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Community
Pharmacy
This page intentionally left blank
Community
Pharmacy
Symptoms, Diagnosis and Treatment

Paul Rutter PhD, FRPharmS, FFRPS, SFHEA

Professor in Pharmacy Practice, School of Pharmacy and Biomedical Sciences,
University of Portsmouth, Portsmouth, UK

FIFTH EDITION

For additional online content visit StudentConsult.com

© 2021, Elsevier Limited. All rights reserved.

First edition 2004

Second edition 2009
Third edition 2013
Fourth edition 2017

The right of Paul Rutter to be identified as author of this work has been asserted by him in accordance with
the Copyright, Designs and Patents Act 1988.

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

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

Notices

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

ISBN: 978-0-7020-8020-3

Senior Content Strategist: Pauline Graham

Senior Content Development Specialist: Helen Leng
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Printed in China

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

Contents

Useful websites vii

Preface ix
Introduction xi
How to use this book xv

1 Making a diagnosis 1

2 Respiratory system 9

3 Ophthalmology 55

4 Ear conditions 83

5 Central nervous system 97

6 Women’s health 129

7 Gastroenterology 161

8 Dermatology 229

9 Musculoskeletal conditions 299

10 Paediatrics 323

11 Specific product requests 353

Abbreviations 379
Glossary of terms 381
Index 383
This page intentionally left blank
Useful websites
(addresses correct as of April
2020)
Evidence-Based Medicine
http://www.bandolier.org.uk/
Centre for Medicines Optimization
Centre for Reviews and Dissemination
Health Services Technology Assessment Texts (US Site)
King’s Fund
National Institute for Health and Care Excellence
Regional Drugs and Therapeutic Centre
Medicine Information and Regulation
https://www.medicines.org.uk/emc
European Medicines Agency
Medicines and Healthcare Products Regulatory Agency
NICE Clinical Knowledge Summaries
Therapeutic Goods Administration (Australia)
UK Medicines Information
US Food and Drug Administration
Professional Bodies and Regulators
British Dental Association
British Medical Association
General Dental Council
General Medical Council
General Pharmaceutical Council
Health and care Professions Council
Pharmaceutical Society of Australia
Royal College of Nursing
Royal Pharmaceutical Society
The Nursing and Midwifery Council
UK Pharmacy Organizations and Trade Bodies
Association of the British Pharmaceutical Industry
British Pharmaceutical Students Association
https://www.ghp.org.uk/
National Pharmaceutical Association
Pharmaceutical Services Negotiating Committee
The Proprietary Association of Great Britain
UK Clinical Pharmacists Association
International Healthcare Organizations
International Pharmaceutical Federation (FIP)
International Pharmaceutical Students’ Federation
World Health Organization
Pharmacy Journals
Chemist and Druggist
International Journal of Clinical Pharmacy
International Journal of Pharmacy Practice
Pharmaceutical Journal
Research in Social and Administrative Pharmacy
The Pharmacist
Wider Healthcare Journals of Interest to Community
Pharmacy
British Journal of General Practice
British Medical Journal
Health and Social Care in the Community
Health Services Research
Journal of Evaluation in Clinical Practice
Journal of Prescribing Practice
Journal of Self Care
Nursing Standard
The Lancet
General Health Sites for Healthcare Workers
Medscape
Selfcare forum
General Health Sites for Patients
http://www.patient.co.uk
http://www.healthfinder.gov/
http://www.bbc.co.uk/health/
This page intentionally left blank
Preface
Demand on healthcare professionals to deliver high-quality
patient care has never been greater. A multitude of factors
impinge on healthcare delivery today, including an aging
population, more sophisticated medicines, high patient
expectation and health service infrastructure, as well as ade-
quate and appropriate staffing levels. In primary care, the
medical practitioner role is still central in providing this care,
but shifting the workload from secondary to primary care is
placing greater demands on their time, resulting in new
models of service delivery that increasingly involve other
allied health professionals.
This is leading to a breakdown of the traditional boundaries
of care among doctors, nurses and pharmacists. In particular,
certain activities once seen as medical practitioner responsibil-
ity are now being performed by nurses and pharmacists as
their scope of practice expands. The traditional role of supply-
ing medicines safely and efficiently through the community
pharmacy still exists, but greater patient-facing cognitive
roles are now firmly established. Health prevention services
are now routine; for example, smoking cessation, weight man-
agement and vaccination programmes. The pharmacy is now
seen (by many governments) as a place where the general pub-
lic can be managed for everyday healthcare needs without vis-
iting a doctor. The most notable long-term global healthcare
policy, which directly affects pharmacy, is the reclassification
of prescription-only medicines to nonprescription status. In
the UK, over 100 medicines have been deregulated since the
first switches took place in 1983. More recent switches have
included products from new therapeutic classes, allowing
community pharmacists to manage and treat a wider range
of conditions.
Further deregulation of medicines to treat acute illness
from different therapeutic areas seems likely in the medium
to long term, especially because healthcare professional
opinion to acute medicine deregulation is broadly positive,
and the impact on the general practice workload associated
with dealing with minor ailments is high (representing
100–150 million GP consultations per annum). Pharmacists,
more than ever before, need to demonstrate that they can be
trusted with this additional responsibility. Therefore, phar-
macists require greater levels of knowledge and understand-
ing about commonly occurring medical conditions. They will
need to be able to recognise their signs and symptoms and
use an evidence-based approach to treatment.
This was, and still is, the catalyst for this book. Although
other books targeted for pharmacists about diagnosis have
been published, this text aims to give a more in-depth view
of minor conditions and explains how to differentiate them
from more sinister pathology, which may present in a similar
way. The book is intended for all nonmedical healthcare
staff, but especially for pharmacists, from undergraduate
students to experienced practitioners.
It is hoped that the information contained within the book
is both informative and useful.
This page intentionally left blank
Introduction
Community pharmacists are the most accessible healthcare
professional. No appointment is needed to consult a pharma-
cist, and patients can receive free unbiased advice almost
anywhere. A community pharmacist is often the first health
professional from whom the patient seeks advice and, as
such, provides a filtering mechanism whereby minor self-
limiting conditions can be appropriately treated with the cor-
rect medication, and patients with more sinister pathology
referred on to an appropriate practitioner for further investi-
gation. On a typical day, a pharmacist practising in an ‘aver-
age’ community pharmacy can realistically expect to help
between 5 and 15 patients a day who present with various
symptoms for which they are seeking advice, reassurance,
treatment or a combination of all three.
Probably of greatest impact to community pharmacy prac-
tice globally is the increased prominence of self-care. Self-
care is not new; people have always taken an active role in
their own health. What is different now is the attitude towards
self-care by policy makers, healthcare organisations, not-for-
profit agencies and front-line healthcare workers. Health
improvements have been seen in people adopting health-
enhancing behaviours rather than just through medical inter-
vention. This has led to self-care being seen in a broader con-
text than just the way in which people deal with everyday
illness. In the UK, the self-care forum (http://www.
selfcareforum.org/) was established; its purpose is to promote
self-care and to embed it in everyday life.
So what is self-care?
Fundamentally, the concept self-care puts responsibility on
individuals for their own health and well-being. The World
Health Organization defines self-care as ‘the ability of indi-
viduals, families and communities to promote health, prevent
disease, and maintain health and to cope with illness and
disability with or without the support of a health-care
provider’.
Self-care has been described as a continuum (Fig. 1), start-
ing with individual choices on health (e.g., exercising), moving
through to managing their own ill health (e.g., self-medicating)
either on their own or with help. As people progress along the
continuum, more facilitation by others is required until a
person needs fully managed care.
What is self-medication?
Self-medication is just one element of self-care and can be
defined as the selection and use of medicines by individuals
to treat self-recognised illness or symptoms. How these med-
icines are made available to the public vary from country to
country, but all have been approved by regulatory agencies
as being safe and effective for people to select and use
without the need for medical supervision or intervention.
In many countries (e.g. Australia, New Zealand, France,
Sweden, Canada, UK), regulatory frameworks support the
reclassification of medicines away from prescription-only
control by having a gradation in the level of medicine avail-
ability, whereby certain medicines can only be purchased at
a pharmacy. These ‘pharmacy medicines’ usually have to be
sold by the pharmacist or under his or her supervision. Over
the last 4 decades, this approach to reclassification has seen
a wide range of therapeutic agents made available to con-
sumers, including proton pump inhibitors (US, EU-wide),
orlistat (EU-wide), triptans (UK, Germany) and beta-2
agonists (Singapore, Australia).
Facilitated self-medication
Most purchases of nonprescription medicines are by the con-
sumer alone, who uses product information from packaging
to make an informed decision on whether to make the pur-
chase. When consumers seek help at the point of purchase,
this can be termed facilitated self-medication. Where medi-
cines are purchased through pharmacies, staff are in a strong
position to facilitate self-care decision making by consumers
because, in most pharmacies, the transaction takes place
through a trained counter assistant or the pharmacist. Lim-
ited research has shown that consumer purchasing decisions
are affected by this facilitation. Nichol et al. and Sclar et al.
both demonstrated that consumers (25% and 43%, respec-
tively) altered their purchasing decision when proactively
approached by pharmacy students. Furthermore, a small
xii Introduction
Pure self-care
Responsible
individual
The self-care continuum
Daily Lifestyle Self-managed Minor
choices ailments ailments
Healthy living Minor ailments
Fig. 1 The self-care continuum.
proportion of consumers did not purchase anything (13%
and 8%) or were referred to their physician (1% and 4%).
These studies highlight how the pharmacy team can posi-
tively shape consumer decisions and help guide them to
arguably better alternatives.
Community pharmacy and self-care
Increasing healthcare costs, changes in societal lifestyle,
improved educational levels, and increasing consumerism
are all influencing factors on why people choose to exercise
self-care. Of greatest importance are probably consumer
purchasing patterns and controlling costs.
Consumerism
Changes in society have led people to have a different outlook
on health and how they perceive their own health and ill
health. Today, people have easy access to information; the
Internet gives almost instantaneous access to limitless data
on all aspects of health and care, which means that people
across the globe have the means to query decisions and chal-
lenge medical opinion. This growing empowerment is also
influenced by greater levels of education; having information
is one thing, but being able to understand it and utilise it is
another. This has proved challenging to healthcare systems
and workers, having to move from traditional structures
and paternalistic doctrines (e.g., ‘doctor knows best’) to a
patient-focused and -centred type of care. This heightened
public awareness about health, in the context of self-care,
allows individuals to make informed choices and to recognise
that much can be done by themselves. The extent of self-care is
no better exemplified than by the level of consumer self-
medication. The use of nonprescription medicines is the most
prevalent form of medical care in the world. Sales are huge,
with the global market estimated to be worth 73 billion euros.
Pure medical care
Professional
responsibility
Long-term Acute Compulsory Major
conditions conditions psychiatric care trauma
Long-term conditions In-hospital care
Despite the enormous sums of money spent on nonpre-
scription medicines, approximately only 25% of people reg-
ularly purchase them (25% tend to seek medical attention,
and 50% do nothing). The extent to which this happens var-
ies from country to country and, in some markets, this is con-
siderably higher; for example, South Africa and the United
States, where 35% to 40% of people use over-the-counter
(OTC) medications on a regular basis.
Many papers and commissioned reports have shown that
access and convenience shape the purchasing patterns of
consumers. These factors seem to be unaffected by country
or time. Reports spanning 30 years have repeatedly con-
cluded that these play an important part in consumer deci-
sion making. The element of convenience does have a
country context; for example, in Western countries, this is
primarily due to ease of access that negates the need for
doctor seeking that is often associated with higher cost
and increased time. In developing countries, ‘convenience’
is more associated with ‘need’ due to lower levels of health
infrastructure and access to medical resources.
Costs
As populations across the globe live longer lives, whether
through better hygiene, nutrition or advances in medicine,
providing medical care is becoming more and more expen-
sive. In an attempt to control costs, many countries have
gone through major healthcare reforms to maximise existing
resources, both financial and staffing, to deliver effective and
efficient healthcare. These reforms include integrating self-
care into mainstream public health policy, including the
management of long-term conditions.
Encouraging more people to exercise greater levels of
self-care, for acute or chronic problems, has the potential
to shift costs away from professional care. Figures from
the UK give some indication as to the magnitude of potential

