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Clinical Cases in
INTERNAL MEDICINE
This page intentionally left blank
Clinical Cases in
INTERNAL MEDICINE

SAMY AZER
MB, BCh, MSc Medicine, PhD (Syd), MEd (NSW), FACG, MPH (NSW)
Professor of Medical Education
College of Medicine, King Saud University, Saudi Arabia
Formerly Professor of Medical Education, Universiti Teknologi
MARA, Malaysia
Visiting Professor of Medical Education, University of Toyama, Japan
Formerly Senior Lecturer of Medical Education, Faculty of
Medicine, Dentistry and Health Sciences, the University of
Melbourne and School of Medicine, the University of Sydney,
Australia
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

Copyright © 2022 Elsevier Australia.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
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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).

ISBN: 978-0-7020-8049-4

Notice
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, in particular, independent verification of diagnoses and drug dosages 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.

National Library of Australia Cataloguing-in-Publication Data

Content Strategist: Larissa Norrie

Content Project Manager: Subodh Kumar
Proofread by Annabel Adair
Cover by Georgette Hall
Index by Innodata Indexing
Typeset by
Printed in ••

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

 To
The memory of my parents

To
My family for their love and support, and

To
My grandchildren – Jemimah, Elizabeth, Christopher, Asher
 FOREWORD

To face the challenges of modern health care, future physicians must master not only an
extensive knowledge base but also the analytical and integrative thinking skills needed
to provide safe, comprehensive patient care in the context of clinical complexity.
While many textbooks present the content of this comprehensive knowledge base, Clinical
Cases in Internal Medicine additionally guides learners on the process to apply knowledge and
scientifically understand the various concerns (expressed in lay terms) that patients entrust their
physicians to address. In this textbook, the concise and memorable case discussions highlight
the differential diagnoses that must be systematically considered and review the mechanisms
that explain the patient’s signs and symptoms and the basis for why certain treatments work.
The tables and figures are truly high-yield and helpful in practice. The questions, throughout
the chapter, are framed very thoughtfully around queries that arise in clinical decision-making,
in education of patients and families and in preparation for standardised examinations.
This textbook is ideal for students – in both problem-based learning (PBL) and tra-
ditional curricula – hoping to deepen their learning through case-based and interactive
learning approaches.
Professor Samy Azer is an internationally renowned medical educator, who cur-
rently serves as Professor of Medical Education at the College of Medicine, King Saud
University in Saudi Arabia. He has formerly served as Professor of Medical Education
at the Universiti Teknologi MARA in Malaysia;Visiting Professor of Medical Education
at the University of Toyama in Japan; and Senior Lecturer of Medical Education at the
Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne and
at the School of Medicine at the University of Sydney in Australia.
Through his commitment to innovations that optimise clinical learning and teaching and
through publications and other connections that make these innovations graspable and acces-
sible, Professor Azer has been an inspiration to the global community of medical educators and
students alike. I join Professor Azer in his hope that educator colleagues, students and future
patients will all benefit from the journey of learning through the cases presented in this text.

Anthony P. S. Guerrero, M.D.

Professor and Chair, Department of Psychiatry
The Char, McDermott, and Andrade Endowed
University of Hawai’i John A. Burns School of Medicine
United States

vi
FOREWORD

Medical curricula have changed worldwide to reflect the changing roles of health sys-
tems and the challenges faced by graduating doctors. The advances in technology and
the overwhelming increase in scientific and medical publications add to these challenges
and the need to prepare our doctors at the best international standards and reassuring
their continuing professional development.
This book addresses these needs as a learning resource to be used by students and
other recommended and prescribed resources and enables them to study 50 clinical
cases and apply knowledge to clinically relevant topics in their undergraduate curricu-
lum.
Practising clinicians tend to use ‘schema’ in their reasoning to arrive at a diagnosis
based on pattern recognition and previous experience. However, undergraduate students
did not have sufficient experience and seeing patients in the wards may not be available
for their clinical training. Furthermore, most hospitals are moving to minimally invasive
techniques and one-day care and minimising the length of hospital stay with the new
developments in diagnosis and patient management. These days there are changes in
hospital admission because of the COVID-19 pandemic. These changes have affected
bedside teaching worldwide and the need for alternative teaching/learning methods to
address the students’ learning needs and enhance their clinical skills.
Professor Azer, the chair of the curriculum development and research unit at King
Saud University, has written this book with these challenges in mind. The book reflects
his international expertise in the field and addresses this area of need. International experts
have reviewed the book and provide the core clinical cases taught in internal medicine.
Students may use this book together with their clinical sessions and seeing patients in the
wards presenting with illnesses described. Students may critically compare between clinical
findings they identified in the patient and what was discussed in the clinical cases in the
book. They may also answer questions and revise the MCQs at the end of each case.
Together with reading recommended resources and reviewing their lectures, such
preparation will help in their clinical learning.
I am proud that Professor Azer is an academic at King Saud University for his
achievement and contribution to the medical profession at the global, local and interna-
tional levels. I want to congratulate the author on this achievement, and it is my pleasure
to commend this book as an additional resource to medical students and clinical teach-
ers. This book will be a valuable resource to medical libraries, students and clinicians,
medical educators and curriculum designers.

