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First Aid Clinical Algorithms for the USMLE Step 2 Ck
1st Edition Jonathan Kramer-Feldman Digital Instant
Download
Author(s): Jonathan Kramer-Feldman, Linda Jiang
ISBN(s): 9781264270132, 1264270135
Edition: 1
File Details: PDF, 60.77 MB
Year: 2023
Language: english
 FIRST AID
CLINICAL
ALGORITHMS
FOR THE

USMLE
STEP 2 CK
orithms
to illustrate the clinicaldecision making process

Written by imedical students who recently excelled on the exam

Organized by symptom to mirror actual clinical practice
A one-of-a-kind resource to aid in making a diagnosis
and formulatlhg a treatment plan

Mc
Gra w
Hill JONATHAN KRAMER - FELDMAN LINDA JIANG
 First Aid
Clinical Algorithms
for the USMLE Step 2 CK

Jonathan Kramer-Feldman, MD
Department of Psychiatry
University of California, San Francisco
San Francisco, California

Linda Jiang, MD
Department of Internal Medicine
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

New York  Chicago  San Francisco  Athens  London  Madrid  

Mexico City   Milan  New Delhi  Singapore  Sydney  Toronto

Kramer_Feldman FM_pi_xxii.indd 1 08/06/23 5:00 PM

Copyright © 2024 by McGraw Hill LLC. All rights reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be
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 Jonathan: for my fiancée Elizabeth, my parents Jane and Mitch, my sister Nina,
her husband Adam and their children, Isaac and Zoe. Thank you for your support,
patience, and joy you bring into my life.

Linda: for my parents, Ning Jiang and Qin Wang, and my brother, Henry.
Thank you for your love, care, and support. You inspire me every day to chase my
dreams.