cost savings. Take primary care workload as an example. It
has been reported that approximately 20% to 40% of general
practice (GP) workload constitutes patients seeking help for
minor illnesses at a cost of £2 billion.
Contribution of community pharmacy to self-care
Community pharmacists are uniquely placed to provide sup-
port and advice to the general public compared to other
healthcare professionals. The combination of location and
accessibility means that most consumers have ready access
to a pharmacy where healthcare professional advice is
available on demand. A high level of public trust and con-
fidence in pharmacists’ ability to advise on nonprescription
medicines is afforded to community pharmacists. Although
there is a general global move to liberalise nonprescription
markets, pharmacies in many countries still are the main
suppliers of nonprescription medicines. Pharmacists are,
Introduction xiii
therefore, in a unique position to facilitate consumer self-
care and self-medication, which needs to be expanded and
exploited.
References
Nichol, M. B., McCombs, J. S., Johnson, K. A., et al. (1992). The
effects of consultation on over-the-counter medication
purchasing decisions. Medical Care, 30, 989–1003.
Pharmaceutical Services Negotiating Committee (PSNC) Self-
Care and Links https://psnc.org.uk/services-commissioning/
essential-services/support-for-self-care/
Sclar, D. A., Robison, L. M., Skaer, T. L., (1996). Pharmacy
consultation and over-the-counter medication purchasing
outcomes. Over-the-counter medication intervention project
team. Journal of Clinical Pharmacy and Therapeutics, 21,
177–184.
Self-Care Connect http://www.selfcareconnect.co.uk/
Self-Care Forum http://www.selfcareforum.org/
This page intentionally left blank
How to use the book
The book is divided into 11 chapters. The first chapter lays the
foundations of how to go about making a diagnosis. This is
followed by nine systems-based chapters structured in the
format shown in Fig. 2. The final chapter is product-based
and has a slightly different format. A list of abbreviations
and a glossary are included at the end of the book.
Key features of each chapter
At the beginning of each chapter, there is a short section
addressing basic anatomy and history taking specific to that
body system. A basic understanding of the anatomical loca-
tion of major structures is useful when attempting to diag-
nose or exclude conditions from a patient’s presenting
complaint. It would be almost impossible to know whether
to treat or refer a patient who presented with symptoms sug-
gestive of renal colic if one didn’t know the location of the
kidneys. However, this is not intended to replace an anatomy
text, and the reader is referred to further reading listed
throughout the book for more detailed information on ana-
tomical considerations.
Self-assessment questions
Twenty-five multiple-choice, extended matching questions,
and at least two case studies are presented at the end of each
chapter. These are designed to test factual recall and applied
knowledge. Most questions are constructed to resemble those
in the UK preregistration examination set by the General
Pharmaceutical Council.
The case studies challenge you with real-life situations.
All are drawn from practice and have been encountered by
practising pharmacists but have been modified for inclusion
in this book.
Elements included under each condition
The same structure has been adopted for every condition.
This is intended to help the reader approach differential diag-
nosis from the position of clinical decision making (see
Chapter 1). To help summarise the information, tables and
algorithms are included for many of the conditions.
Arriving at a differential diagnosis
To contextualise how commonly conditions are seen by com-
munity pharmacists, a table listing the likelihood in which
they are encountered is presented. This is designed to frame
the questions that should be asked from the point of working
from the most likely cause of symptoms. To help further, a
table summarising the key questions that should be asked
for each condition is included. The relevance (the rationale
for asking the question) is given for each question. This will
allow readers to determine which questions should be asked
to enable a differential diagnosis to be reached.
Primer for differential diagnosis
A primer for differential diagnosis is available for a number of
the conditions covered. This algorithmic approach to differen-
tial diagnosis is geared towards nearly or recently qualified
practitioners. They are not intended to be solely relied on in
making a differential diagnosis but to act as an aid to memory.
It is anticipated that the primers will be used in conjunction
with the text, thus allowing a broader understanding of the
differential diagnosis of the condition to be considered.
Trigger points indicative of referral
A summary box of trigger factors explaining when it would
be prudent to refer the patient to another healthcare practi-
tioner is presented for each condition. In most cases, a ratio-
nale for referral and time scale is presented. These trigger
factors are not absolute, and professional judgement needs
to be exercised on a case by case basis. For example, a person
with a cough of 3 days’ duration would not normally consti-
tute a referral but, if the person showed obvious visible signs
of being in respiratory distress, this would require referral.
Evidence-based OTC medication and
practical prescribing and product
selection
These two sections present the reader first, with an evalua-
tion of the current literature on whether OTC medicine works,
and second, with a quick reference to the dose of the
xvi How to use the book

1. Respiratory system
2. Ophthalmology
3. Ear conditions
4. The central nervous system
5. Women's health
6. Gastroenterology
7. Dermatology
8. Musculoskeletal conditions
9. Paediatrics
10. Specific product requests Background
General overview of eye anatomy
History taking and the eye exam
Red eye
Eyelid disorders
Dry eye
Self-assessment

Red eye
Background
Prevalence and epidemiology
Aetiology
Arriving at a differential diagnosis
Clinical features of conjunctivitis
Conditions to eliminate
Evidence base for over-the-counter
medication
Practical prescribing and product selection
Further reading and web sites

Fig. 2 Structure of the book.

medicine and when it needs to be prescribed with caution or
when it should be avoided. This does not replace standard
textbooks such as Martindale or Stockley’s Drug Interactions,
but it does allow the user to find basic data in one text with-
out having to consult three or four other texts to answer sim-
ple questions.
Side effects listed for products are drawn from the Sum-
mary of Product Characteristics, which can be found via the
electronic medicine compendium (https://www.medicines.
org.uk/emc). Only side effects listed as very common (1/
10) or common (1/100) are shown unless the product is
associated with more unlikely but serious side effects of
which the patient should be made aware.
The pregnancy and breastfeeding recommendations in
this book are based largely on those from standard texts, such
as Briggs and associates Drugs in Pregnancy and Lactation
and, Schaefer and colleagues Drugs During Pregnancy and
Lactation. Many manufacturers of OTC medicines advise
against their products being used in these groups but, where
possible, reference is made in the summary tables to the rec-
ommendations from these standard and trusted sources. This,
hopefully, will provide extra information for practitioners
when faced with queries from pregnant and lactating women,
and allow them to recommend products when manufacturer
information stipulates avoidance.
Hints and tips boxes
A summary box of useful information is provided near the
end of the discussion of each condition. This contains
information that does not fall readily into any of the other
sections but is nonetheless useful. For example, some of
the hints and tips boxes give advice on how to administer
eye drops, suppositories, and other forms of medicines.
Further reading and websites
To supplement the text, a list of selected references and further
reading at the end of each condition is provided for those who
wish to seek further information on the subject. Websites are
 How to use the book xvii

also provided, and all of these were checked, active and rele-
vant at the time of this writing (Spring 2020).
Electronic resources
Finally, all information presented in the book is accurate
Access to additional material is hosted on Elsevier’s
and factual as far as the author is aware. It is acknowledged
electronic portal. The electronic resource holds additional
that guidelines change, products become discontinued and
material that includes the following:
new information becomes available over the lifetime of a
book. Therefore, if any information in this book is not current • A chapter on evidence-based medicine
or valid, the author would be grateful of any feedback, • Videos on physical examination
positive or negative, to ensure that the next edition is as • Additional written case studies
up to date as possible. • More multiple-choice questions
This page intentionally left blank

Making a diagnosis
In this chapter
Community pharmacy performance when dealing with
patients’ signs and symptoms 1
Current pharmacy training in making a diagnosis 2
Clinical reasoning 3
Global health care policy now has a strong self-care focus,
and various strategies have been put into place to encourage
consumers to have a more active role in exercising self-care.
Pharmacies unquestionably handle and manage large
numbers of consumers who seek help and advice for minor
illness, and advocates of pharmacy have argued that this
will decrease physicians’ workloads regarding minor illness,
allowing them to concentrate more on complex
patient care.
The expansion of nonprescription medicines has contrib-
uted to the growth seen in the market and given consumers
greater choice. It has also provided community pharmacy
with an opportunity to demonstrate real and tangible bene-
fits to consumers. For example, in the UK, government-
endorsed (and funded) services such as Minor Ailment
Schemes have shown the positive impact that community
pharmacy can have on patient outcomes. However, research
data on the effectiveness of community pharmacy staff to
differentially diagnose patients is less convincing.
Community pharmacy performance
when dealing with patients’ signs
and symptoms
Regardless what degree of control is placed on medicine
availability in different countries, pharmacists can now man-
age and treat a wider number of conditions than ever before.
This raises the question as to whether pharmacists are capable
of selling these medicines appropriately. Early research of
pharmacist-consumer interactions in pharmacy practice did
Chapter 1
Summary 4
Consultation and communication skills 6
Conclusion 7
not address this but concentrated more on auditing question-
ing behaviour and analysing the advice people received
(Cantrill et al., 1997). This body of work did illustrate the fol-
lowing: the basic nature of performance; types of questions
asked; frequency of advice provided; and consumer percep-
tion to questioning. The findings were broadly critical of
pharmacist performance. Over the same time period, covert
investigation by the UK consumer organization, ‘Which’, also
concluded that pharmacists generally performed poorly.
(Consumers’ Association, 1999).
Further practice research (mainly from developed coun-
tries) has sought to determine the outcome of these interac-
tions rather than the mechanics of the interaction. Findings
from all papers raise questions over pharmacist ability to
consistently perform at expected levels. Lamsam & Kropff
(1998), found that in one-third of interactions, the pharma-
cists made recommendations without assessing the patient’s
symptoms and, in a further third of cases, recommendations
were poor, which could have potentially caused harm. Hors-
ley et al. (2004) found that the expected outcome was only
reached in half of observed cases. Driesen and Vandenplas
(2009) and Bilkhu et al. (2013) also reported poor perfor-
mance, and in each study – diarrhoea in a baby and allergic
conjunctivitis in an adult – it was suggested that too few
questions were asked. Tucker et al. (2013) compared pharma-
cist performance to doctors and nurses across a spectrum of
dermatological conditions. Pharmacists performed more
poorly than doctors, and only 40% of pharmacists were able
to identify all lesions correctly. Data from developing coun-
tries are limited but a review by Brata et al. (2013) also
highlighted inconsistent information gathering, leading to
inappropriate recommendations.
2 Making a diagnosis