Professor Badran AlOmar

President, King Saud University

vii
 PREFACE

Clinical Cases in Internal Medicine is not a textbook covering the whole undergraduate
curriculum in internal medicine. Although reading texts and daily engagement with
simulated patients and actual patients is vital to enhance your competency in medicine,
students also need to complement their learning through case-based learning.
This book is written for students as a learning resource to use with other standard
textbooks and resources recommended in this discipline. It comprises 50 cases in inter-
nal medicine covering different body systems and focuses on common diseases that all
medical students should know.
Learning through cases helps students to master several skills and deepen their under-
standing by applying theoretical knowledge. It brings factual knowledge to what they
face in practice. Case scenarios also stimulate students' thinking to interpret the history
findings and clinical findings, generate hypotheses, construct a differential diagnosis,
relates basic knowledge from physiology and pathology to the clinical picture, interprets
laboratory findings and design a management plan.
Clinical Cases in Internal Medicine can be used on an individual basis or in small-group
tutorials with or without a tutor. After reading the case scenarios, students could start answer-
ing each question that follows the scenario—one student in the group summarise critical
points raised in the group discussion- act as the group scribe, and guiding the group discus-
sion. During this process, students may identify gaps in their knowledge or issues they do not
know. Also, questions raised could stimulate further thinking, search for answers/evidence and
turning the discussion into a meaningful session. Through active learning, and self-regulated
learning and examining other resources, students could deepen their understanding of the
case, explore relationships, and turn their learning into engaging and stimulating behaviour.
After completing the case discussion, a section titled ‘back to basics’ has been included
in each case. This section aims at linking knowledge from physiology, pathology, patho-
genesis, microbiology and pharmacology with the case clinical discussion. Students may
try answering the short-answer questions in this section, then compare their responses
with the answers provided. Each case discussion ends with 5-6 multiple-choice questions
that students could try on their own, then check at the end their performance against
model answers and justification given. At last, the case discussion ends with ‘a take-home
message’. and ‘further readings’ from the literature. These resources are recommended
for students to dig deeper and read more about current knowledge related to the case.
I wish success to all my current students and graduates at different universities where I
was honoured to teach and other universities worldwide enforcing active learning practices.
Samy Azer
Melbourne
2021

viii
ACKNOWLEDGEMENTS

I am particularly indebted to my undergraduate and postgraduate medical students at

the University of Sydney and the University of Melbourne in Australia, the University
of Toyama in Japan, the Universiti Teknologi MARA in Malaysia and my current
students at King Saud University in Saudi Arabia. Their engagement, questions and
areas that they found difficult to understand have been an excellent source for me as I
prepared the manuscript of this book.
I am indebted to the work of many individuals, particularly the publication team
of Elsevier, for providing a professional standard during the book production. I thank
Laurence Hunter, the content strategist, Elsevier Oxford, the United Kingdom. He
was the first content strategist who handled the book before retiring. I thank Nimisha
Goswami, the head of the content strategy, Elsevier India, who also dealt with the book
content. I also thank Larissa Norrie, head of content strategy, Australia, who made signifi-
cant help and support in the book production. Also, I thank Annabel Adair for the proof-
reading of the book as a freelance proofreader. I deeply appreciate and thank Subodh
Kumar, who carried out the content development and project management responsibil-
ity. His hard work in preparing the proofs at professional standards is appreciated.

ix
 ABBREVIATIONS

5-HT 5-hydroxytryptamine
ACE Angiotensin-converting enzyme
AChR Anti-acetylcholine receptor
ACTH Adrenocorticotrophic hormone
ADH Antidiuretic hormone
AFB Acid-fast bacillus
AHR Airway hyper-reactivity
AIDS Acquired immunodeficiency syndrome
ALT Alanine aminotransferase
ANA Antinuclear antibody
Anti-La (or SS-B) These occur in 10%–20% of patients with systemic lupus
autoantibodies erythematosus and 50% of patients with primary or secondary
Sjögren syndrome; maternal anti-La (SS-B) autoantibodies
are associated with neonatal lupus syndromes, particularly
congenital heart block
Anti-Ro (anti-SS-A) These are anti–Sjögren-syndrome-related antigen A autoanti-
autoantibodies bodies; also called anti-Ro
Anti-U1-RNP It is a serological marker for MCTD; It can be also detected
in patients with systemic sclerosis or SLE
APACHE-II Acute Physiology and Chronic Health Evaluation II
APC Adenomatous polyposis coli
AST Aspartate aminotransferase
ATP Adenosine triphosphate
AV node Atrioventricular node
B. burgdorferi Borrelia burgdorferi
BCG Bacillus Calmette–Guérin vaccine
BCR-ABL It is a mutation formed by the combination of two genes,
known as BCR and ABL; the mutated chromosome 22 is
called the Philadelphia chromosome (referring to the city
where researchers first discovered Ph chromosome)
BG Blood glucose
BMD Bone mass density
BMI Body mass index
BNP Brain natriuretic peptide
BPPV Benign paroxysmal positional vertigo
C, T, L, S nerve roots C, cervical; T, thoracic; L, lumbar; S, sacral nerve roots
C. jejuni Campylobacter jejuni

x
 Abbreviations xi

C. trachomatis Chlamydia trachomatis

C3, C4 Complement fragments C3 and C4
C3NeF C3 nephritic factor
cAMP Cyclic 39,59-adenosine monophosphate
CAP Community-acquired pneumonia
CD41 A T-helper white blood cell
CD81 It is a cytotoxic T-cell; also known as T-killer cell or cytotoxic
T-lymphocyte
CEA Carcinoembryonic antigen
CFU Colony-forming unit
CK-MB Creatine kinase myocardial band
CML Chronic myeloid leukaemia
CMV Cytomegalovirus
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
COX Cyclooxygenase
CRF-1 Corticotrophin-releasing factor-1
CRP C-reactive protein
CSF Cerebrospinal fluid
CT scan Computed tomography scan
cTn Cardiac troponin
cTnI Cardiac troponin I
cTnT Cardiac troponin T
CTPA Computed tomography pulmonary angiography
CURB-65 score C, confusion; U, urea; R, respiratory; B, blood pressure; 65,
age . 65
CXCL Chemokines playing a role in chemoattractant for several
immune cells, and angiogenesis/arteriogenesis and cancer
progression
CYP2E1 It is a member of the cytochrome P450, which is involved in
metabolism of xenobiotics
D receptor Dopamine receptor
Delta wave In ECG, the delta wave is a slurred upstroke in the QRS
complex, commonly associated with pre-excitation syndrome
such as WPW
DHEAS Dehydroepiandrosterone sulphate
DIP Distal interphalangeal joints
DKA Diabetic ketoacidosis
DMARDs Disease-modifying antirheumatic drugs
DNA Deoxyribonucleic acid
xii Abbreviations