Kramer_Feldman FM_pi_xxii.indd 3 08/06/23 5:00 PM

 Contents
Acknowledgments ix
Editors xi
Contributors xv
Introduction xix

Internal Medicine 1 3-5 Macrocytic Anemia 99

3-6 Bleeding Disorders 101
Cardiology 1
3-7 Coagulation Factor Disorders 102
1-1 Chest Pain 2 3-8 Platelet Disorders 105
1-2 Ischemic Chest Pain 3 3-9 Hypercoagulability 109
1-3 Post-MI Complications 6 3-10 Acute Deep Vein Thrombosis 111
1-4 Non-Ischemic Chest Pain (Cardiac) 8 3-11 Anticoagulation 113
1-5 Non-Ischemic Chest Pain (Pulmonary) 9 3-12 Eosinophilia, Neutropenia, Transplant 114
1-6 Non-Ischemic Chest Pain (GI) 10 3-13 Transfusion Reactions 116
1-7 Non-Ischemic Chest Pain (Musculoskeletal) 11 3-14 Lymphoma 119
1-8 Congestive Heart Failure 12 3-15 Leukemia 122
1-9 Acute Decompensated Heart Failure 13 3-16 Plasma Cell Dyscrasias 125
1-10 Cardiogenic Shock 15 3-17 Mediastinal Masses 128
1-11 Cardiomyopathy 18 3-18 Commonly Tested Cancers 129
1-12 Dilated Cardiomyopathy 19 3-19 Oncologic Emergencies 130
1-13 Restrictive Cardiomyopathy 22
1-14 Hypertrophic Cardiomyopathy 25
1-15 ACLS Protocols: Adult Cardiac Arrest (VF/pVT/Asystole/PEA),
Endocrinology 131
Adult Bradyarrhythmia, and Adult Tachyarrhythmia 4-1 Hypoglycemia 132
with a Pulse 27 4-2 Hyperglycemia 134
1-16 Bradyarrhythmias 30 4-3 Treatment for Type 2 Diabetes 136
1-17 Supraventricular Tachyarrhythmias 32 4-4 Hypothyroidism 137
1-18 Ventricular Tachyarrhythmias 35 4-5 Hyperthyroidism 140
1-19 Antiarrhythmic Drugs 37 4-6 Thyroid Malignancies 143
1-20 Pericardial Disease 38 4-7 Bone Mineral Disorders 145
1-21 Valvulopathies 42 4-8 Hypercalcemia 148
1-22 Syncope 44 4-9 Hypocalcemia 152
1-23 Syncope (Cardiac) 45 4-10 Adrenal Insufficiency 154
1-24 Syncope (Non-Cardiac) 46 4-11 Cushing’s Syndrome 157
1-25 Hypertension 48 4-12 Etiologies of Secondary Hypertension 160
1-26 Hyperlipidemia 51
Infectious Diseases 163
Gastroenterology 53 5-1 Respiratory Tract Infections 164
2-1 Dysphagia 54 5-2 Pneumonia 165
2-2 Diarrhea 57 5-3 Subacute Pulmonary Infections 168
2-3 Chronic Inflammatory Diarrhea 58 5-4 Tongue Lesions 171
2-4 Chronic Non-Inflammatory Diarrhea 61 5-5 Throat Pain 173
2-5 Jaundice 64 5-6 Ear Pain 176
2-6 Elevated Transaminases 67 5-7 Sinusitis 178
2-7 Liver Cirrhosis and its Sequelae 72 5-8 CNS Infection in an Immunocompetent Host 180
2-8 Abdominal Pain 76 5-9 CNS Infection in an Immunocompromised Host 183
2-9 Melena 83 5-10 Endocarditis 185
2-10 Hematochezia 85 5-11 Cystitis 187
2-11 Vitamin and Mineral Deficiencies 87 5-12 Acute Inflammatory Diarrhea 189
5-13 Acute Non-Inflammatory Diarrhea 192
Hematology-Oncology 89 5-14 Roundworm and Tapeworm Infections 194
3-1 Anemia 90 5-15 Zoonoses 196
3-2 Microcytic Anemia 91 5-16 Arthropod-Borne Diseases 198
3-3 Normocytic Non-Hemolytic Anemia 94 5-17 Fever in a Returning Traveler 200
3-4 Normocytic Hemolytic Anemia 96 5-18 HIV-AIDS 202

Kramer_Feldman FM_pi_xxii.indd 5 08/06/23 5:00 PM

 vi Contents

Nephrology 205 9-18 Skin Necrosis 346

6-1 Hyponatremia 206 9-19 Genital Lesions 348
6-2 Hypotonic Hyponatremia 208 9-20 Scalp Pathologies 350
6-3 Hypernatremia 211 9-21 Oral Lesions 352
6-4 Hypokalemia 214 9-22 Pruritis 354
6-5 Hyperkalemia 216 9-23 Nail Pathologies 356
6-6 Acid-Base Disorders 219
6-7 Acidosis 220 Surgery 359
6-8 Respiratory Acidosis 221 Trauma 359
6-9 Anion Gap Metabolic Acidosis 224 10-1 Trauma ABCs 360
6-10 Non-Anion Gap Metabolic Acidosis 227 10-2 Head Trauma 363
6-11 Metabolic Alkalosis 229 10-3 Shock 365
6-12 Acute Kidney Injury 231 10-4 Chest Trauma 367
6-13 Prerenal Acute Kidney Injury 232 10-5 Abdominal Trauma 370
6-14 Intrinsic Acute Kidney Injury 235 10-6 Pelvic Injury 371
6-15 Post-Renal Acute Kidney Injury 237 10-7 Neck Trauma 374
6-16 Glomerular Disease 238 10-8 Extremity Trauma 376
6-17 Nephritic Syndrome 239 10-9 Burns 378
6-18 Nephrotic Syndrome 242 10-10 Bites and Stings 381
6-19 Dysuria in Men 244 10-11 Toxicology 383
6-20 Dysuria in Women 246 10-12 Major Drug Reactions 385
6-21 Renal Cysts 248 10-13 Spinal Cord Trauma 390