Current pharmacy training in making
a diagnosis
The use of protocols, guidelines and mnemonics seem to have
been almost universally adopted by pharmacists. Many
mnemonics have been developed, as highlighted in a 2014
review (Shealy, 2014). The use of these decision aids seems
to have had little impact on improving performance, and
recent research findings have shown that community pharma-
cists overrely on using this type of questioning strategy (Akh-
tar & Rutter, 2014; Iqbal & Rutter, 2013; Rutter & Patel, 2013).
Do not use mnemonics
At best, these tools allow for standardizing information
gained from patients from and between pharmacists and
the wider pharmacy team. The more fundamental and impor-
tant point is not simply asking questions but determining
how that information is used. Having a set of data still
requires interpretation, and this inability to synthesize gath-
ered information appropriately is where research has
highlighted pharmacists’ failings.
Mnemonics are rigid, inflexible and often inappropriate.
Every patient is different, and it is unlikely that a mnemonic
can be fully applied and, more importantly, using mnemon-
ics can mean that vital information is missed, which could
shape decision making. Some of the more commonly used
mnemonics are discussed briefly in the next section.
WWHAM
This is the most common mnemonic in use and is widely
taught and used in the UK. It is the simplest to remember
but also the worst to use. It gives the pharmacist very limited
information from which to establish a differential diagnosis.
If used, it should be used with caution and is probably only
helpful as a basic information-gathering tool. WWHAM
might be appropriate to allow for counter assistants to gain
a general picture of the person’s presenting complaint but
should not be advocated as a tool to establish a diagnosis.
Other examples of mnemonics that have been suggested
as being helpful for pharmacists in a differential diagnosis
are ENCORE, ASMETHOD and SIT DOWN SIR. Although
these are more comprehensive than WWHAM, they still
are limited. None take into consideration all factors that
might affect a differential diagnosis. All fail to establish a full
history from the patient with respect to lifestyle and social
factors or the relevance of a family history. They are designed
to establish the nature and severity of the presenting com-
plaint, which in many cases will be adequate but for intermit-
tent conditions (e.g., irritable bowel syndrome, asthma, hay
fever) or conditions where a positive family history is impor-
tant (e.g., psoriasis, eczema), they might miss important
information that is helpful in establishing the correct
diagnosis.
ENCORE
Meaning of
the letter Attributes of the mnemonic
E Explore Positive points
N No medication ‘Observe’ section suggests taking into
C Care account the appearance of the
O Observe patient – does he or she look poorly?
R Refer Negative points
E Explain Sections on ‘No medication’ and
‘Refer’ add little to the differential
diagnosis process; no social or
lifestyle factors taken into account;
no family history sought

AS METHOD

Meaning of the letter Attributes of the mnemonic Attributes of

Meaning of the letter the acronym
W Who is the patient? Positive points
W What are the Establishes presenting complaint A Age, appearance Positive points
symptoms? Negative points S Self or someone else Establishes the nature of problem
H How long have the Fails to consider general M Medication and if patient has suffered
symptoms been appearance of patient. No E Extra medicines from previous similar episodes
present? social or lifestyle factors taken T Time persisting Negative points
A Action taken? into account; no family history H History Exact symptoms and severity of
M Medication being sought; not specific or in-depth O Other symptoms social or lifestyle factors not
taken? enough; no history of previous D Danger symptoms taken into account; no family
symptoms history sought
 Clinical reasoning 3

SIT DOWN SIR cause of the person’s cough and ask questions based on
this assumption (see step 4, below).
Meaning of the letter Attributes of the acronym
2. Take account of the person’s age and sex
Epidemiological studies show that age and sex will 1
S Site or location Positive points influence the likelihood of certain conditions. For example,
I Intensity or severity Establishes the severity and it is very unlikely that a child who presents with cough will
T Type or nature nature of problem and if the have chronic bronchitis, but the probability of an elderly
D Duration patient has suffered from person having chronic bronchitis is much higher. Likewise,
O Onset previous similar episodes croup is a condition seen only in children. Sex can dramat-
W With (other Negative points ically alter the probability of people suffering from certain
symptoms) Fails to consider general conditions. For instance, migraines are three times more
N Annoyed or appearance of patient; no common in women than in men, yet cluster headache is four
aggravated social or lifestyle factors times more common in men than in women. Use this to your
S Spread or radiation taken into account; no family advantage. It will allow you to internally change your
I Incidence or history sought thought processes as to which conditions are most likely
frequency pattern for that person.
R Relieved by 3. General appearance of the patient
Does the person look well or poorly? This will shape
your thinking about the severity of the problem. If a child
is running around a pharmacy, they are likely to be health-
Clinical reasoning ier than a child who sits quietly on a chair, not talking.
Taking these three points into consideration, you
Decision making processes associated with clinical practice are should be able to form some initial thoughts about the
an essential skill and are central to the practise of professional person’s health status and ideas of what may be wrong
autonomy. Clinical reasoning is the cornerstone on which a with them. At this point, questions should be asked.
diagnosis is made and relies on the practitioner being both 4. Hypothetical-deductive reasoning
knowledgeable and a good decision-maker. Clinical reasoning Based on this (limited) information, the pharmacist
is an evidence-based, dynamic process in which the health should arrive at a small number of hypotheses. The phar-
professional combines scientific knowledge, clinical experi- macist should then set about testing these hypotheses by
ence and critical thinking, with existing and newly gathered asking the patient a series of questions.
information about the patient against a backdrop of clinical
uncertainty. It is a thinking process that allows the pharmacist Ask the right question, at the right time, for the right reason
to make wise decisions specific to individual patient context.
Whether we are conscious of it or not, most people will, at The answer to each question asked allows the pharmacist
some level, use clinical reasoning to arrive at a differential to narrow down the possible diagnosis by eliminating
diagnosis. It fundamentally differs from using mnemonics particular conditions or confirming his or her suspicions
in that it is built around clinical knowledge and skills that of a particular condition. In effect, the pharmacist asks
are applied to the individual patient. It involves recognition questions with knowledge of the expected answer. For
of cues and analysis of data. example, a confirmatory type of question asked of a
patient suspected of having allergic conjunctivitis might
Steps to consider in clinical reasoning be ‘Do your eyes itch?’ In this case, the pharmacist is
expecting the patient to say ‘yes’ and thus helps support
1. Use epidemiology to shape your thoughts.
your differential diagnosis. If a patient states ‘no’, this is
What is the presenting complaint? Some conditions
an unexpected answer that casts doubt on the differen-
are much more common than others. Therefore, you can
tial diagnosis; therefore, further questions will be asked
form an idea of what condition the patient is likely to
and other diagnostic hypotheses explored. This cycle of
be suffering from based on the laws of probability. For
testing and retesting the hypotheses continues until you
example, if a person presents with a cough, you should
arrive at a differential diagnosis.
already know that the most common cause of cough is
a viral infection. Other causes of cough are possible and Good questioning following these principles means that
need to be eliminated. Your line of questioning should you will end up with the right diagnosis about 80% of
therefore be shaped by thinking that this is the default the time.
4 Making a diagnosis
5. Pattern recognition
In addition, clinical experience (pattern recognition)
also plays a part in the process. Certain conditions have very
characteristic presentations and, with experience, it is rela-
tively straightforward to diagnose the next case drawing on
previous cases seen. Therefore, much of daily practice will
consist of seeing new cases that strongly resemble previous
encounters and comparing new cases to old.
Pattern recognition is therefore much more commonly
used by experienced or expert diagnosticians compared
with novices. This is generally because there is a gap
between the expert-novice knowledge and clinical expe-
rience. Research has shown that experienced doctors tend
to only use hypothetical-deductive strategies when pre-
sented with difficult cases.
6. Physical examination
The ability to perform simple examinations (e.g., eye,
ear, mouth and skin examinations) increases the probabil-
ity of arriving at the correct diagnosis. Where appropriate
(provided that pharmacists are suitably trained), exami-
nations should be conducted. Seeing a rash or viewing
an eardrum will provide much better data on which to
base a decision than purely a patient description. Through-
out this text, where examinations are possible, instruction
is given in how to perform these examinations. Student
consult has some videos on how to perform these physical
examinations.
7. Safety netting
Even if you are confident of your differential diagnosis,
it is important to use a safety net. You are not going to get it
right all the time; making an incorrect diagnosis is inevita-
ble. It has been reported that more than 50% of patients do
not receive a definitive diagnosis at the end of a consulta-
tion with a family doctor (Heneghan et al., 2009).
Many people will present to the pharmacist at an early
stage in the evolution of their illness. This means that they
may not present with classical textbook symptoms or
have not yet developed any red flag – type symptoms
when seen by the pharmacist. For example, a child may
have a headache but no other symptoms yet later go on
to develop a stiff neck and rash and be diagnosed with
meningitis, or a person may have an acute cough that
subsequently develops into pneumonia. Using a safety
net attempts to manage these situations.
This should take one of two forms:
• Conditional referrals
This should be built into every consultation. It is more
than a mere perfunctory ‘If you don’t get better come
back to me or see the doctor’. It has to be tailored and spe-
cific to the individual and the symptoms. For example, if
a person presents with a cough of 10 days’ duration, after
how many more days would you ask them to seek further
medical help – 3 days? 5 days? 7 days? Longer?
In this case, knowledge of cough duration is impor-
tant. If the differential diagnosis is a viral cough, then
we know that this symptom typically lasts 10 to
14 days, but it is not unusual for the symptom to last
21 days. Longer than 21 days suggests that the cough
is becoming chronic and requires further investiga-
tion. A conditional referral in this case would be any-
thing between 5 and 10 days; in other words, the
person has had the cough for between 2 and 3 weeks,
which is starting to become longer than one would
expect for a viral cough. Conversely, if the cough
had been present for just 2 days, a conditional referral
after a further 2 more weeks would be appropriate.
• Advise patients on warning symptoms
It is entirely reasonable to highlight to patients
signs and symptoms that they may develop subse-
quent to your consultation. For example, a child suf-
fering with diarrhoea is managed by the pharmacist,
but the pharmacist highlights the signs of dehydration
to the child’s parents. This would be good practice
because the consequence of dehydration is clinically
more significant than the diarrhoea itself.
Summary
In practice, family doctors tend to use a mixture of
hypothetico-deductive reasoning and pattern recognition
augmented with physical examination and, where needed,
laboratory tests. It can seem to some patients that the doctor
asks very few questions, spends very little time with them,
and closes the consultation even before they have ‘warmed
the seat’. In these cases, the doctor is probably exhibiting
very good clinical reasoning. Research has shown that with
greater experience, doctors tend to rely more on nonanalyti-
cal decision making (e.g., pattern recognition), whereas nov-
ice practitioners use analytical models (hypothetico-
deductive reasoning) more frequently.
Most pharmacists will exhibit some degree of clinical rea-
soning but most likely at a subconscious level. The key to
better performance is shifting this activity from the subcon-
scious to conscious. Gaining clinical experience is funda-
mental to this process. Critical for pharmacists is the need
to learn from uncertainty. When referrals are made, every
attempt should be made to follow up with the doctor about
the outcome of the referral or encourage the patient to return
to the pharmacy to see how they got on. Knowing what
another person (usually a more experienced diagnostician)
believed what the diagnosis was allows you to build up expe-
rience and, when faced with similar presenting symptoms,
have a better idea of the cause. Without this feedback, phar-
macists reach a ‘glass ceiling’, where the outcome is always
the same – referral – which might not be necessary.

Differential diagnosis – an example
A 35-year-old female patient, Mrs JT, asks to speak to the
pharmacist about getting some painkillers for her headache.
She appears smartly dressed and in no obvious great discom-
fort but appears a little distracted.
Step 1: Use epidemiology to shape
your thoughts
In primary care, headache is a very common presenting
symptom that can have many causes. Table 1.1 highlights
the conditions associated with headache that can be seen
by community pharmacists.
From this background information, you should already
be thinking that the probability of Mrs JT’s headaches
are going to be caused by the four conditions that are
commonly seen by community pharmacists – tension-type
headache, migraine, sinusitis and eye strain. This is not to
say that it could not be caused by the other conditions,
but the likelihood that they are the cause is much lower.
Step 2: Take account of the person’s age and sex
Does age or sex have any bearing on shaping your
thoughts? The person is a woman, and we know that
migraines are more common in women compared with
men. So, although tension-type headache is the most com-
mon cause of headache, the chances of it being caused by
migraine needs to be given more prominence in your think-
ing. Will age affect your thinking? In this case, probably
not, because the common causes of headache do not really
show any real variation with age.
At this point, you should still be considering all four con-
ditions as likely, but migraine as a cause should now be
thought of more seriously along with the most common
cause of headache: tension.
Table 1.1
Conditions associated with headache that can be seen
by community pharmacists
Incidence Cause
Most likely Tension-type headache
Likely Migraine, sinusitis, eye strain
Unlikely Cluster headache, medication overuse
headache, temporal arteritis, trigeminal
neuralgia, depression
Very unlikely Glaucoma, meningitis, subarachnoid
haemorrhage, raised intracranial pressure
Summary 5
Step 3: The general appearance of the patient
Nothing obvious from her physical demeanour is construc-
tive regarding your thinking. Her ‘distracted’ state might
be as a consequence of the pain from the headache and worth
1
exploring.
Step 4: Hypothetico-deductive reasoning
Each question asked should have a purpose; again, it is about
asking the right question, at the right time and for the right
reason. In this case, we are initially considering the condi-
tions of tension-type headache, migraine, sinusitis and eye
strain (listed in that sequence in terms of likelihood). It is
important that your clinical knowledge be sufficiently sound
to know how these different conditions present so that sim-
ilarities and differences are known, allowing questions to be
constructed to eliminate one type of headache from another.
This will allow you to think of targeted questions to ask.
Table 1.2 highlights associated signs and symptoms of these
four conditions.
We can see that the location and nature of pain for the
four conditions vary, as do the severity of pain experienced
(although pain is subjective and difficult to measure
reliably).
A reasonable first question would be about the location of
pain. If the patient says, ‘It is bilateral and towards the back’,
this points towards the tension-type headache (other causes
are frontal or unilateral).
Given this information, if we asked about the nature of
pain next, and working on the hypothesis of tension-type
headache, we would be expecting a response from the patient
of an ‘aching, nonthrobbing headache’, which might worsen
as the day goes on. If patients describe symptoms similar to
our expectation, this further points to tension-type headache
as being the correct diagnosis.
To further confirm your thinking, you could ask about the
severity of pain. In tension-type headache, we are expecting
a response that does not suggest debilitating pain. Again, if
we found that the pain was bothersome but not severe, this
would point to tension-type headache.
At this point, we might want to ask other questions that
rule out other likely causes. We know that migraine is asso-
ciated with a positive family history. We would expect the
patient to say there was no family history if our working dif-
ferential diagnosis is tension-type headache. Likewise, ask-
ing about previous episodes of the same type of headache
would help rule out migraine due to its episodic and recurrent
nature. Similarly, eye strain is closely associated with close
visual work. If the person has not been doing this activity
more than normal, it tends to rule out eye strain. Finally,
sinusitis is a consequence of upper respiratory tract infection
so, if the person has not had a recent history of colds, this will
rule out sinusitis.
6 Making a diagnosis

Table 1.2
Associated signs and symptoms
Type of Duration Timing and nature Location Severity Precipitating Who is
headache (pain factors affected?
score,
0–10)
Tension- Can last Symptoms worsen as day Bilateral; 2–5 Stress due to All age
type days progresses; nonthrobbing pain Most changes in groups;
often at work or home both sexes
back of environment equally
head affected
Migraine Average Associated with Usually 4–7 Food (in 10% of Three times
attack menstrual cycle and weekends; unilateral sufferers); more
lasts throbbing pain and nausea; family history common
24 hours dislike of bright lights and in women
loud noises
Sinusitis Days Dull ache that begins as unilateral Frontal 2–6 Valsalva Adults
movements
Eye strain Days Aching Frontal 2–5 Close vision work All ages

Therefore, we are expecting certain responses to these
questions if the symptoms are a consequence of suffering
from a tension-type headache. If the patient answers in a neg-
ative way, this would start to cast doubt on your differential
diagnosis. If this happens, you need to revisit your hypothesis
and test another one – that is, think that the symptoms are
caused by something else, and recycle your thought processes
to test a hypothesis of a different cause of headache.
Consultation and communication skills
The ability of the community pharmacist to diagnose the
patient’s presenting signs and symptoms is a significant
challenge given that unlike most other healthcare profes-
sionals, community pharmacists do not normally have access
to the patient’s medical record and thus have no idea about
the person’s problem until a conversation is initiated.
For the most part, pharmacists will be totally dependent
on their ability to question patients to arrive at a differential
diagnosis. It is therefore vital that pharmacists possess excel-
lent consultation and communication skills as a prerequisite
to determining a differential diagnosis. This will be drawn
from a combination of good questioning technique, listening
actively to the patient and picking up on nonverbal cues.
Many models of medical consultation and communica-
tion have been developed. Probably the most familiar and
most widely used model is the Calgary-Cambridge model of
consultation. This model is widely taught in pharmacy and
medical education and provides an excellent platform in
which to structure a consultation. The model is structured
into the following:
1. Initiating the session
• Establishing initial rapport
• Identifying the reason(s) for the consultation
2. Gathering information
• Exploration of problems
• Understanding the patient’s perspective
• Providing structure to the consultation
3. Building the relationship
• Developing rapport
• Involving the patient
4. Explanation and planning
• Providing the correct amount and type of information
• Aiding accurate recall and understanding
• Achieving a shared understanding: Incorporating the
patient’s perspective
• Planning: Shared decision making
• Closing the session
For more detailed information on this model, there are
numerous Internet references available, and the authors of
the model have written a book on communication skills
(Silverman et al., 2013).

Conclusion
The way in which one goes about establishing what is wrong
with the patient will vary from practitioner to practitioner.
However, it is important that whatever method is adopted,
it must be sufficiently robust to be of benefit to the patient.
Using a clinical reasoning approach to differential diagnosis
has been shown to be effective in differential diagnosis and is
the method advocated throughout this book.
References
Akhtar, S., & Rutter, P. (2015). Pharmacists thought processes in
making a differential diagnosis using a gastro-intestinal case
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472–479. https://doi.org/10.1016/j.sapharm.2014.09.003.
Bilkhu. P., Wolffsohn, J. S., Taylor, D., et al. (2013). The
management of ocular allergy in community pharmacies in
the United Kingdom. International Journal of Clinical
Pharmacy, 35, 190–194.
Brata, C., Gudka, S., Schneider, C. R., et al. (2013). A review of
the information-gathering process for the provision
of medicines for self-medication via community
pharmacies in developing countries. Research in Social and
Administrative Pharmacy, 9, 370–383.
Cantrill, J. A., Weiss, M. C., Kishida, M., et al. (1997). Pharmacists’
perception and experiences of pharmacy protocols: A step in
the right direction? International Journal of Clinical
Pharmacy, 5, 26–32.
Consumers’ Association. (1999). Counter advice. Which Way to
Health? 3, 22–25.
Driesen, A., & Vandenplas, Y. (2009). How do pharmacists
manage acute diarrhoea in an 8-month-old baby? A
simulated client study. International Journal of Clinical
Pharmacy, 17, 215–220.
Horsley, E., Rutter, P., & Brown, D. (2004). Evaluation of community
pharmacists’ recommendations to standardized patient
scenarios. The Annals of Pharmacotherapy, 38, 1080–1085.
Iqbal, N., & Rutter, P. (2013). Community pharmacists reasoning
when making a diagnosis: A think-aloud study. International
Journal of Pharmacy and Practice, 21, 17–18.
Lamsam, G. D., & Kropff, M. A. (1998). Community pharmacists’
assessments and recommendations for treatment in four case
scenarios. The Annals of Pharmacotherapy, 32, 409–416.
Rutter, P., & Patel, J. (2013). Decision making by community
pharmacists when making an over-the-counter diagnosis in
Conclusion 7
response to a dermatological presentation. Self Care,
4,125–133.
Shealy, K. M. (2014). Mnemonics to assess patients for self-care:
Is there a need? Self Care, 5,11–18.
1
Silverman, J., Kurtz, S., & Draper, J. (2013). 3rd ed. Boca Raton, FL:
CRC Press.
Tucker, R., Patel, M., Layton, A. M., et al. (2013). An examination
of the comparative ability of primary care health
professionals in the recognition and treatment of a range of
dermatological conditions. Self Care, 4, 87–97.
Which? Can you trust your local pharmacy’s advice? http://www.
which.co.uk/news/2013/05/can-you-trust-your-local-
pharmacys-advice-319886. Accessed 17th March 2020
Further reading
Aradottir, H. A. E., & Kinnear, M. (2008). Design of an algorithm to
support community pharmacy dyspepsia management.
Pharmacy World and Science, 30, 515–525.
Bertsche, T., Nachbar, M., Fiederling, J. (2012). Assessment of a
computerised decision support system for allergic rhino
conjunctivitis counselling in German pharmacy. International
Journal of Clinical Pharmacy, 34, 17–22.
Heneghan, C., Glasziou, P., Thompson, M., et al. (2009).
Diagnostic strategies used in primary care. BMJ, 338, b946.
Rutter P. (2015). Role of community pharmacists in patients’ self-
care and self-medication. Integrated Pharmacy Research and
Practice, 4, 57–65
Schneider, C., Gudka, S., Fleischer, L., et al. (2013). The use of
a written assessment checklist for the provision of
emergency contraception via community
pharmacies: A simulated patient study. Pharmacy Practice,
11, 127–131.
Schneider, C., Emery, L., Brostek, R., et al. (2013). Evaluation
of the supply of antifungal medication for the
treatment of vaginal thrush in the community pharmacy
setting: A randomized controlled trial. Pharmacy Practice, 11,
132–137.
Watson, M. C., Bond, C. M., Grimshaw, J. M., et al. (2006). Factors
predicting the guideline compliant supply (or non-supply) of
non-prescription medicines in the community pharmacy.
Quality and Safety in Health Care, 15, 53–57.
Lighter reading
Helman, C. (2006). Suburban Shaman – tales from medicine’s
frontline. London: Hammersmith Press.
This page intentionally left blank