DR4 It is a serotype of HLA, which is associated with extra-

articular rheumatoid arthritis, obstructive hypertrophic
cardiomyopathy, IgA nephropathy, certain types of systemic
lupus erythematosus and polymyalgia rheumatica
dsDNA Double-stranded DNA
DVT Deep venous thrombosis
DXA (or DEXA) Dual-energy x-ray absorptiometry
E. coli Escherichia coli
EBV Epstein-Barr virus
ECG Electrocardiogram
ECL Enterochromaffin-like cells
EHEC Enterohaemorrhagic Escherichia coli
EIEC Enteroinvasive Escherichia coli
ELISA Enzyme-linked immunosorbent assay
ELISpot Enzyme-linked immunospot
EMG Electromyogram
EML4-ALK EML4 is echinoderm microtubule-associated protein-like 4
gene that has been fused to the anaplastic lymphoma kinase
(ALK) gene; this fusion leads to the production of a protein,
EML4-ALK; first isolated from small cell lung cancer
eNOS Endothelial nitric oxide synthase
EPEC Enteropathogenic Escherichia coli
ERCP Endoscopic retrograde cholangiopancreatography
ESR Erythrocyte sedimentation rate
ESRD End-stage renal disease
ETEC Enterotoxigenic Escherichia coli
FAP Familial adenomatous polyposis
FEV1 Forced expiratory volume of 1 second
FGF23 Fibroblast growth factor 23
FRAX Fracture Risk Assessment Tool
FVC Forced vital capacity
G6PD deficiency Glucose-6-phosphate dehydrogenase deficiency
GABA Gamma-aminobutyric acid
GADA Glutamate decarboxylase alpha
GDP Guanosine diphosphate or guanosine 5'-diphosphate
GGT Gamma-glutamyl transferase
GH Growth hormone
GINA Global Institute for Asthma
GN Glomerulonephritis
GnRH Gonadotrophin-releasing hormone
GP Globus pallidus
GTP Guanosine-59-triphosphate
 Abbreviations xiii

H. influenzae Haemophilus influenzae

H. pylori Helicobacter pylori
H1-receptor Histamine antagonist receptor-1
HAP Hospital-acquired pneumonia
HAV Hepatitis A virus
Hb Haemoglobin
HbA1c Haemoglobin A1c
HBsAg Hepatitis B surface antigen
HBV Hepatitis B virus
HCO32 Bicarbonate
HCV Hepatitis C virus
HDL High-density lipoprotein
HDV Hepatitis D virus
HEV Hepatitis E virus
HGPRT Hypoxanthine-guanine phosphoribosyltransferase
Hib Haemophilus Influenzae type b
HIV Human immunodeficiency virus
HLA Human leukocyte antigen
hs-cTnT High-sensitivity cardiac troponin T
IA2A Insulinoma-associated protein 2 autoantibody
IAA Islet cell autoantigen
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
IBS-C Constipation-predominant IBS
IBS-D Diarrhoea-predominant IBS
IBS-M Mixed bowel pattern IBS
IBS-U Unclassified IBS
ICA Islet cell antibodies
Ig Immunoglobulin
IGF-1 Insulin-like growth factor type 1
IL Interleukin
IM Intramuscular
INR International normalised ratio
ITP Immune thrombocytopenic purpura
IU International unit
IV Intravenous
JVP Jugular venous pressure
K. pneumoniae Klebsiella pneumoniae
Kv124 antibodies These are the antibodies directed to the potassium
voltage-gated channel; subfamily members 1–4
LA Left atrium
LDDST Low-dose dexamethasone suppression test
xiv Abbreviations

LDH Lactate dehydrogenase

LDL Low-density lipoprotein
LMWH Low-molecular-weight heparin
LRP4 Lipoprotein receptor-related peptide 4
LTB4 Leukotriene B4
LTD4 Leukotriene D4
LV Left ventricle
M. catarrhalis Moraxella catarrhalis
MALT Mucosa-associated lymphoid tissue
MCHC Mean corpuscular haemoglobin concentration
MCTD Mixed connective tissue disease
MCV Mean corpuscular volume
MEN type 1 Multiple endocrine neoplasia type 1
MERS-CoV Middle East respiratory syndrome coronavirus
MGDF Megakaryocyte growth and development factor
MGUS Monoclonal gammopathy of undetermined significance
MHC Major histocompatibility complex
MRI Magnetic resonance imaging
MuSK Muscle specific tyrosine kinase
N. meningitides Neisseria meningitidis
NADP1 Nicotinamide adenine dinucleotide phosphate
NADPH Reduced nicotinamide adenine dinucleotide phosphate; it
used in anabolic cellular reactions
NAPQI N-acetyl-p-benzoquinone imine
NICE National Institute for Health and Care Excellence
NLRP3 NLRP3 inflammasome complex is implicated as a regula-
tor of the innate inflammatory phenotype of several diseases,
including gout and type 2 diabetes
NPA Neutral protamine aspart
NPH Neutral protamine Hagedorn
NPL Neutral protamine lispro
NSAIDs Nonsteroidal anti-inflammatory drugs
OP receptor Opioid receptors
OPG Osteoprotegerin
OS Opening snap
P wave In ECG, the P wave represents atrial depolarisation, atrial
contraction or atrial systole
P. aeruginosa Pseudomonas aeruginosa
P. falciparum Plasmodium falciparum
P. jirovecii Pneumocystis jirovecii
P. malariae Plasmodium malariae
P. mirabilis Proteus mirabilis
 Abbreviations xv