Pulmonology 251 Pre- & Post-Op Care 393

7-1 Dyspnea 252 11-1 Post-Op Abdominal Distention 394
7-2 Acute Dyspnea 253 11-2 Peri-Op Chest Pain 396
7-3 Acute-on-Chronic Dyspnea 254 11-3 Post-Op Fever 397
7-4 Chronic Dyspnea 255 11-4 Post-Op Altered Mental Status 400
7-5 Wheezing 257
7-6 Stridor 260
7-7 Hypoxemia 262
Gastrointestinal 401
7-8 V/Q Mismatch: Shunt 263 12-1 Esophagus 402
7-9 V/Q Mismatch: Other Causes 265 12-2 Stomach 405
7-10 Pulmonary Hypertension 268 12-3 Small Bowel 408
7-11 Approach to Pulmonary Function Tests 270 12-4 Colorectal 411
7-12 Pulmonary Function Tests 271 12-5 Hepatic Disease 414
7-13 Acute Cough 274 12-6 Biliary Disease 417
7-14 Chronic Cough 277 12-7 Pancreas 420
7-15 Hemoptysis 281 12-8 Hernia 422
7-16 Pulmonary Nodules 283
7-17 Pulmonary Vascular Diseases 285 Endocrine 425
7-18 Pleural Disease 287 13-1 Pancreatic Neuroendocrine Tumors 426
7-19 Cavitary Pulmonary Lesion 289 13-2 Adrenals 428
13-3 Parathyroids 430
Rheumatology 293
8-1 Polyarticular Joint Pain 294 Urology 431
8-2 Chronic Inflammatory Polyarticular Joint Pain 296 14-1 Lower Urinary Tract Symptoms 432
8-3 Rheumatologic Serologies 298 14-2 Lower Urinary Tract Symptoms (Irritative) 433
8-4 Petechiae 300 14-3 Lower Urinary Tract Symptoms (Obstructive) 435
8-5 Additional Rheumologic Diagnoses 304 14-4 Retention 437
8-6 Progressive Generalized Weakness 306 14-5 Incontinence 439
14-6 Kidney Stone Types 441
Dermatology 309 14-7 Kidney Stone Management 442
9-1 Hyperpigmented Macules 310 14-8 Urologic Emergencies 443
9-2 Hypopigmented Lesions 313 14-9 Male GU Cancers 446
9-3 Papular Skin Lesions 315 14-10 Hematuria 448
9-4 Flesh-Toned Papular Lesions 317 14-11 Erectile Dysfunction 450
9-5 Cystic Skin Lesions 319
9-6 Vascular Malformations 321 Otolaryngology–Head and Neck 451
9-7 Erythroderma 323 15-1 ENT: Neck Masses – Lymphadenopathy 452
9-8 Generalized Erythema 325 15-2 ENT: Other Masses 454
9-9 Localized Erythema 327 15-3 ENT: Emergencies 456
9-10 Pediatric Rashes 329
9-11 Vesicular Lesions 331 Orthopedic 457
9-12 Bullous Lesions 334
16-1 Adult Fractures 458
9-13 Pustular Lesions 336
16-2 Knee Injuries 460
9-14 Lichenified Plaque Lesions 338
16-3 Ankle Injuries 463
9-15 Scaling and Crusted Lesions 340
16-4 Hand Injuries 464
9-16 Ulcerous Lesions 342
16-5 Foot Pain 467
9-17 Nodular Skin Lesions 344

Kramer_Feldman FM_pi_xxii.indd 6 08/06/23 5:00 PM

 Chapter <CN> <Chapter Title to Come>
Contents vii

16-6 Emergencies 469 23-40 Precocious Puberty 627

16-7 Adult Bone Lesions 471 23-41 Delayed Puberty 629
16-8 Neurovascular Injuries 474 23-42 Acute Leg Pain/Limp 631
23-43 Chronic Leg Pain/Limp 634
Neurosurgery 479 23-44 Pediatric Upper Extremity Fractures 637
17-1 Spinal Disorders 480 23-45 Pediatric Lower Extremity Fractures 639
17-2 Intracranial Hemorrhage 483 23-46 Non-Accidental Trauma 641
17-3 Intracranial Tumors 486
17-4 Pituitary Disorders 488 Obstetrics 643
17-5 Vascular Occlusive Diseases 491 24-1 Vaginal Bleeding in Pregnancy 644
24-2 Recurrent Pregnancy Loss 646
Vascular 495 24-3 Hypertension in Pregnancy 648
18-1 Aortic Disease 496 24-4 Diabetes in Pregnancy 650
18-2 Peripheral Vascular Disease 498 24-5 Anemia in Pregnancy 652
24-6 Abnormal LFTs in Pregnancy 654
Breast 501 24-7 Placental Abnormalities 656
19-1 Malignant Breast Masses 502 24-8 Intrauterine Growth Restriction 658
19-2 Benign Breast Masses 505 24-9 Macrosomia 660
24-10 Trophoblastic Disease 662
Ophthalmology 509 24-11 Amniotic Fluid Abnormalities 665
24-12 Preterm Labor 667
20-1 Adult Ophthalmology 510 24-13 Fetal Heart Tracing 669
20-2 Eye Trauma 518 24-14 Onset of Labor 671
24-15 Stages of Labor 673
Transplant 521 24-16 Postpartum Fever 675
21-1 Transplant Rejection 522 24-17 Postpartum Hemorrhage 677
24-18 Postpartum Mood Changes 679
Anesthesia 525
22-1 Anesthesia 526 Gynecology 681
25-1 Acute Pelvic Pain 682
Pediatrics 529 25-2 Dyspareunia 684
23-1 Early Childhood Well-Child Check 530 25-3 Vulvar/Vaginal Cancers 686
23-2 Middle Childhood and Adolescent Well-Child Check 532 25-4 Vulvar/Vaginal Infections and Inflammation 688
23-3 Term and Preterm Infant Care 535 25-5 Vulvar Dystrophies 690
23-4 Birth Injuries 538 25-6 Genital Ulcers 692
23-5 Abnormal Newborn Screen 540 25-7 Abnormal Vaginal Discharge 694
23-6 Neonatal Skin Lesions 542 25-8 Incontinence 696
23-7 Birth Defects: Part 1 545 25-9 Primary Amenorrhea 698
23-8 Birth Defects: Part 2 547 25-10 Secondary Amenorrhea 701
23-9 Birth Defects: Part 3 549 25-11 Dysmenorrhea 703
23-10 Neonatal Unconjugated Hyperbilirubinemia 551 25-12 Abnormal Uterine Bleeding 705
23-11 Neonatal Conjugated Hyperbilirubinemia 554 25-13 Adnexal Mass 708
23-12 Neonatal Eye Discharge 556 25-14 Ovarian Cancer 710
23-13 Neonatal Respiratory Distress 558 25-15 Cervical Pathology 712
23-14 Neonatal Heart Defects 562
23-15 Neonatal Emesis 567 Neurology 715
23-16 Genetic Disorders: Inborn Errors of Metabolism 569
23-17 Genetic Disorders: Aneuploidy 571 26-1 Weakness/Sensory Loss 716
23-18 TORCH Infections 574 26-2 Myopathy/Neuromuscular Junction 717
23-19 Childhood Presentations 578 26-3 Polyneuropathy 719
23-20 Febrile Child: Part 1 579 26-4 Myelopathy 721
23-21 Febrile Child: Part 2 581 26-5 Stroke Syndrome 726
23-22 Febrile Child: Part 3 583 26-6 Stroke Management 730
23-23 Faltering Growth 587 26-7 Coma 733
23-24 Abnormal Head Circumference 588 26-8 Altered Mental Status 736
23-25 Bloody Stools 590 26-9 Movement Disorders and Dementia 739
23-26 Childhood Respiratory Distress 593 26-10 Dementia 740
23-27 Childhood Murmurs 596 26-11 Neurodegenerative Movement Disorders 742
23-28 Immunologic Disorders: Part 1 598 26-12 Hyperkinetic Disorders 744
23-29 Immunologic Disorders: Part 2 600 26-13 Tremor 746
23-30 Immunologic Disorders: Part 3 602 26-14 Gait 748
23-31 Pediatric Solid Tumors 605 26-15 Secondary Headache 750
23-32 Pediatric Liquid Tumors 609 26-16 Brain Tumors 753
23-33 Pediatric Ophthalmology 611 26-17 Primary Headache Disorders 756
23-34 Abnormal Tone 614 26-18 Dizziness 758
23-35 Progressive Muscle Weakness 615 26-19 Vertigo 759
23-36 Abnormal Movements: Seizures 617 26-20 Seizures 761
23-37 Pediatric Urinary Complaints 619 26-21 Visual Complaints 763
23-38 Penile Abnormality 622 26-22 Diplopia 764
23-39 Testicular Abnormality 624 26-23 Acute Monocular Vision Loss 767

Kramer_Feldman FM_pi_xxii.indd 7 08/06/23 5:00 PM

 viii Contents

26-24 Visual Field Defects 770 27-15 Sleep Disorders 803

26-25 Chronic Vision Loss 772 27-16 Sexual & Gender Identity Disorders 805
27-17 Self-Harm/Suicide 807
27-18 Pediatric Psychiatry 809
Psychiatry 775 27-19 Pediatric Psychiatry Presentations 810
27-1 Diagnosis of Psychiatric Concerns 776
27-2 Psychology, Psychodynamic & Behavioral Factors 777
27-3 Personality Disorders 779 Biostatistics, Epidemiology, and Medical Ethics 813
27-4 Psychotic Disorders 781 28-1 Biostatistics and Epidemiology 814
27-5 Antipsychotics 783 28-2 Disease Prevention 818
27-6 Psychotropic-Induced Movement Disorders 785 28-3 Vaccinations 818
27-7 Mood Disorders 787 28-4 Immunization Schedules 819
27-8 Antidepressants 789 28-5 Screening Recommendations 823
27-9 Mood Stabilizers 792 28-6 Medical Ethics 825
27-10 Anxiety Disorders 794
27-11 Anxiolytics 796
27-12 Substance Use Disorders 798 Abbreviations 827
27-13 Somatoform, Factitious & Related Disorders 800 Image and Table Acknowledgments 833
27-14 Eating Disorders 801 Index 849

Kramer_Feldman FM_pi_xxii.indd 8 08/06/23 5:00 PM

 Acknowledgments
This book would not have been possible without the tireless efforts of a number of medical students, as well as resident, fellow, and attend-
ing physicians who spent countless hours on this book on top of their full-time clinical and academic responsibilities. Our deepest gratitude
is offered to Carson Quinn, MD, Gaurang Gupte, MD, and Matthew Williams, MD, MBA, for their creative energy and dedication to this
book. We thank Bob Boehringer for his expert guidance and sense of humor, Revathi Viswanathan, Kim Davis, Kay Conerly, Lior Raz-Farley, and
everyone else at McGraw Hill who helped make this book a reality.

Kramer_Feldman FM_pi_xxii.indd 9 08/06/23 5:00 PM

 Editors
Associate Editor
Carson Quinn, MD
Department of Neurology
Harvard Medical School
Massachusetts General Hospital
Brigham and Women’s Hospital
Boston, Massachusetts

Project Manager
Gaurang Gupte, MD
Department of Anesthesiology
Washington University School of Medicine in St. Louis
Barnes–Jewish Hospital
St. Louis, Missouri

Section Editors
Medicine
Karly Hampshire, BS Valentina Jaramillo-Restrepo, MD
University of California, San Francisco School of Medicine Department of Internal Medicine
San Francisco, California University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Jessica Meng Jia Hao, MD
Combined Family Medicine and Psychiatry Mitchell Lynn, MD, MBA
University of Pittsburgh Medical Center Department of Radiology
St. Margaret Hospital, Western Psychiatric Hospital University of Missouri–Kansas City
Pittsburgh, Pennsylvania Kansas City, Missouri

Surgery
Chelsie Anderson, MD Jorge Zarate Rodriguez, MD
Department of General Surgery Department of General Surgery
University of California, San Francisco Washington University School of Medicine in St. Louis
San Francisco, California Barnes–Jewish Hospital
St. Louis, Missouri
Edward Andrews, MD
Department of Neurosurgery Michael Sadighian, MD
University of Pittsburgh Medical Center Department of Urology
Pittsburgh, Pennsylvania University of Southern California
Los Angeles, California
Nicolás Matheo Kass, BA
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

Kramer_Feldman FM_pi_xxii.indd 11 08/06/23 5:00 PM

 xii Editors

Neurology
Carson Quinn, MD Prashanth Rajarajan, MD, PhD
Department of Neurology Department of Neurology
Harvard Medical School Harvard Medical School
Massachusetts General Hospital Massachusetts General Hospital
Brigham and Women’s Hospital Brigham and Women’s Hospital
Boston, Massachusetts Boston, Massachusetts

Obstetrics and Gynecology Psychiatry

Christina N. Schmidt, BS Jimmy He, MD
Department of Obstetrics and Gynecology Department of Psychiatry
University of California, San Francisco School of Medicine Kaiser Permanente Oakland Medical Center
San Francisco, California Oakland, California

Pediatrics
Florence Lambert-Fliszar, MD Divya Kalyani Natarajan, MD, MPhil
Department of Pediatrics Department of Pediatrics
University of Washington School of Medicine University of Washington School of Medicine
Seattle Children’s Hospital Seattle Children’s Hospital
Seattle, Washington Seattle, Washington

Faculty Editors
Rachel Bratlie, DO, PMH-C Gerome V. Escota, MD, FIDSA
Adult and Perinatal Psychiatrist Section of Infectious Disease and Travel Medicine
Director of Residency Education Park Nicollet Clinic and Specialty Center
Department of Psychiatry St. Louis Park, Minnesota
Kaiser Permanente Oakland Medical Center
Oakland, California Maria Farooq, MD
Fellow
Dennis Chang, MD Department of Hematology-Oncology
Associate Professor of Medicine National Cancer Institute
Department of Internal Medicine National Institutes of Health
Washington University School of Medicine in St. Louis Bethesda, Maryland
Barnes–Jewish Hospital
St. Louis, Missouri Francesca Galbiati, MD
Fellow
Steven Cheng, MD Department of Endocrinology
Professor of Medicine Harvard Medical School
Department of Internal Medicine (Nephrology) Brigham and Women’s Hospital
Washington University School of Medicine in St. Louis Boston, Massachusetts
Barnes–Jewish Hospital
St. Louis, Missouri Tanmay Gokhale, MD, PhD
Fellow
David Daniels, MD Department of Cardiology
Assistant Professor of Psychiatry University of Pittsburgh Medical Center
Department of Psychiatry Pittsburgh, Pennsylvania
Washington University School of Medicine in St. Louis
Barnes–Jewish Hospital G. Kyle Harrold, MD
St. Louis, Missouri Instructor in Neurology
Department of Neurology
Casey Duncan, MD, MS Harvard Medical School
Assistant Professor of Surgery, General Surgery, and Surgical Brigham & Women’s Hospital
Oncology Boston, Massachusetts
Department of Surgical Oncology
UT Health Sciences Center at Houston
Houston, Texas

Kramer_Feldman FM_pi_xxii.indd 12 08/06/23 5:00 PM

 Editors xiii

Jennifer Jo, MD Joseph Sleiman, MD

Fellow Fellow
Department of Gastroenterology Department of Gastroenterology, