perhaps the reason why not only the cattle but also the funny little black pigs wear straw sandals when they travel.
After our chairs had been upset more than once we decided that it was less unpleasant to walk, and the soldiers came valiantly to the rescue when the road was specially difficult, as in the case of long flights of slippery steps. Sometimes they gave us a hand, and sometimes they clutched an elbow to save us. The descriptions of slippery places and the perils of the road, as given in the Book of Psalms, were perpetually before our mental vision. Nothing could more accurately describe Chinese roads in wet weather. The coolies tied little metal things on to their sandals, which was somewhat of a help, but we felt almost thankful when at midday the rain settled into a steady downpour; for, though it was rather dreary, it was less slippery. There were a large number of chairs on the road, and some as important-looking as our own. This was the only bit of the journey when we travelled like mandarins, but we lacked the smart military uniforms of the mandarins’ coolies; ours were the most disreputable, ragged-looking crew, and much less satisfactory as carriers than those we had in Shantung or Yünnan. In the nine days that we had been travelling from Wanhsien we had only once met a four-bearer chair, but now we were nearing the capital—Chengtu—the road was much more crowded with traffic of all sorts. The last stage of the journey is through comparatively level country. After a breakneck descent from the mountains we entered the plain in which Chengtu is situated. It is about ninety miles in length by forty broad, and has been well described as a garden. Colonel Manifold estimates that it contains a population of 1700 to the square mile, and there are seventeen cities in it. The old familiar groan of wheelbarrows greeted our ears once more, though the type is slightly different here from that of Shantung; they are much smaller and only accommodate one person, or (as we frequently saw) one fat pig, lying on his back, with his legs in the air. The seat is immediately behind the wheel, and it looks decidedly comic to see a woman, wearing tight pink trousers, with a leg cocked jauntily on either side of the wheel.
SUNLIGHT AND MIST IN THE MOUNTAINS
In this part of the country we passed through villages much more frequently, and the people had a busier air. There are markets held every few days in one or other of the villages, so that we continually met people coming from them laden with their spoils. They kept passing us on the road wearing paper caps over their hats, and on inquiry we learnt that this was done to preserve their pristine freshness. The fields were full of people weeding, and they looked very comfortable, seated on their little stools, and with warming-pans between their feet; for it was the week before Christmas, and the weather was growing cold. The minute kind of care the peasants here give to their crops is most interesting, each individual plant in a field being carefully attended to and manured. Each member of a family seems to share in the toil and to have implements suited to his or her size, some of them the “cutest” little weapons imaginable. The people look well fed and attended to, but their clothing is often a network of rags, and their houses are singularly dark and forbidding.
If there is any scarcity through unfavourable crops, they suffer immediately and acutely, as agriculture is the most important industry of the province. The men have such long pipes that they frequently use them as walking-sticks. Often the women came round and smilingly interrogated us. Then we went through an amusing dumb conversation of the most friendly sort. The subject is usually the same—feet—and they never fail to admire our English boots, if not our feet. We, on our side, express much admiration of the exquisite embroidery of their shoes, though we do not admire their feet. Everywhere they seem to think we must be doctors, and they come and explain what a pain they have in the region of the digestion. We administer a harmless and comforting dose of ginger, and they swallow it with the utmost faith, which we hope may cause it to be doubly efficacious. In any case it is a sign of our goodwill, and establishes a friendly feeling among the people, and I do not see that it can do any harm.
We reached Chengtu on the morning of the fourteenth day, and spent a full hour wandering in search of the English missionary’s house, on whose kind hospitality we were reckoning; for there are many missions in this large city, and our men at once made for the most imposing, which, needless to say, is American.
It may seem strange to people at home to hear that travellers habitually swoop down on missions, often without even giving notice beforehand, and are invariably welcomed with courtesy and kindness. Travelling in China would be a much more difficult matter than it is if it were not for the ungrudging helpfulness and hospitality of the missionaries. Those to whom we had been directed were unable to take us in, on account of illness, but had made arrangements for us to be entertained at the Friends’ mission, and helped us in many other ways.