P. ovale Plasmodium ovale

P. vivax Plasmodium vivax
p53 Tumour suppressor gene p53 (a 53-kilodalton [kDa] protein)
PAS stain Periodic acid–Schiff stain
pCO2 The partial pressure of carbon dioxide
PCR Polymerase chain reaction
PCV Packed cell volume
PDGFR Platelet-derived growth factor receptor
PE Pulmonary embolism
PEF Peak expiratory flow
PET scan Positron emission tomography scan
PfEMP1 P. falciparum erythrocyte membrane protein 1
PG Prostaglandin
PGE2 Prostaglandin E2
pH Potential of hydrogen or power of hydrogen; it is a scale to
specify the acidity or basicity of an aqueous solution
Ph chromosome Philadelphia chromosome
PIP Proximal interphalangeal joints
PKCiota (PKCI) Protein kinase Ciota
PLA2R Phospholipase A2 receptor
PO Per oral
POEMS syndrome It is a syndrome characterised by polyneuropathy,
organomegaly, endocrinopathy, monoclonal gammopathy
and skin changes
PTH Parathyroid hormone
Q wave In ECG, the Q wave represents left-to-right depolarisation
of the interventricular septum
R wave In ECG, the R wave is the first upward deflection after the
P wave; it represents early ventricular depolarisation
RA Right atrium
RANKL Receptor activator of nuclear factor kb ligand
RBCs Red blood cells
RF Rheumatoid factor
RNA Ribonucleic acid
RV Right ventricle
S. aureus Staphylococcus aureus
S. flexneri Shigella flexneri
S. pneumoniae Streptococcus pneumoniae
S. saprophyticus Staphylococcus saprophyticus
S. typhimurium Salmonella typhimurium
S1 1 S2 heart sounds First and second heart sounds
xvi Abbreviations

S3 heart sound The third heart sound, is an extra heart sound, also known as
the ventricular gallop; it occurs just after S2
S4 heart sound The fourth heart sound, is an extra heart sound, also known
as the atrial gallop; it occurs just before S1 when the atria
contract to force blood into the left ventricle; it can be heard
in acute myocardial infarction, cardiomyopathy, aortic stenosis
and left bundle branch block
SA node Sinoatrial node
SAH Subarachnoid haemorrhage
SaO2 Oxygen saturation
SARS-CoV Severe acute respiratory syndrome
SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2
SC Subcutaneous
SIADH Syndrome of inappropriate antidiuretic hormone secretion
SLE Systemic lupus erythematosus
SPEP Serum protein electrophoresis
SSTR2 Somatostatin receptor type 2
ST segment In ECG, the ST segment represents the interval between
ventricular depolarisation and repolarisation
T wave In ECG, the T wave represents the repolarisation of the
ventricles
T3 Tri-iodothyronine
T4 Thyroxine
TB Tuberculosis
TGF-ß Transforming growth factor-beta
Th-1 or Th1 cell T-helper cell-type 1
TH1 T-helper type 1 cells are a lineage of CD41
TH2 T-helper type 2 cells are a distinct lineage of CD41
TIA Transient ischemic attack
TIBC Total iron-binding capacity
TNF-a Tumour necrosis factor-alpha
TNM staging Staging of cancer: T, tumour size; N, spread to lymph nodes;
M, metastasis
TP53 gene It is located on the short arm of chromosome 17 (17p13.1)
and its mutation plays a role in cancer development
TPMT Thiopurine methyltransferase
TRAb TSH receptor IgG antibody, also known as thyrotrophin
receptor antibody
TRAs Thrombopoietin receptor agonists
TSH Thyroid-stimulating hormone
tTG Tissue transglutaminase
 Abbreviations xvii

TTP Thrombotic thrombocytopenic purpura

UGI Upper gastrointestinal
UPEP Urine protein electrophoresis
UTI Urinary tract infection
V/Q scan Ventilation/perfusion scan
VAP Ventilation-associated pneumonia
WBC White blood cell
WPW syndrome Wolff–Parkinson–White syndrome
Y. enterocolitica Yersinia enterocolitica
ZN stain Ziehl–Neelsen stain
 CONTENTS

Forewords vi-vii
Preface viii
Acknowledgements ix
Abbreviations x

Section 1 Gastroenterology and Hepatobiliary Systems 1

Case 1.1 ‘I Have Tummy Pain . . . ’ 3
Case 1.2 ‘I Am Losing Weight . . . ’ 11
Case 1.3 ‘Not Regular . . . ’ 19
Case 1.4 ‘As Dark as Coffee Grounds . . . ’ 28
Case 1.5 ‘There Is Blood in My Stool . . . ’ 40
Case 1.6 ‘It Is Itching All Over . . . ’ 51
Case 1.7 ‘Not Feeling Well . . . ’ 58
Case 1.8 ‘I Have the Runs . . . ’ 68
Case 1.9 ‘Nothing Is Working for Me . . . ’ 77

Section 2 Cardiovascular and Respiratory Systems 85

Case 2.1 ‘Short of Breath . . .  87
Case 2.2 ‘Still Coughing . . . ’ 97
Case 2.3 ‘I Was Admitted to Hospital . . . ’ 105
Case 2.4 ‘I Have Been Smoking for Over 20 Years . . . ’ 113
Case 2.5 ‘Nearly Fainted in the Bathroom . . . ’ 121
Case 2.6 ‘Like a Stone on My Chest . . . ’ 129
Case 2.7 ‘Not Feeling Well . . . ’ 138
Case 2.8 ‘In the Backyard . . . ’ 146
Case 2.9 ‘While at the University Campus . . . ’ 153
Case 2.10 ‘I Am Coughing Up Blood . . . ’ 159