Respiratory system
In this chapter
Background 9
General overview of the anatomy of the
respiratory tract 9
History taking and physical examination 10
Cough 10
Background
Diseases of the respiratory tract are among the most common
reasons for consulting a general practitioner (GP). The aver-
age GP sees approximately 700 to 1000 patients each year
with respiratory disease. Although respiratory disease can
cause significant morbidity and mortality, the vast majority
of conditions are minor and self-limiting.
General overview of the anatomy of
the respiratory tract
The basic requirement for all living cells to function and sur-
vive is a continuous supply of oxygen. However, a byproduct
of cell activity is carbon dioxide, which, if not removed, poi-
sons and kills the cells of the body. The principal function of
the respiratory system is therefore the exchange of carbon
dioxide and oxygen between blood and atmospheric air. This
exchange takes place in the lungs, where pulmonary capil-
laries are in direct contact with the linings of the lung’s ter-
minal air spaces, the alveoli. All other structures associated
with the respiratory tract serve to facilitate this gaseous
exchange.
The respiratory system is divided arbitrarily into the upper
and lower respiratory tracts. In addition to these structures,
the respiratory system also includes the oral cavity, rib cage
and diaphragm.
Chapter 2
The common cold 20
Sore throats 28
Rhinitis 34
Self-assessment questions 44
Upper respiratory tract
The upper respiratory tract comprises those structures located
outside the thorax – the nasal cavity, pharynx and larynx.
Nasal cavity
The internal portion of the nose is known as the nasal cavity
and lies over the roof of the mouth. It is a hollow structure but
is separated by a midline partition known as the septum. The
septum has a rich blood supply, which means that direct
blows to the nose result in nosebleed. The cavity is divided
into a larger respiratory region and a smaller olfactory
region. The nasal cavity is connected to the pharynx through
two openings called the internal nares. The respiratory region
is lined with cilia and plays an important part in respiration
because it filters out large dust particles. The inhaled air cir-
culates, allowing it to be warmed by close contact with blood
from the capillaries. Mucus secreted from goblet cells also
helps moisten the air.
Pharynx
The pharynx is a tubelike structure approximately 12 cm
long that serves as a common pathway for the respiratory
and digestive tracts. It has three anatomical divisions – the
nasopharynx, oropharynx and laryngopharynx. It is lined
with a ciliated mucous membrane that helps with the
removal of dust particles as to does the larynx. It also affects
speech production by changing shape to allow vowel sounds
to be formed.
10 Respiratory system
Larynx (voice box)
The triangular shaped larynx is a short passageway that
connects the pharynx with the trachea that lies in the mid-
line of the neck. It protects the airway against the entrance
of liquids and foods during swallowing via the glottis and
epiglottis, which act like trap doors to ensure that liquids
and food are routed into the oesophagus and not the
trachea.
Lower respiratory tract
The lower respiratory tract is located almost entirely within
the thorax. It is comprised of the trachea, bronchial tree
and lungs.
Trachea (windpipe) and bronchi
The trachea is an 11-cm-long tube that lies in front of the
oesophagus and extends from the larynx to the fifth thoracic
vertebra, where it divides into the right and left primary
bronchi. The bronchi divide and subdivide into bronchioles
and resemble an inverted tree trunk, giving rise to the term
bronchial tree. Eventually, these divisions form terminal
bronchioles, giving rise to alveolar ducts and sacs, the walls
of which consist of alveoli where gaseous exchanges take
place. The epithelial lining of the bronchial tree acts as a
defence mechanism known as the mucociliary escalator. Cilia
on the surface of cells beat upwards in organized waves of
contraction, thus expelling foreign bodies.
Lungs
The lungs are paired, cone-shaped organs divided in to lobes;
the left lung has two lobes and the right lung three lobes, which
occupy the thoracic cavity. The thoracic cavity plays an impor-
tant part in respiration because it becomes larger when the
chest is raised and smaller when it is lowered, affecting inspi-
ration and expiration. Enclosing the lungs are the pleural
membranes; the inner membrane covers the lungs, and the
outer membrane is attached to the thoracic cavity. Between
the membranes is the pleural cavity, which contains fluid
and prevents friction between the membranes during breath-
ing. If the pleura is inflamed, respiration becomes painful.
History taking and physical
examination
Cough, cold, sore throat and rhinitis often coexist, and an
accurate history is therefore essential to differentially diag-
nose a patient who presents with symptoms of respiratory
disease. A number of similar questions must be asked for
each symptom, although symptom-specific questions are
also needed (and are discussed under each heading that
follow). Currently, examination of the respiratory tract is
outside the remit of the community pharmacist unless they
have additional qualifications (e.g., independent prescriber
status). An examination involving palpation, percussion
and auscultation may support a differential diagnosis after
history taking.
Cough
Background
Coughing is the body’s defence mechanism in an attempt to
clear the airways of foreign bodies and particulate matter.
This is supplemented by the mucociliary escalator – the
upward beating of the finger-like cilia in the bronchi that
move mucus and entrapped foreign bodies to be expectorated
or swallowed. Cough is the most common respiratory symp-
tom and one of the few ways whereby abnormalities of the
respiratory tract manifest themselves. Cough can be very
debilitating to the patient’s well-being and can also be dis-
ruptive to family, friends and work colleagues.
Coughs can be described as productive (chesty) or nonpro-
ductive (dry, tight, tickly). However, many patients will say that
they are not producing sputum, although they may go on to say
that they ‘can feel it on their chest’. In these cases, the cough is
probably productive in nature and should be treated as such.
The British Thoracic Society Guidelines (2019) state that
cough is usually self-limiting and will resolve in 3 or 4 weeks
without the need for antibiotics. Coughs are classified as
acute or chronic in nature, and guidance from current Clin-
ical Knowledge Summaries define cough as follows:
• Acute when present for less than 3 weeks
• Subacute when present for 3 to 8 weeks
• Chronic when present for more than 8 weeks
Although these times are only considered indicative,
patients who present with cough, other than acute cough
(not being systemically unwell), are usually best referred to
a medical practitioner for further investigation.
Prevalence and epidemiology
Statistics from UK general medical practice show that respira-
tory illness accounts for more patient visits than any other
disease category. Acute cough is usually caused by a viral
upper respiratory tract infection (URTI) and constitutes 20%
of consultations. This translates to 12 million GP visits per
year and represents the largest single cause of primary care
consultation. These data are echoed elsewhere; for example,
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anti-Jewish feeling which found vent in the violent persecution of the
Jews during the years immediately preceding the conquest of the
peninsula. If so, the Spaniards by their treatment of the Jews created
the situation which they feared. The Mohammedan invasion was
prepared by the intrigues of the Jews of Spain with their co-
religionists in Africa, who exposed to the Saracens the weaknesses
of the Visigothic kingdoms. Tarik, the Mohammedan conqueror, in his
triumphant career through the peninsula, after the
711
battle of Xeres, where Roderic the last of the Visigothic
kings had fallen, was everywhere supported by the Jews. Cordova,
Granada, Malaga, and other cities were entrusted to the safe-
keeping of the Jews, and Toledo was betrayed to the invader by the
Jews, who, while the Christian inhabitants were assembled in church
praying for divine help, threw the gates open to the
712
enemy, acclaiming him as a saviour and an avenger.
Persecution had again awakened the desire for redemption,
which had never been allowed to remain dormant long.
About 720
The new Messiah appeared in the person of a Syrian
Jewish Reformer, named Serene. It so happened that the Jews of
Syria were at that time suffering almost as cruelly at the hands of the
fanatical Caliph Omar II. as at those of the Christian Emperor Leo.
When, therefore, the Messiah arose, promising to
717–720
restore them to independence and to exterminate their
enemies, many Eastern Jews lent an attentive ear to his gospel. The
Redeemer’s fame reached Spain, and the Jews of that country also,
still smarting under the sufferings of centuries and probably
disappointed in the extravagant hopes which they had built upon the
Arab conquest, hastened to enlist under his banner. But Serene’s
career was cut short by Omar II.’s successor. The Commander of the
Faithful seized the Messiah and subjected him to a severe cross-
examination. Whether it was due to the subtlety of the theological
riddles propounded to him by the Caliph, or to some more tangible
test of constancy, the Prophet’s courage failed him. It was even said,
by those who had refused to follow the Messiah, or who having
followed were disillusioned, that Serene declared his mission to be
only a practical pleasantry at the expense of his credulous co-
religionists. Be that as it may, poor Serene was delivered up to the
tender mercies of the Synagogue, and his disgrace dissipated the
Messianic dream for the time.
But in less than a generation another Reformer of the Messianic
type appeared in the Persian town of Ispahan to rekindle the
enthusiasm and try the faith of his people. This was Obaiah Abu Isa
ben Ishak. He, somewhat more modest than his predecessor,
claimed to be only one—though the last and most perfect—of a line
of five forerunners who were to prepare the way for the coming
Redeemer. He also held out the promise to free the children of Israel
from thraldom. Nor did he preach to deaf ears. One of the most
striking inconsistencies in the Jewish character is the combination
which it presents of unlimited shrewdness and suspiciousness with
an almost equal capacity for being duped. The people who in every
age have been hated as past masters of deceit, have themselves
often been the greatest victims of imposture. Religious belief is so
strong in them that, especially in times of suffering, nothing seems
improbable that agrees with their predisposition. Libenter homines id
quod volunt credunt. Ten thousand Jews rallied round Obaiah’s
standard. The war for independence began at Ispahan and for a
while seemed to promise success. But the Prophet fell in battle, and,
though his memory was kept green by his followers, who endured till
the tenth century, none proved able to carry on the work of
deliverance.
 CHAPTER VI