CITY GATE, CHENGTU
CHAPTER XV Chengtu
CHENGTU is unquestionably the cleanest city in China, and probably is the most progressive and enlightened of any purely native city. The streets are broad and well kept, and the foreigner can walk anywhere without the slightest fear of molestation. At almost every street corner there is a policeman, and many of them have sentry-boxes. They are neatly dressed in a sort of European uniform, and are decidedly clean and civil. They wear a kind of small black sailor-hat, and the smarter ones wear black thread gloves of native manufacture and carry stout walking-sticks. Altogether, they are the best type of police we met. There are no beggars with their hideous whine and incomparable dirt. This is a magnificent triumph for the head magistrate, as a few years ago they numbered twenty thousand in Chengtu; but he was determined to put an end to the system, and has entirely succeeded. We met a large school of boys neatly dressed, and were told that these were the children of the beggars, whom he had collected into a large school, where they are taught trades at the expense of the municipality
On the day of our arrival a kind friend offered to take us round the city For the first time since leaving Shanghai, we found we could go on a real shopping expedition, and we had a glorious afternoon of it. It would be hard to find a more fascinating place than Chengtu for shopping. The curio shops had much that was attractive, though nothing of any great value. We were told that we must proceed with great caution if we wished to get things at a reasonable price; and fortunately we were able to discuss in an unknown tongue, which was a great advantage to us in dealing with the shopkeepers. Our
method of procedure was as follows:—firstly, to look with interest at all the things we did not want, such as a baby’s feeding-bottle or old beer-bottles; secondly, to point out all the flaws in anything that we did want, turning up our noses till they were nearly out of joint; thirdly, to ask the prices of many things, and to exclaim “Ai-ah” in an incredulous tone on hearing the price of the things that we wanted to purchase. Then we named a price about five times below what was asked. Finally we left the shop and strolled away up the street, while our kind friend further discussed the matter with the shopkeeper, we having previously arranged with him in English how high we were willing to go. On an average we got the things at about half the price named originally, but sometimes we got them considerably cheaper. There was not much old china to be seen, but a few bronzes and a good deal of interesting brass, mostly modern. Chengtu is a great place for the manufacture of horn things, especially lanterns, which are most ingeniously constructed. The sheets of horn are joined by being melted together, and Hosie gives a most interesting description in his trade report of the way that these and other things are made in Chengtu. There is a great manufacture of masks, and of whole heads of the same kind, which are painted brilliant colours, especially pink. In another street it is interesting to watch the sacred money being made. Outside each shop a tree trunk is set up about six feet high; the top of it is carved to form a mould, the shape of a silver shoe. Into this the paper—made from bamboo or rice straw—is beaten into shape with a hammer by a man standing upon the counter in order to reach up to it. The basket-shops, too, are most enticing, and here they make the largest baskets I have ever seen, about four feet high and about two yards in diameter. This is the place from which loofah comes; it is the inside of a peculiar kind of melon. Chengtu is the great trade centre, too, for spices and musk, furs, &c., which come from Tibet; but the great trade of the place is in silks, as in the days of Marco Polo—and these were brought to the house another day for us to see. The figured crêpe de Chine was beautiful, and the shades were different from those to be seen at home. I got a lovely figured brocade at about 3s. 9d. per yard, and crêpe de Chine at 1s. 6d. You can see these silks being woven in numbers of the dark-looking houses, and the design is made by a
person sitting above the loom, almost in the roof. Another charming industry is that of ribbons and braids, which are made on the most ingenious little machines. The people sit outside their doors working at them, as you see the women with their lace bobbins in European countries.
The people seem a poor, cheerful, thrifty folk, and there is an air of prosperous activity throughout the whole city. Many parts of it are extremely picturesque, and there are beautiful trees of various kinds shading the wide thoroughfares. In the evening our attention was attracted by tall poles, with lights placed so high up that they could have been of no possible use to anybody. We found that they were put up by pious persons to light the “orphan spirits”—that is to say, to show the way home to people who had died away from their own city.