Section 3 Nervous System 167

Case 3.1 Tremor in Hands 169
Case 3.2 Not Moving 177
Case 3.3 Is It Because of My Back Pain? 186
Case 3.4 I Have Severe Headache 197
Case 3.5 Because of Double Vision 205
Case 3.6 In the Intensive Care Unit 212
Case 3.7 Things Are Spinning Around Me 218
Case 3.8 My Feet Are Painfully Hot 225

xviii
 Contents xix

Section 4 Rheumatology and Immune System 233

Case 4.1 ‘Stiffness in the Morning . . . ’ 235
Case 4.2 ‘Progressive Pain in My Knees’ 245
Case 4.3 ‘After My Fall . . . ’ 251
Case 4.4 ‘Is It Serious?’ 260
Case 4.5 ‘I Have Pain in My Heels . . . ’ 268
Case 4.6 ‘Red and Tender . . . ’ 274
Case 4.7 ‘I Was Nearly Dead . . . ’ 282

Section 5 Endocrine System 289

Case 5.1 ‘The Trouble with My Vision . . . ’ 291
Case 5.2 ‘I Feel Too Hot . . . ’ 298
Case 5.3 ‘Did Not Work . . . ’ 308
Case 5.4 ‘Too Tired . . . ’ 317
Case 5.5 ‘They Rushed Me to the Emergency Room . . . ’ 324
Case 5.6 ‘Trying Hard to Lose Weight . . . ’ 331

Section 6 Haematology System 343

Case 6.1 ‘Looking Pale . . . ’ 345
Case 6.2 ‘After Returning From a Holiday in Europe . . . ’ 353
Case 6.3 ‘Bleeding Gums . . . ’ 361
Case 6.4 ‘Unexpected Outcomes . . . ’ 367
Case 6.5 ‘Before Travelling to Congo in Africa . . . ’ 373
Case 6.6 ‘Sweating and Chills . . . ’ 380

Section 7 Renal System 389

Case 7.1 ‘ . . . After Severe Attack of Diarrhoea’ 391
Case 7.2 ‘ . . . Fluid Build-up in My Body’ 400
Case 7.3 ‘I Only Feel Tired . . . ’ 411
Case 7.4 ‘Burning Pain on Passing Urine . . . ’ 420

Index of Cases 428

Index 430
Another random document with
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principle of arrangement. Thus, instead of arranging metallic
minerals according to the metal, under iron, copper, &c., all the
sulphurets were classed together, all the oxides together, all the
sulphates together, and so in other respects. That such an order was
a great improvement on the preceding one, cannot be doubted; but
we shall see, I think, that as a strict scientific system it was not
successful. The discovery of isomorphism, however, naturally led to
such attempts. Thus Gmelin also, in 1825, published a mineral
system, 50 which, like that of Berzelius, founded its leading
distinctions on the electro-negative, or, as it was sometimes termed,
the formative element of bodies; and, besides this, took account of
the numbers of atoms or proportions which appear in the
composition of the body; distinguishing, for instance, Silicates, as
simple silicates, double silicates, and so on, to quintuple silicate
(Pechstein) and sextuple silicate (Perlstein). In like manner,
Nordenskiöld devised a system resting on the same bases, taking
into account also the crystalline form. In 1824, Beudant published his
Traité Elémentaire de Minéralogie, in which he professes to found
his arrangement on the electro-negative element, and on Ampère’s
circular 349 arrangement of elementary substances. Such schemes
exhibit rather a play of the mere logical faculty, exercising itself on
assumed principles, than any attempt at the real interpretation of
nature. Other such pure chemical systems may have been
published, but it is not necessary to accumulate instances. I proceed
to consider their result.
50 Zeitsch. der Min. 1825, p. 435.

Sect. 3.—Failure of the Attempts at Systematic Reform.

It may appear presumptuous to speak of the failure of those whom,
like Berzelius and Mohs, we acknowledge as our masters, at a
period when, probably, they and some of their admirers still hold
them to have succeeded in their attempt to construct a consistent
system. But I conceive that my office as an historian requires me to
exhibit the fortunes of this science in the most distinct form of which
they admit, and that I cannot evade the duty of attempting to seize
the true aspect of recent occurrences in the world of science. Hence
I venture to speak of the failure of both the attempts at framing a
pure scientific system of mineralogy,—that founded on the chemical,
and that founded on the natural-history principle; because it is clear
that they have not obtained that which alone we could, according to
the views here presented, consider as success,—a coincidence of
each with the other. A Chemical System of arrangement, which
should bring together, in all cases, the substances which come
nearest each other in external properties;—a Natural-history System,
which should be found to arrange bodies in complete accordance
with their chemical constitution:—if such systems existed, they
might, with justice, claim to have succeeded. Their agreement would
be their verification. The interior and exterior system are the type and
the antitype, and their entire correspondence would establish the
mode of interpretation beyond doubt. But nothing less than this will
satisfy the requisitions of science. And when, therefore, the chemical
and the natural-history system, though evidently, as I conceive,
tending towards each other, are still far from coming together, it is
impossible to allow that either method has been successful in regard
to its proper object.

But we may, I think, point out the fallacy of the principles, as well
as the imperfection of the results, of both of those methods. With
regard to that of Berzelius, indeed, the history of the subject
obviously betrays its unsoundness. The electro-positive principle
was, in a very short time after its adoption, proved and
acknowledged to be utterly untenable: what security have we that
the electro-negative element is 350 more trustworthy? Was not the
necessity of an entire change of system, a proof that the ground,
whatever that was, on which the electro-chemical principle was
adopted, was an unfounded assumption? And, in fact, do we not find
that the same argument which was allowed to be fatal to the First
System of Berzelius, applies in exactly the same manner against the
Second? If the electro-positive elements be often isomorphous, are
not the electro-negative elements sometimes isomorphous also? for
instance, the arsenic and phosphoric acids. But to go further, what is
the ground on which the electro-chemical arrangement is adopted?
Granted that the electrical relations of bodies are important; but how
do we come to know that these relations have anything to do with
mineralogy? How does it appear that on them, principally, depend
those external properties which mineralogy must study? How does it
appear that because sulphur is the electro-negative part of one body,
and an acid the electro-negative part of another, these two elements
similarly affect the compounds? How does it appear that there is any
analogy whatever in their functions? We allow that the composition
must, in some way, determine the classified place of the mineral,—
but why in this way?