MIDDLE AGES

“Jews massacred in France,” “Jews massacred in Germany,” “Jews

massacred in England,” “Jews massacred in Germany and France,”
“Jews massacred in Spain,” again and again and again. These
headings, not to mention expulsions, oppressions and spoliations
without number, stare us in the face as we turn over the pages of the
history of Mediaeval Europe, and the cold lines assume a terrible
significance as we peruse tale after tale of bodily and mental
torment, such as no other people ever suffered and survived. And as
we read on, and try to realise the awful scenes, the desolate cry of
the sufferers rings in our ears, like a long-drawn wail borne across
the centuries: “How long, O Lord, how long?”
It would, of course, be an absurd exaggeration to assert that the
life of Israel through the Middle Ages was an unbroken horror of
carnage and rapine. There were spells of respite, some of them fairly
long, during which the Jew was permitted to live and grow fat. But
these Sabbaths of rest can be likened not inaptly to the periods
during which a prudent husbandman suffers his land to lie fallow, in
the hope of a richer harvest. They are only intervals between the
acts of a tedious and bloody tragedy, with a continent for its stage
and seven centuries for its night. But, though covering so vast an
extent in space and time, the drama is not devoid of unity: the unity
of plot. The motives and the characters are ever the same, each
scene ends in strict accord with the foregoing, and the performance
is a masterpiece of mournful monotony. Nor is it easy to bestow the
crown of excellence on any European nation of actors without being
unjust to their colleagues.
 The drama naturally divides itself into two periods: the period of
spontaneous but unsystematic hostility, and the period of deliberate
and organised persecution.
While the Church was engaged in disseminating the gospel
abroad, in rooting out heresy at home and in establishing her own
authority, she had little time to devote to the persecution of the Jews;
and the only canon law against them was the prohibition to dwell
under the same roof with Christians and to employ Christian
servants—a law which, in the absence of rigorous supervision, often
remained a dead letter, and much oftener was observed, simply
because neither side felt any violent desire to break it. The Jews
consequently throve amazingly, their synagogues grew in number
and splendour, and their antipathy to outside influences, though
continuing to be as implacable as ever, found its chief expression in
social isolation tempered by commercial exploitation.
In every country and in every city in Europe they remained
sharply separated from their Christian neighbours, shunning
intermarriage with them, and forming a perfectly distinct body of
people, with the synagogue for its centre and its soul. The
synagogue elected its own officers in accordance with the traditions
of the Temple and the instructions of the Talmud, passing communal
ordinances which, as in ancient times, regulated the whole of Jewish
life: enforcing monogamy, prohibiting shaving, fixing the tax on meat,
restraining gambling, forbidding the promiscuous dancing of Jews
and Jewesses, dictating marriage settlements and divorce, defining
the dress and diet of men and women. The State frequently levied
the taxes on the Jewish community in a lump sum, leaving the
assessment among individual members and the collection to the
41
officers of the synagogue. Justice also was administered by the
Beth Din, or Jewish religious tribunal. Thus, despite much external
interference, the Jewries constituted self-governing colonies—
strange oases in mediaeval society. Their members were neither
villeins nor freeholders; neither men-at-arms nor mechanics.
Feudalism concerned them as little as Catholicism. They took no
more part in the martial exercises than in the spiritual devotions of
their neighbours. They belonged neither to the knightly orders nor to
the commercial and industrial corporations; but they lived a life of
their own, in closer communion of interests and tastes with their
brethren in Cairo or Babylon than with their fellow-townsmen. In the
ninth century, for instance, Babylon was to the Jews of Western
Europe what Rome was to the Catholics—the oracle of Divine
knowledge—and Rabbinical decisions issued therefrom were
obeyed as implicitly as Papal Bulls. The Mediaeval Jews were as
indifferent to the beauties of Chivalry as to its duties. The notes of
the minstrel fell dead upon their ears, and the sterile subtleties of
Talmudical exegesis thrilled them more than the amours of romance.
Latin, the language of Western Christendom, was abhorred by the
descendants of those whom the Roman destroyer of the Temple had
driven into exile, and the study of the Torah was the one form of
literature to which all Jews, old and young, rich and poor, devoted
themselves with a single-minded earnestness worthy of the ancient
Pharisees and Scribes. Even in their mutual greetings they retained
the oriental formula “Peace be to thee,” “To thee a goodly blessing.”
This ominous isolation was to the Jews a source of pride, with
which no bribe could induce them to part. The thought of making
themselves one with the uncircumcised was as repugnant to them as
it had been to their ancestors on entering Canaan. Their poetical
literature, which through the Jewish hymn-book supplied a bond of
sympathy between all the scattered sections of Mediaeval Jewry, is a
lasting monument of their sorrows and of their self-glorification; of
their faith in the promises of the past and of their firm trust in the
future. All these sentiments may be regarded as embodied in that
love for an idealised and idolised Zion which brightened many a
gloomy hour, and which was for the Jews what political ambitions
and aspirations were for their Christian neighbours. They looked
upon themselves but as sojourners in the land, and upon their
residence among the Gentiles as an evil dream from which the Lord
in His time would awaken them, and lead His people back to the land
of their fathers. Israel still was the slave of the Idea, and its victim.
This social isolation was symbolised and perpetuated by local
segregation. The Jews everywhere dwelt together in special
quarters, distinguished even amid the gloom and squalor of a
mediaeval town by a darkness and dirtiness which contrasted
curiously with the occasional magnificence of the interior of the
houses and with the personal cleanliness of the inmates. In these
quarters they resided, many families in one house, eating meat killed
and cooked in a special manner, frequently fasting when their
neighbours feasted, and feasting when they fasted; or, worse still,
sometimes, by a fatal coincidence, celebrating their Deliverance
while the Christians mourned the sufferings of their Saviour; as a
rule, resting on the day on which the others worked, and working on
the day on which they rested. They attended no mass, partook of no
sacrament, showed no reverence for the crucifix and the saints; but
they lived unbaptized, unblest and circumcised, worshipping their
own God after their own fashion and in their own tongue, indulging in
mysterious ablutions, observing the new moons and a thousand
quaint rules of conduct, abstaining from touching fire from Friday
evening till Saturday night, from eating pork, from drinking wine and
milk, or from using vessels, touched by a Gentile. Their religious
symbolism was alien to that of their neighbours; their allegorical
wedding customs, their rejoicings and their wailings equally weird;
their music as wonderful as their symbolism; the nasal sing-song
strains that floated out of the windows of the synagogue of a
morning, or those that filled the night air with their strangeness, as a
funeral procession hurried through the street, sounded horribly
harsh, unmelodious, and unmeaning to non-Hebrew ears. Their very
children were unlike the children of the Gentile; precocious in
worship as in work, they knew nothing of the sprightly brownies,
elves, and fairies of European folk-lore, but believed in the solemn
and sober spirits of Asiatic mythology. Altogether they must have
seemed a singular and sinister people, with usury for their favourite
pursuit, and prayer for their main recreation.
Thus they lived, and when they died they were buried in special
cemeteries, emphasising the amiable principle that there could be no
union or intercommunion between Jew and Gentile even in death.
Is it to be wondered at that the Jews everywhere were looked
upon with aversion and suspicion? The chastity of Jewish life, the
gracious charm of the Sabbath, the serene beauty of the Jewish
home were unknown, for Jewish homes in the Middle Ages rarely
received a non-Jewish guest. If an inquisitive Catholic strayed into a
synagogue on a Sabbath morning, what he saw therein would tend
to strengthen his antipathy. He would find a congregation of men
with their heads covered, gathered together in a place which had
none of the attributes of a church: no images, no font, no altar, no
holy-water stoup; a club-room rather than a House of the Lord. He
would see some of these men absorbed in learned study, and others
in lively gossip; some chanting, and others chattering aloud; many
dropping in casually at odd times; all heedless of the precentor,
whose trilling airs soared aloft in triumphant discord, amid the
pandemonium of tongues, now melting into melodramatic tears or
hysterical laughter, now drowned by the shrill blast of the ram’s horn.
How could the ignorant Gentile know that these listless or
belated worshippers had already prayed abundantly at home, and,
like people who go to a public banquet after having enjoyed a good
dinner in private, had no appetite for further devotion? To him the
whole scene, with the din of children crying and running about, and
the free and easy nonchalance of the men, must have appeared an
orgy of indecorous levity. Worse still, he might have surprised this
congregation discussing lawsuits, or prices of goods; for the
synagogue was much more than a prayer-house to the Jew, and in it
were made proclamations and bargains such as the mediaeval
citizen was accustomed to see made in the market-place. Everything
that the visitor witnessed would impress him as uncouth, unchristian,
and uncanny; and he would go away amazed and scandalised, if not
disgusted.
And yet, such is the apparent inconsistency of human nature, it
was to this despised and detested assembly that the Christians of
the lower orders, when ill, often had recourse for medical assistance.
As in the old days at Rome, so in mediaeval Europe the Hebrew rites
commanded the veneration of the Gentiles. The mystery of the
unknown fascinated them. Many people, who ordinarily shunned the
Jewish community, in time of trouble repaired to the synagogue, took
part in its processions and ceremonies, and made votive offerings,
that ailing friends might recover, that seafaring relatives might reach
harbour in safety, that women in child-bed might be happily
delivered, and that the barren might rejoice in offspring. The real
proficiency of the Jews in medicine encouraged the popular
superstition; for medicine and magic were as closely associated in
the mediaeval mind as they still are in the minds of the less
advanced races. Jewish women were dreaded as sorceresses, and
the Rabbis were believed to be on terms of intimacy with the powers
of darkness. It was held that

“Unregarded herbs, and flowers, and blossoms

Display undreamt of powers when gathered by them.”