The following day we visited the famous Buddhist monastery, enclosed by a wall above which rose lofty trees. Passing through the fine entrance, we faced a large gilt Buddha in a narrow shrine; back to back with this, and divided off by a thin partition, was another figure of the Buddha, facing the court. Here the Abbot received us most courteously, and sent for his secretary to show us round. The accompanying diagram shows the ordinary sort of arrangement both of temples and monasteries. The temples generally form a group of buildings separated from one another by courts one behind the other in a straight line, the principal buildings forming the ends, and minor buildings running along the sides of the courts. The hall of meditation of the monks was an imposing room with seats along the walls, on which the monks sit cross-legged, looking very much like Buddhas. Everything was beautifully clean in the dining-hall, which was filled with long tables, on which three bowls and a pair of chopsticks were placed at intervals for each monk. In the kitchen we saw an enormous boiler, where over a bushel of rice is cooked for each meal, to supply the appetites of a hundred and fifty monks. A large wooden fish acts as a gong for summoning the monks to meals, and another gong is used to summon them to tea.
PLAN OF MONASTERY, CHENGTU
One of the monks looked as if he had been recently branded for sainthood with nine marks about the size of threepenny-bits, symmetrically dotted over his skull. Hackmann gives an interesting description of the way this is done in his book Der Buddhismus. The candidate for sainthood has small pieces of incense fastened on to his shaven head by means of resin. These are lighted and allowed to burn into the flesh, while a chant is kept up by the other monks, and the sufferer has some one to press his temples with his thumbs to relieve the pain.
BUDDHIST MONASTERY
At the end of the third courtyard we were taken into a lofty temple, where the Abbot’s throne faced the doorway. A gilt Buddha,
with fruit and flowers placed on a table, formed a sort of altar in front of it. Round doorways, without doors, led to guest-rooms on either side of this hall, and we were hospitably entertained in one with tea and cakes. By permission of the Abbot, I returned next day to make a sketch of this picturesque interior, and in this sketch the doorway is shown, which is very characteristic of Szechwan architecture. Many of the inns in this province have circular doorways and windows. The Abbot came and talked with us very politely, and on inquiry I learnt that a most beautiful painting of lotus blossoms in black and white, which hung over the doorway, was by a celebrated artist, and had been presented to the monastery by a pious worshipper. The Abbot sat down and began discussing our respective religions, which he said were exactly the same. While agreeing as to their fundamental principle being the same, I felt unable to discuss their differences, being somewhat inattentive, I fear, owing to my endeavour to get on with the sketch as rapidly as possible. Next the Abbot was sure we must be hungry, though we had just been regaled with excellent sweets and tea, and, despite our refusing it, he insisted on sending us some of the meal to which he had been summoned. A monk soon appeared with bowls of vermicelli and greens. It was not unpalatable, and much easier to manage with chopsticks than might be supposed, as the bowl is held close to the mouth and the food shovelled in with chopsticks aided by suction. At intervals the novices came in to worship, and prostrated themselves before the altar. Most of the monks were dressed in pretty silver-grey robes, but some in the orthodox orange, and the Abbot wore a blue cloak. It was certainly an attractive community, a great contrast to those we saw in Peking.
Educationally Chengtu stands in the front rank of Chinese cities. Everywhere there are schools and colleges established on the new lines, and more are being built. The people are so enthusiastic that they have rather overshot the mark, it may be thought. In order to facilitate the girls’ going to school they are being dressed as boys, so that they may pass through the streets unnoticed to attend the various schools which have been started for them. One girl came to a friend of mine to seek admission to her school, and not only did the European take her for a boy (telling her the boys’ school was on the
other side of the road), but so also did the Chinese gatekeeper, who insisted she had come to the wrong place. At the recent athletic sports the students put up a notice that no lady with bound feet would be admitted to the ground, and we hear that this notice is now being put up everywhere throughout the empire on such occasions. Anti-foot-binding is certainly making good progress among the upper classes, and we even saw a shoe-shop with large shoes for ladies prominently displayed on the counter. Nowhere else have we seen this.