I do not dwell on the remark which Berzelius himself 51 makes on

Nordenskiöld’s system;—that it assumes a perfect knowledge of the
composition in every case; although, considering the usual
discrepancies of analyses of minerals, this objection must make all
pure chemical systems useless. But I may observe, that
mineralogists have not yet determined what characters are
sufficiently affixed to determine a species of minerals. We have seen
that the ancient notion of the composition of a species, has been
unsettled by the discovery of isomorphism. The tenet of the
constancy of the angle is rendered doubtful by cases of
plesiomorphism. The optical properties, which are so closely
connected with the crystalline, are still so imperfectly known, that
they are subject to changes which appear capricious and arbitrary.
Both the chemical and the optical mineralogists have constantly, of
late, found occasion to separate species which had been united, and
to bring together those which had been divided. Everything shows
that, in this science, we have our classification still to begin. The
detection of that fixity of characters, on which a right establishment
of species must rest, is not yet complete, great as the progress is
which we have made, by acquiring a knowledge of the laws of
crystallization and of 351 definite chemical constitution. Our
ignorance may surprise us; but it may diminish our surprise to
recollect, that the knowledge which we seek is that of the laws of the
physical constitution of all bodies whatever; for to us, as
mineralogists, all chemical compounds are minerals.
51 Jahres Bericht. viii. 188.

The defect of the principle of the natural-history classifiers may be

thus stated:—in studying the external characters of bodies, they take
for granted that they can, without any other light, discover the
relative value and importance of those characters. The grouping of
Species into a Genus, of Genera into an Order, according to the
method of this school, proceeds by no definite rules, but by a latent
talent of appreciation,—a sort of classifying instinct. But this course
cannot reasonably be expected to lead to scientific truth; for it can
hardly be hoped, by any one who looks at the general course of
science, that we shall discover the relation between external
characters and chemical composition, otherwise than by tracing their
association in cases where both are known. It is urged that in other
classificatory sciences, in botany, for example, we obtain a natural
classification from external characters without having recourse to
any other source of knowledge. But this is not true in the sense here
meant. In framing a natural system of botany, we have constantly
before our eyes the principles of physiology; and we estimate the
value of the characters of a plant by their bearing on its functions,—
by their place in its organization. In an unorganic body, the chemical
constitution is the law of its being; and we shall never succeed in
framing a science of such bodies but by studiously directing our
efforts to the interpretation of that law.

On these grounds, then, I conceive, that the bold attempts of Mohs

and of Berzelius to give new forms to mineralogy, cannot be deemed
successful in the manner in which their authors aspired to succeed.
Neither of them can be marked as a permanent reformation of the
science. I shall not inquire how far they have been accepted by men
of science, for I conceive that their greatest effect has been to point
out improvements which might be made in mineralogy without going
the whole length either of the pure chemical, or of the pure natural-
history system.

Sect. 4.—Return to Mixed Systems with Improvements.

In spite of the efforts of the purists, mineralogists returned to mixed

systems of classification; but these systems are much better than
they were before such efforts were made. 352

The Second System of Berzelius, though not tenable in its

rigorous form, approaches far nearer than any previous system to a
complete character, bringing together like substances in a large
portion of its extent. The System of Mohs also, whether or not
unconsciously swayed by chemical doctrines, forms orders which
have a community of chemical character; thus, the minerals of the
order Haloide are salts of oxides, and those of the order Pyrites are
sulphurets of metals. Thus the two methods appear to be converging
to a common centre; and though we are unable to follow either of
them to this point of union, we may learn from both in what direction
we are to look for it. If we regard the best of the pure systems
hitherto devised as indications of the nature of that system, perfect
both as a chemical and as a natural-history system, to which a more
complete condition of mineralogical knowledge may lead us, we may
obtain, even at present, a tolerably good approximation to a
complete classification; and such a one, if we recollect that it must
be imperfect, and is to be held as provisional only, may be of no
small value and use to us.

The best of the mixed systems produced by this compromise

again comes from Freiberg, and was published by Professor
Naumann in 1828. Most of his orders have both a chemical
character and great external resemblances. Thus his Haloides,
divided into Unmetallic and Metallic, and these again into Hydrous
and Anhydrous, give good natural groups. The most difficult minerals
to arrange in all systems are the siliceous ones. These M. Naumann
calls Silicides, and subdivides them into Metallic, Unmetallic, and
Amphoteric or mixed; and again, into Hydrous and Anhydrous. Such
a system is at least a good basis for future researches; and this is,
as we have said, all that we can at present hope for. And when we
recollect that the natural-history principle of classification has begun,
as we have already seen, to make its appearance in our treatises of
chemistry, we cannot doubt that some progress is making towards
the object which I have pointed out. But we know not yet how far we
are from the end. The combination of chemical, crystallographical,
physical and optical properties into some lofty generalization, is
probably a triumph reserved for future and distant years.

Conclusion.—The history of Mineralogy, both in its successes and

by its failures, teaches us this lesson;—that in the sciences of
classification, the establishment of the fixity of characters, and the
discovery of such characters as are fixed, are steps of the first
importance in the progress of these sciences. The recollection of this
maxim may aid us in 353 shaping our course through the history of
other sciences of this kind; in which, from the extent of the subject,
and the mass of literature belonging to it, we might at first almost
despair of casting the history into distinct epochs and periods. To the
most prominent of such sciences, Botany, I now proceed.