And Christian knights applied to them for scraps of parchment

covered with Hebrew texts as protective charms for their persons
and castles.
Even so at the present day the Christians of the East resort to
Mohammedan friars for charms and amulets of all kinds, and
Mohammedans make offerings to Christian saints. Creeds may be
mutually exclusive; there is free trade in popular religion. This
liberalism, however, is not incompatible with a deep and abiding
abhorrence. It is not the deities but the demons of the rival race that
the ignorant strive to propitiate. The act is the outcome of fear, and
the help received implies no gratitude. Consequently, the mediaeval
Jews and Gentiles, like modern Christians and Turks, despite
superstitious sympathy, contiguity of centuries, occasional
intercourse for festive purposes, and interchange of gifts, cherished
no fellow-feeling for each other. Even genuine personal friendship
could do little to counteract national and religious antipathy. The
Jews were still aliens and infidels, therefore enemies, and they
frequently fell victims to insult and assault, and sometimes to
massacre, at the hands of the populace. Hostility found an
appropriate occasion for self-manifestation on the great festivals of
the Church, and more especially at Easter. At those times the sight
of a Jew reminded the Christians of the Old Crime, and the
maltreatment of him suggested itself as a natural deed of piety. The
sentiment was holy; the practical expression of it partly childish,
partly fiendish.
At Toulouse, for example, it was the traditional custom to slap a
Jew on the face every Good Friday. The Count opened the
ceremony by publicly giving the president of the Jewish community a
box on the ear, and his subjects followed suit, until the blow was
commuted for a tribute in the twelfth century. At Beziers pious
wantonness took the form of an attack on the Jews’ houses with
stones from Palm Sunday till Easter. The use of other weapons was
contrary to the rules of the game; but none other were needed. A
sermon from the Bishop was the regular preamble to the
commencement of hostilities, and this Christian pastime continued in
public favour year after year until a prelate, less cruel or more
practical than his predecessors, abolished it for a consideration. In
May 1160 a treaty was concluded providing that any priest who
should stir up the people against the Jews should be
excommunicated, while the Jews, on their side, pledged themselves
to pay four pounds of silver every Palm Sunday. Elsewhere, an old
pagan rite for the propitiation of the powers of vegetation was
cloaked in the devotional cremation of a straw “Judas” during Holy
Week; a custom still surviving in many parts of Europe. But racial
and religious animosity, especially when fuelled by material
grievances, knows no seasons. In Germany Jew-baiting was a
perennial amusement of gentlemen impoverished by usury, and the
Judenstrasse, or Jews’ street, a not unusual field of ignoble
distinction.
However, during the earlier Middle Ages, the Jews, though
exposed to popular hatred, were generally shielded from popular
outrage by the princes, spiritual and temporal, who countenanced
their usury, sharing the profits, and availed themselves, not without
strict precautions, of their medical skill and administrative ability. We
find them as land-owners, physicians and civil officials in Provence
and Languedoc. At Montpellier, under the wing of the Count of
Toulouse, there flourished a Jewish academy where medicine and
Rabbinical literature were cultivated successfully—an institution
which helped much to create and promote a medical profession
throughout Southern Europe, while the great School of Salerno also
owed much to Jewish talent. In a word, medical studies in the Middle
Ages were deeply indebted to the Hebrew doctors. They were the
first to discard the ancient belief in the demoniacal origin of disease
and to substitute physic for exorcisms. Their adoption of rational
methods in the treatment of patients helped to revolutionise the
theory and practice of medicine, to emancipate the European mind
from superstition, and to earn for them the cordial detestation of the
monks and priests, whose relics and prayers were discredited and
whose incomes decreased in proportion to the Jewish practitioners’
success. Thus the animosity of the lower clergy against the
mediaeval Jew may, in part, be traced to professional rivalry.
In Spain the Jews had always been most numerous and
prosperous. Under the Saracen conquerors, with few exceptions,—
as, for instance, the persecution by Ibn Tumart,—they enjoyed a
peace such as they had seldom experienced under Christian rule.
The liberty usually accorded to them enabled the Spanish Jews to
attain distinction in other fields of activity besides money-lending.
They were farmers, land-owners and slave-dealers. The last kind of
trade was particularly encouraged by the Caliphs of Andalusia who
formed their bodyguards of picked Slavonian slaves. They also were
physicians, financiers, civil administrators, and they vied with their
Mohammedan masters in learning as well as in material splendour
and love of display. The influence of Moorish culture on the spiritual
and intellectual development of the Spanish Jews has been very
ably outlined by a modern Jewish writer in the following words:
—“The milder rule of the Moslem gave the Jew a needed pause in
the struggle for existence, and the similarity of the Semitic genius in
both prevented the perceptible tendency to narrowness, and brought
the Jewish mind again into free contact with the world’s thought....
The first aim of the Caliphs, after the victory of Islam was assured,
was to resuscitate Greek science and philosophy. Translators were
employed to bring forth from their Syriac tombs Aristotle and Galen.
42
And the Jews at once took part in this Semitic renaissance.” The
writer might have added that it was mainly through the
instrumentality of the Jews that this Arabic resuscitation of Hellenic
philosophy and science was transmitted from Islam to Christendom.
Learned Jews, familiar with both languages, rendered the Arabic
translations of Aristotle into Latin, thus bringing them within reach of
the Schoolmen, who valued these versions highly, not only for their
fidelity to the original but also for the explanatory comments which
accompanied the text. In fact, the first acquaintance of mediaeval
Europe with any of the Aristotelian writings, other than the Organon,
43
was due to the Arabs and Jews of Spain. Thus these two Semitic
races, by a dispensation of fate the irony of which was not to
become apparent until our own day, were the first to stimulate in
Western students a thirst for Hellenic literature and to supply them
with the means of gratifying it.
The first school founded by the Jews in Spain was that of
Cordova (948), followed by those of Toledo, Barcelona and Granada.
All these institutions were thronged with eager students and formed
centres of light, the rays whereof shone all the brighter amid the
gloom of the Dark Ages. Not only Talmudic, Biblical, and Cabbalistic
lore were there cultivated, but secular philosophy was diligently
studied; and Aristotle was revered as a disciple of Solomon! Poetry,
music, mathematics, astronomy, metaphysics and medicine were
also included in the curriculum, and the Spanish Jews, as the result
of this encyclopaedic training, were men of the broadest and most
varied culture; the same individual often combining in his own person
the subtleties of the Rabbinical scholar with the elegant taste of a
poet; the sagacity of a financier with the practical skill of a physician.
915–970 All these talents are found embodied in Abu-Yussuf
Chasdai of Cordova, a European in every respect
except religion and name. From his father Chasdai inherited great
wealth and liberal views on its uses. He studied the science of
medicine, but he shone especially as a patron and man of letters,
and as a diplomatist. Hebrew, Arabic, and Latin were almost equally
familiar to him. He rendered brilliant political services to Caliph
Abdul-Rahman III. in his relations with the Christian sovereigns of
Northern Spain and other European potentates, and he was
rewarded by his master with a post which in reality, though not in
name, represented the powers of a Minister of Foreign Affairs, of
Trade, and of Finance, all in one—an elevation which enabled
Chasdai “to take the oppressor’s yoke from his people,” and “to
break the scourge that wounded it.” Fate decreed that envoys from
the Byzantine persecutors of the Jews should come to Cordova to
solicit the aid of the Western against the Eastern Caliphs, and they
were received by the Jewish Minister.
Under the paternal, if at times despotic, rule of the Caliphs the
Hebrew character cast away some of its sternness and austerity—a
change which is pleasantly reflected in the literature of the period.
The Hebrew Muse ceased to weep and wail over old misfortunes,
and the lays of the Hispano-Jewish minstrels laugh with the sunshine
or sigh with the lyric tenderness of their new country. These traits are
brilliantly illustrated by the work of the Castilian poet Jehuda Halevi,
born in 1086, and thus described by an enthusiastic co-religionist:

“Pure and true, without blemish,

Were both his song and his soul.
When the Creator had formed this soul,
Pleased with Himself at His work,
He kissed the beautiful creation,
And the glorious echo of his holy kiss
Trembles yet in every song of the poet,
Sanctified through this Divine grace.”

There is nothing mournful in Halevi’s poetry. In his early youth he

sang of wine and of the gazelle-like eyes of his beloved, of her rosy
lips, of her raven hair, and of her unfaithfulness. In his manhood he
studied the Talmud, natural science, and metaphysics. He also, like
many other Jewish writers, practised medicine; not with conspicuous
success, as he naïvely confesses in a letter to a friend: “I occupy
myself in the hours which belong neither to the day nor to the night
with the vanity of medical science, although I am unable to heal.”
Halevi’s heart remained wholly devoted to poetry, and his
masterpiece is the Songs of Zion, wherein he pours forth all that
deep veneration for the past and that ardent belief in the future glory
of Israel, which have inspired Jewish genius through the ages.
Jehuda voices the national sentiment in the following touching lines:

“O City of the world, beauteous in proud splendour,

From the far West, behold me solicitous on thy behalf!
Oh that I had eagle’s wings, that I might fly to thee,
Till I wet thy dust with my flowing tears!
My heart is in the East,
Whilst I tarry in the West.
How may I be joyous,
Or where find my pleasure?
How fulfil my vow,
O Zion! when I am in the power of Edom,
And bend beneath Arabia’s yoke?
Truly Spain’s welfare concerns me not;
Let me but behold thy precious dust,
And gaze upon the spot where once the Temple stood.”

Nor was the longing a mere matter of sentiment. Jehuda was

earnestly convinced that Israel could not have a national existence
outside the Holy Land. He urged his people to quit the fields of Edom
and to seek its native home in Zion. But the cry aroused no echo.
The Jews of Spain, allowed to enjoy the comforts and luxuries of
existence, felt no desire to exchange the real for a wild chase after
the ideal. The poet, however, proved his own sincerity by
undertaking a weary pilgrimage to Jerusalem. Leaving his peaceful
home, his only daughter, his friends, his pupils, and his studies, he
set out on his adventurous journey, accompanied by the good
wishes and praises of numerous admirers through Spain. The long
and stormy voyage and the hardships thereof did not quench the
poet’s enthusiasm for the Holy Land:

“The sea rages, my soul rejoices;

It draws near the Temple of its God!”
 At Alexandria, Halevi was met by a crowd of Jews to whom his
name was known and dear. They entertained him sumptuously, but
could not prevail upon him to relinquish his aim. Once more Halevi
resisted the seductions of safety and comfort and set out for
Jerusalem, which he found in the possession of unsympathetic
Christian princes and bishops. His sentiments of disillusion and
sorrow are commemorated in the lines:

“Mine eye longed to behold Thy glory,

But, as if I were deemed unworthy,
I could only tread on the threshold of Thy Temple.
I must also endure the sufferings of my people;
Therefore I wander aimlessly about,
44
As I dare not pay homage to any other being.”

This prophet and singer of Zionism died in the land which his
soul loved so dearly.
Another great Jew of Spain was Moses Maimonides, born at
Cordova in 1135. He came of a long line of Rabbis, who traced their
descent from the royal house of David, and he might be described as
a Talmudist by inheritance as well as by training. He had scarcely
completed his thirteenth year when Cordova was taken by the
fanatical sect of the Almohades, who offered to the Jews and
Christians of the city the alternatives of Islam or death. The ancient
Jewish community was broken up, and the family of Maimonides
migrated to Almeria. But this town also, three years later, fell into the
hands of the same fanatical Mohammedans, and the Jews and
Christians were once more driven forth to seek freedom of worship
elsewhere. Henceforward the family of Maimonides wandered hither
and thither through Spain, unable to find a home. But this roaming
life did not prevent the youth from attaining great proficiency in
various branches of learning, sacred and profane. His father’s
teaching was always ready at hand, and his own quick and clear
intellect found it easy to acquire and to digest the lessons of
experience. Aristotle, as has been said, was much studied, though
little understood, by the Jews and Arabs of Spain. Maimonides’
intellect had much in common with the Greek philosopher’s scientific
mind, while he possessed a sense of religion to which the Greek was
a stranger. In the character of Maimonides the two temperaments,
the Hebraic and the Hellenic, the reasoning and the emotional, met
in a harmonious combination. Truth in thought as well as in action,
was the object for which he strove, and the idle fictions of poetry
were as severely condemned by him as by the mediaeval monks;
but he was far from adopting the monastic definition of poetry as “the
Devil’s wine.” His earnestness was free from fanaticism, and he
could be severe without being savage. Unsparing in his scorn of
what he considered false, he was most forbearing towards the
victims of falsehood. Like many earnest men, Maimonides was born
a missionary. Neither fatigue of body nor pain of mind deterred him
from the diffusion of what he deemed to be the light, and to the
propagation of rational Judaism he devoted his whole life
ungrudgingly and unfalteringly. To this end he made himself master
of all the knowledge accessible in his time. He studied ancient
Paganism as well as contemporary Islam and Christianity;
philosophy, medicine, logic, mathematics, and astronomy. Thus
equipped, he entered the arena.
His people, after ten years’ wandering in Spain, had repaired to
Fez, where persecution had driven many Jews to assume the mask
of Mohammedanism—a form of compulsory hypocrisy, examples of
which abounded in every country. A zealot wrote a pamphlet
denouncing these apparent renegades as traitors to the cause of
Israel. Maimonides, who was one of them, undertook to vindicate
their conduct. But, while defending their prudence, he strove to
combat their lukewarmness, and to confirm the wavering;
endeavours which nearly cost him his life at the hands of the
Mohammedans. In the dead of night he and his family embarked on
board a vessel bound to Palestine. After a month’s perilous voyage
the refugees landed at St. Jean d’Acre (Acco), whence they
proceeded to Jerusalem, then in Christian hands, and finally reached
Egypt. There Maimonides lost his father first, and then his brother,
suffered severely in his health and fortune, and was obliged to eke
out a modest livelihood by the practice of medicine. But in the midst
of all afflictions and occupations he continued his first great work on
the Talmud, which appeared in 1168 under the characteristic title,
The Light. This work, though it failed to make its mark among the
Jews of Egypt, gradually brought fame to the author abroad. In 1175
he was already revered as a great Rabbinical authority, and
questions bearing on religion and law were submitted to him from all
parts of Israel. At the same time he busied himself with the affairs of
the Cairo community of which he was made Rabbi. In 1180 he
completed his Religious Code, in which he wedded Judaism to
philosophy. The object of the book was to introduce light and limit
into the chaos of Biblical and Talmudical teaching. The Code
attained wide popularity, and copies of it were diligently conned in
every corner of the Jewish world from India in the East to Spain in
the West. The learning as well as the character of Maimonides
excited universal respect, and many were the titles bestowed upon
the sage by his admiring co-religionists. Maimonides was proclaimed
“the Enlightener of the eyes of Israel.” Opposition and calumny, the
involuntary tributes which envy pays to success, came in due
course; but Maimonides who had not been intoxicated by praise did
not suffer himself to be intimidated by obloquy. His reputation as a
physician was almost as great as his theological renown; a
Mohammedan poet declares that “Galen’s art heals only the body,
but Maimonides’ the body and soul”; Saladin, then Vizier of Egypt,
engaged him as his physician, and Richard Coeur de Lion, who
during his crusade in the Holy Land heard of Maimonides, invited
him to be his physician in ordinary, an honour which the sage
declined. Thanks to the high esteem in which he was held by the
Mohammedan rulers of Egypt, Maimonides was, in about 1187,
made supreme and hereditary head of all the Egyptian communities.
While at the height of his power and popularity Maimonides found
himself once more exposed to the danger which he had so narrowly
escaped in Morocco. A traveller from that country recognised in the
official chief of the Hebrew community of Egypt his pseudo-
Mohammedan friend of Fez, and denounced him as an apostate.
The penalty for apostacy prescribed by the Laws of Islam is death.
Maimonides, however, succeeded in convincing the Vizier of the
Moorish visitor’s mistake, and thus was enabled to return to the calm
pursuit of his labours, communal, medical and philosophical. Soon
afterwards Palestine was re-conquered by Saladin, and the Jews
were allowed to settle in Jerusalem—a boon for which Maimonides
is supposed to be responsible.
1190 In the midst of his manifold duties, and his feud
with a rival Rabbi of Baghdad, Maimonides found time
to produce another philosophical work, the Guide to the Perplexed, a
work which forms the crown of his intellectual achievement, and
which has been pronounced “perhaps the most remarkable
45
metaphysical tour de force in the history of human thought.” At any
rate, it is a brave attempt at reconciliation between Aristotelian
philosophy and Judaic religion, between Rationalism and Revelation,
between Hellenic free-thought and Hebrew feeling. Therein is
propounded the eternal problem of the origin and destiny of things,
and solved in a manner that carried conviction at the time. The book
has, indeed, been a guide to the perplexed for many generations,
and, though it has not always commanded obedience among the
Jews, it has served as a stimulus to enquiring minds and, through
mediaeval scholasticism, has exercised an abiding influence over
Christian theology. If metaphysical speculation be of any value to
mankind, the world owes a great debt to the work of Maimonides. He
died in 1204, at the age of seventy, full of years and honours, and his
end was followed by a general outburst of grief. In Egypt both Jews
and Mohammedans held a public mourning for three days, in
Jerusalem a public fast was proclaimed, and similar funeral services
and fasts were observed in many synagogues all over the world. The
verdict of his contemporaries was, “From Moses the Prophet till
Moses Maimonides there has never appeared his equal.” Posterity
was not so unanimous in its appreciation. His tomb at Tiberias was
adorned with the epitaph:

“Here lies a man, and yet no man.

If thou wert a man, Angels of heaven
Must have overshadowed thy mother.”
 This inscription was in later times replaced by the following:
46
“Here lies Moses Maimonides, the excommunicated heretic.”
The two epitaphs form an epitome of the sage’s posthumous career
—characteristic, though hardly unique. Maimonides had to share the
fate of all advocates of compromise ere he was accepted as the
47
oracle of Jewish orthodoxy.
The condition of Israel across the Pyrenees must now engage
our attention.
768–814 Charlemagne, the great founder of the Frankish
Empire, in spite of his enthusiasm for the advancement
of the Catholic faith and in defiance of the decrees of a Church which
he adored, and by which he was afterwards honoured as a saint,
considered it his duty to contribute to the progress of the Jewish
colonies in France and Germany. If the Churchman saw in the Jews
the enemies of Christ, the statesman saw in them useful subjects,
through whose international connections the interests of his Empire
might be served. Among other liberties, he allowed them to act as
intermediaries in the slave trade. Exempt from the burdens as well
as from the honours of chivalry on one hand, and from the
degradation of the peasantry on the other, the Jews at this period
devoted all their energies to commerce. But Charlemagne was more
than an imperial shopkeeper. The spiritual needs of his subjects,
Jewish no less than Christian, received as much attention from him
as their material welfare. Though his own learning was of very late
and limited growth, this great soldier was keenly alive to the value of
scholarship, and he endeavoured to diffuse education by
encouraging learned men of both creeds to bring their lights from
Italy to the dark regions of the North. Under his long reign the Jews
prospered and spread over many parts of Germany. In the ninth
century great Jewish colonies were to be found in Magdeburg,
Mersburg, and Ratisbon, whence they penetrated into the Slavonic
lands of Bohemia and Poland. But even Charlemagne could not
quite overlook the chasm which separated the Jew from the
Christian. In deposing against a Christian, the Jewish witness was
obliged to stand within a circle of thorns, to hold the Torah in his right
hand, and to call down upon himself frightful curses if he spoke not
the truth. The Jews were also forbidden to buy or sell sacred church
vessels, to receive Christian hostages for debt, and to trade in wine
and cereals.
814–840 The favourable condition of Israel in Western
Europe, with the exception of the above prohibitions,
lasted under Charlemagne’s successor Louis, who, a pious Catholic
though he was, did not refrain from bestowing benefits upon the
Jews and from defending them against popular prejudice and
ecclesiastical oppression. Influenced partly by the principles of
enlightened statesmanship which he had inherited from his father,
and partly by the philo-judaism of his second wife Judith, he
showered many favours upon the Jews. The works of the Jewish
writers, Josephus and Philo, were assiduously studied at Court.
Jews and Jewesses were received and petted in royal circles, and
their co-religionists were held in high esteem by the nobility. They
were exempt from the barbarous punishment of the scourge and
from the ordeals of fire and water. They were permitted to employ
Christian workmen and to own Christian slaves, to settle their
disputes in their own courts of justice, to build new synagogues, to
farm the revenues of the realm, and to carry on trade freely. For their
sake the market-day was changed from the Sabbath to Sunday. In
return for all these privileges they had to pay a tax to the treasury,
which exercised a supervision over their incomes.
But this very toleration excited the resentment of strict Catholics,
who could not see without disgust the canons of the Church
disregarded and her enemies honoured. The clerical party, under the
leadership of St. Agobard, Bishop of Lyons, wished to reduce the
Jews to the position which they occupied under the bigoted
Merovingian dynasty. An opportunity for the expression of these
feelings offered itself in an incident such as has often proved the
immediate cause of bloodshed between the faithful and unbelievers
in the Ottoman Empire. A female slave of a rich Jew of Lyons ran
away from her master and sought freedom in baptism. The Jews
demanded the restoration of the slave. The Bishop refused to
comply. The Court supported the Jews, the clerical party the Bishop.
The Emperor endeavoured to restore peace by summoning a council
wherein the bishops and the heads of the Jewish community might
settle their differences by argument. The adversaries met and
“roared rather than spoke” to each other. The council broke up, and
the feud continued to rage. The Bishop preached to his flock
sermons hostile to the Jews. The friends of the latter
828
intrigued in the Imperial Court on their behalf, and
prevailed upon the Emperor to command St. Agobard to desist from
his oratorical exercises, and the Governor of Lyons to lend his
assistance to the Jews.
The bellicose saint paid no heed to the Imperial mandate, and
the Emperor was obliged to send two courtiers to enforce respect for
his orders; but they failed. The bishop then appealed to his brother
prelates, entreating them to bring home to Louis his sinful conduct.
His appeal met with hearty response. It was generally felt that the
question was a test of the relative strength of Church and Court, and
the supporters of the one were as determined to uphold their cause
as were the partisans of the other. A number of prelates met at
Lyons and held a consultation as to the best means of humbling the
Jews and bringing the Emperor to the path of orthodoxy. The fruit of
this meeting was a joint letter of protest “concerning
829
the superstitions of the Jews,” addressed to Louis. The
manifesto produced no result, and in the following year the Bishop of
Lyons joined the conspiracy of the Emperor’s sons against their
father, was worsted, and paid for his treason by temporary exile to
Italy, whence, however, he soon returned on condition, it seems, that
he should leave the Jews alone.
The struggle only served to demonstrate the Emperor’s power
and determination to protect his material interests in the teeth of
ecclesiastical opposition. Nor did Louis the “Pious”
838
withdraw his countenance from the Jews even after the
scandalous apostasy of his favourite Bishop Bodo to Judaism—an
event which produced an enormous shock through Frankish
Christendom, especially as it occurred directly after the bishop’s visit
48
to Rome. It is probable that a closer inspection of the Holy See