There is a large military medical college at which there are three French doctors. Their presence is not altogether agreeable to the Chinese, and when one retired recently the officials took the opportunity of suggesting that he should not be replaced. They said that they could not afford his salary. How great must have been their disappointment when they were informed that their new professor had already arrived, and that the French authorities were quite willing to pay for him! Foreign competition in China has its funny side, but I marvel at the way the Chinese endure it.
The University is an interesting but eminently unpicturesque place, and the students are cramming Western subjects in a way to cause intellectual dyspepsia. As everywhere in China, English is the main subject, and they have a professor from Cambridge, with two English assistants and a Dane. French, German, and Japanese are also taught, and there is only one professor for Chinese classics. Sunday is a holiday, and many students spend the week-end at home. The walls of the class-rooms are nearly all window, but it is in no ways disturbing to Chinese students to have any number of spectators, or to be able to see into the adjoining class-rooms. Each study is occupied by three or four students, and the studies are simply partitioned corridors with a passage down the centre and a railing on either side of it, instead of walls. The dining-rooms are like outdoor restaurants with a roof over them, and the students sit four at a table. The fees for the year, including everything, are thirty dollars (about £3. 10s.). Many students are very anxious to study in England, but cannot possibly raise the necessary funds; and until proper arrangements are made to look after them when they do
come, it is hardly a desirable plan. America is far ahead of us in this respect, and England would do well to follow her example. Everything is in our favour at present, and it might be of the utmost value as regards the development of China, and the commercial interests of England, to seize the opportunity of educating some of her ablest scholars. A Chinese gentleman told me that students returning from England are very apt to be full of bumptiousness because they have come out head of their class in English schools, while they have failed to assimilate what they have learnt. We spent an evening with some students, answering questions about the different countries we had visited. They wanted to know about the government, the religious and general conditions of other lands. Naturally the questions covered far too big an area to admit of satisfactory answers, but probably the men would have been willing to listen all night, if we had been willing to go on talking. They were most interested to hear the reasons why we admire China and the points of superiority which it possessed.
MILITARY YAMEN
On the last day of the year the Viceroy and the Tartar general sent presents to all the foreign community. Their visiting-cards were brought in, and a list of the presents which were waiting outside— hams, pigeons, ducks, fruits, and sweetmeats. We went outside to see them, and found the presents displayed on trays on the top of large boxes, or hung round them. It is customary to select about two things; visiting-cards are sent back with the remainder, and a small present of money is given to the servants who bring the gifts. They replace what has been selected from a supply inside the box, and then carry them on to the next house. We went to see the Tartar general’s yamen in the Manchu city, a very pretty spot embowered in trees, and quite typical of Chinese official buildings. The inscription over the entrance is “Yamen of the greatest General,” and on the doors and walls are highly coloured pictures of the tutelary gods, two celebrated generals of the T’Ang dynasty ( . . 618 to 905); one is white-faced, and the other red-faced. These pictures are repeated all along the wall, and also on the doorways of the inner courtyard, which in the sketch appears in the background. They are singularly ugly, but as the pictures of the door-gods are seen on the houses of all, even the poorest, the sketch of them may not be devoid of interest. On private houses some of them are quite little papers like advertisements, while again some of the private houses have large gilt figures covering the whole doors. One day we went outside the city to visit a fine temple, and came to a place where there is a road on which you can drive in carriages. This is the only place in the province where there is a carriage, but we did not have the privilege of seeing it. The walls are broad enough and smooth enough on the top to make a splendid carriage drive—four or five vehicles might easily drive abreast—and as they are ten miles round, it would really be a fine promenade. In the spring the view must be very beautiful, for there is a range of snowy mountains in the distance, and many branches of the Min River water the intervening plain. During the whole week that we spent at Chengtu we never saw the mountains, on account of the mist; but it was not hard to imagine the beauty of the place when the flowers are out and the brilliant butterflies hovering round them.
We took part in an interesting event while we were staying here —the purchase of land for a Christian university. Heavy bundles of silver “tings” had to be weighed before the payment was settled. Four different missionary societies have each agreed to build a college and to provide a certain number of qualified teachers. It is also proposed that Etonians should furnish a hostel. This university scheme for the west seems likely to be the forerunner of one also in the east of the empire, but the latter will be on more ambitious lines.
We were sorrier when the time came for us to leave Chengtu than we were to resume our journey on any other occasion. We had decided to go by river to Kiating, despite the fact that it was very low; and as we left the city we came to the wall where the new barracks are situated, and saw some soldiers doing the goose-step. Others were jumping into a trench, where nearly every one landed on allfours. There was very great hesitation before they dared leap at all. The city is enclosed by one of the branches of the river, and we had not to go very far outside the wall before we reached the point where our boat was moored.
CHAPTER
XVI
The Min River
WE reached the riverside—it looked merely a stream—and found our boat, with the luggage already aboard, looking most unpromising, despite the efforts of our men. It was a small river craft about eight feet broad. Bamboo matting not more than five feet high formed our house-room, with a few planks for a door in front. Fragments of matting made a partial screen in the centre. The floor was of a rudimentary character, just a few boards with large gaps between them, through which one could study the depth of water over which our luggage was precariously poised on low props. In order to prevent all our small things from dropping through the floor, we spread over it our invaluable sheets of oilcotton (a kind of waterproof largely used everywhere in China), and fastened up a curtain at each end of the tiny boat to secure a small amount of privacy. There was just space for our two carrying-chairs and our mattresses. One of the chairs we used as a wardrobe, and the other as a store-cupboard. The bamboo chairs we had procured at the penitentiary of Chengtu, despite the advice of our friends, as we found sedan-chairs very irksome, and decided that open ones would be more comfortable and enable us to see the country better. With long fur coats and foot muffs we felt that we could brave the cold, and there was always the resource of walking if we got too chilly. We never for a moment regretted our decision, and we found that the men carried the open chairs far better than the heavy closed ones. We profited at once by the exchange, as they were able to be used for going to Mount Omi, and we were carried some distance up the mountain. Under the seat was a box in which we could carry all our small things, and the coolies hung their coats, hats, &c., on the back.
As our room was so small we sat mostly on the floor, so as to have everything within reach without getting up. The cooking was a somewhat difficult matter, as the brazier on which it was done was only six inches in diameter, and rather apt to burn a hole in the floor if it was heated sufficiently to do any cooking. We were glad of its warmth, as the weather was very cold. Chopsticks were evidently the correct fireirons, and are just the right size to match the charcoal. With practice I got fairly expert at making palatable dishes, as naturally the range of the menu was much limited. From this time onward I did all the cooking, and I cannot help attributing to this fact mainly the excellent health we enjoyed throughout the whole journey.
It was on his way from Chang Te to Mount Omi that the unfortunate Lieutenant Brooke was murdered by Lolos about a year later than we were there. We were strongly warned about the care requisite in dealing with Lolos, and told that it was imprudent even to mention the name in public, as it is considered a term of reproach. It was suggested that we should spell it if desirous of speaking of them. Their country is marked on the maps as “Independent Lolos,” and covers about 11,000 square miles: no Chinaman dare penetrate into it without the safe-conduct of a Lolo. Their speech, dress, customs, religion, and laws are entirely different from those of the Chinese. No one has yet come into sufficiently close contact with them to ascertain even approximately the number of Lolo tribes in existence at the present time, speaking different dialects. What was true at the time that Baber explored Western Szechwan is equally true to-day—that practically nothing is known about them. He gives a graphic description of the Lolos whom he met, which I quote at length: “They are far taller than the Chinese; taller probably than any European people. During the journey we must have met hundreds of them, but we never saw one who could be called, even from an English standard, short or undersized. They are almost without exception remarkably straight-built, with thin muscular limbs. Their chests are deep, as becomes mountaineers: the speed and endurance with which they scale their native mountains is a prodigy and a proverb for the Chinese. Their handsome oval faces, of a reddish brown among those most exposed to the weather, are furnished with large, level eyes, prominent but not exaggerated