~Additional material in the 3rd edition.~

 B O O K XVI.

C L A S S I F I C AT O RY S C I E N C E S .
 HISTORY
OF

SYSTEMATIC BOTANY AND ZOOLOGY.

. . . . . Vatem aspicies quæ rupe sub altâ
Fata canit, foliisque notas et nomina mandat.
Quæcunque in foliis descripsit carmina virgo
Digerit in numerum atque antro seclusa relinquit
Illa manent immorta locis neque ab ordine cedunt.
Virgil. Æn. iii. 443.

Behold the Sibyl!—Her who weaves a long,

A tangled, full, yet sweetly flowing song.
Wondrous her skill; for leaf on leaf she frames
Unerring symbols and enduring names;
And as her nicely measured line she binds,
For leaf on leaf a fitting place she finds;
Their place once found, no more the leaves depart,
But fixed rest:—such is her magic art.
 INTRODUCTION.

W Ecomplete
now arrive at that study which offers the most copious and
example of the sciences of classification, I mean
Botany. And in this case, we have before us a branch of knowledge
of which we may say, more properly than of any of the sciences
which we have reviewed since Astronomy, that it has been
constantly advancing, more or less rapidly, from the infancy of the
human race to the present day. One of the reasons of this
resemblance in the fortunes of two studies so widely dissimilar, is to
be found in a simplicity of principle which they have in common; the
ideas of Likeness and Difference, on which the knowledge of plants
depends, are, like the ideas of Space and Time, which are the
foundation of astronomy, readily apprehended with clearness and
precision, even without any peculiar culture of the intellect. But
another reason why, in the history of Botany, as in that of Astronomy,
the progress of knowledge forms an unbroken line from the earliest
times, is precisely the great difference of the kind of knowledge
which has been attained in the two cases. In Astronomy, the
discovery of general truths began at an early period of civilization; in
Botany, it has hardly yet begun; and thus, in each of these
departments of study, the lore of the ancient is homogeneous with
that of the modern times, though in the one case it is science, in the
other, the absence of science, which pervades all ages. The
resemblance of the form of their history arises from the diversity of
their materials.

I shall not here dwell further upon this subject, but proceed to trace
rapidly the progress of Systematic Botany, as the classificatory
science is usually denominated, when it is requisite to distinguish
between that and Physiological Botany. My own imperfect
acquaintance with this study admonishes me not to venture into its
details, further than my purpose absolutely requires. I trust that, by
taking my views principally from writers who are generally allowed to
possess the best insight into the science, I may be able to draw the
larger features of its history with tolerable correctness; and if I
succeed in this, I shall attain an object of great importance in my
general scheme. 358
 CHAPTER I.

Imaginary Knowledge of Plants.

T HE apprehension of such differences and resemblances as

those by which we group together and discriminate the various
kinds of plants and animals, and the appropriation of words to mark
and convey the resulting notions, must be presupposed, as essential
to the very beginning of human knowledge. In whatever manner we
imagine man to be placed on the earth by his Creator, these
processes must be conceived to be, as our Scriptures represent
them, contemporaneous with the first exertion of reason, and the first
use of speech. If we were to indulge ourselves in framing a
hypothetical account of the origin of language, we should probably
assume as the first-formed words, those which depend on the visible
likeness or unlikeness of objects; and should arrange as of
subsequent formation, those terms which imply, in the mind, acts of
wider combination and higher abstraction. At any rate, it is certain
that the names of the kinds of vegetables and animals are very
abundant even in the most uncivilized stages of man’s career. Thus
we are informed 1 that the inhabitants of New Zealand have a distinct
name of every tree and plant in their island, of which there are six or
seven hundred or more different kinds. In the accounts of the rudest
tribes, in the earliest legends, poetry, and literature of nations, pines
and oaks, roses and violets, the olive and the vine, and the thousand
other productions of the earth, have a place, and are spoken of in a
manner which assumes, that in such kinds of natural objects,
permanent and infallible distinctions had been observed and
universally recognized.
 1 Yate’s New Zealand, p. 238.

For a long period, it was not suspected that any ambiguity or

confusion could arise from the use of such terms; and when such
inconveniences did occur, (as even in early times they did,) men
were far from divining that the proper remedy was the construction of
a science of classification. The loose and insecure terms of the
language of common life retained their place in botany, long after
their 359 defects were severely felt: for instance, the vague and
unscientific distinction of vegetables into trees, shrubs, and herbs,
kept its ground till the time of Linnæus.

While it was thus imagined that the identification of a plant, by

means of its name, might properly be trusted to the common
uncultured faculties of the mind, and to what we may call the instinct
of language, all the attention and study which were bestowed on
such objects, were naturally employed in learning and thinking upon
such circumstances respecting them as were supplied by any of the
common channels through which knowledge and opinion flow into
men’s minds.

The reader need hardly be reminded that in the earlier periods of

man’s mental culture, he acquires those opinions on which he loves
to dwell, not by the exercise of observation subordinate to reason;
but, far more, by his fancy and his emotions, his love of the
marvellous, his hopes and fears. It cannot surprise us, therefore, that
the earliest lore concerning plants which we discover in the records
of the past, consists of mythological legends, marvellous relations,
and extraordinary medicinal qualities. To the lively fancy of the
Greeks, the Narcissus, which bends its head over the stream, was
originally a youth who in such an attitude became enamored of his
own beauty: the hyacinth, 2 on whose petals the notes of grief were
traced (a i, a i), recorded the sorrow of Apollo for the death of his
favorite Hyacinthus: the beautiful lotus of India, 3 which floats with its
splendid flower on the surface of the water, is the chosen seat of the
goddess Lackshmi, the daughter of Ocean. 4 In Egypt, too, 5 Osiris
swam on a lotus-leaf and Harpocrates was cradled in one. The lotus-
eaters of Homer lost immediately their love of home. Every one
knows how easy it would be to accumulate such tales of wonder or
religion.
2 Lilium martagon.
Ipse suos gemitus foliis inscribit et a i, a i,
Flos habet inscriptum funestaque litera ducta est.—
Ovid.
3 Nelumbium speciosum. ~Correction to text in the 3rd edition,
bottom of page.~

4 Sprengel, Geschichte der Botanik, i. 27.

5 Ib. i. 28.

Those who attended to the effects of plants, might discover in

them some medicinal properties, and might easily imagine more; and
when the love of the marvellous was added to the hope of health, it
is easy to believe that men would be very credulous. We need not
dwell upon the examples of this. In Pliny’s Introduction to that book
of his 360 Natural History which treats of the medicinal virtues of
plants, he says, 6 “Antiquity was so much struck with the properties
of herbs, that it affirmed things incredible. Xanthus, the historian,
says, that a man killed by a dragon, will be restored to life by an herb
which he calls balin; and that Thylo, when killed by a dragon, was
recovered by the same plant. Democritus asserted, and
Theophrastus believed, that there was an herb, at the touch of
which, the wedge which the woodman had driven into a tree would
leap out again. Though we cannot credit these stories, most persons
believe that almost anything might be effected by means of herbs, if
their virtues were fully known.” How far from a reasonable estimate
of the reality of such virtues were the persons who entertained this
belief we may judge from the many superstitious observances which
they associated with the gathering and using of medicinal plants.
Theophrastus speaks of these; 7 “The drug-sellers and the
rhizotomists (root-cutters) tell us,” he says, “some things which may
be true, but other things which are merely solemn quackery; 8 thus
they direct us to gather some plants, standing from the wind, and
with our bodies anointed; some by night, some by day, some before
the sun falls on them. So far there may be something in their rules.
But others are too fantastical and far fetched. It is, perhaps, not
absurd to use a prayer in plucking a plant; but they go further than
this. We are to draw a sword three times round the mandragora, and
to cut it looking to the west: again, to dance round it, and to use
obscene language, as they say those who sow cumin should utter
blasphemies. Again, we are to draw a line round the black hellebore,
standing to the east and praying; and to avoid an eagle either on the
right or on the left; for, say they, ‘if an eagle be near, the cutter will
die in a year.’”
6 Lib. xxv. 5.

7 De Plantis, ix. 9.

8 Ἐπιτραγῳδοῦντες.

This extract may serve to show the extent to which these

imaginations were prevalent, and the manner in which they were
looked upon by Theophrastus, our first great botanical author. And
we may now consider that we have given sufficient attention to these
fables and superstitions, which have no place in the history of the
progress of real knowledge, except to show the strange chaos of
wild fancies and legends out of which it had to emerge. We proceed
to trace the history of the knowledge of plants. 361
 CHAPTER II.

Unsystematic Knowledge of Plants.

A STEP was made towards the formation of the Science of Plants,

although undoubtedly a slight one, as soon as men began to
collect information concerning them and their properties, from a love
and reverence for knowledge, independent of the passion for the
marvellous and the impulse of practical utility. This step was very
early made. The “wisdom” of Solomon, and the admiration which
was bestowed upon it, prove, even at that period, such a working of
the speculative faculty: and we are told, that among other evidences
of his being “wiser than all men,” “he spake of trees, from the cedar-
tree that is in Lebanon even unto the hyssop that springeth out of the
wall.” 9 The father of history, Herodotus, shows us that a taste for
natural history had, in his time, found a place in the minds of the
Greeks. In speaking of the luxuriant vegetation of the Babylonian
plain, 10 he is so far from desiring to astonish merely, that he says,
“the blades of wheat and barley are full four fingers wide; but as to
the size of the trees which grow from millet and sesame, though I
could mention it, I will not; knowing well that those who have not
been in that country will hardly believe what I have said already.” He
then proceeds to describe some remarkable circumstances
respecting the fertilization of the date-palms in Assyria.
9 1 Kings iv. 33.

10 Herod. i. 193.

This curious and active spirit of the Greeks led rapidly, as we have
seen in other instances, to attempts at collecting and systematizing
knowledge on almost every subject: and in this, as in almost every
other department, Aristotle may be fixed upon, as the representative
of the highest stage of knowledge and system which they ever
attained. The vegetable kingdom, like every other province of nature,
was one of the fields of the labors of this universal philosopher. But
though his other works on natural history have come down to us, and
are a most valuable monument of the state of such knowledge in his
time, his Treatise on Plants is lost. The book De Plantis 362 which
appears with his name, is an imposture of the middle ages, full of
errors and absurdities. 11
11 Mirbel, Botanique, ii. 505.

His disciple, friend, and successor, Theophrastus of Eresos, is, as

we have said already, the first great writer on botany whose works
we possess; and, as may be said in most cases of the first great
writer, he offers to us a richer store of genuine knowledge and good
sense than all his successors. But we find in him that the Greeks of
his time, who aspired, as we have said, to collect and systematize a
body of information on every subject, failed in one half of their object,
as far as related to the vegetable world. Their attempts at a
systematic distribution of plants were altogether futile. Although
Aristotle’s divisions of the animal kingdom are, even at this day,
looked upon with admiration by the best naturalists, the
arrangements and comparisons of plants which were contrived by
Theophrastus and his successors, have not left the slightest trace in
the modern form of the science; and, therefore, according to our
plan, are of no importance in our history. And thus we can treat all
the miscellaneous information concerning vegetables which was
accumulated by the whole of this school of writers, in no other way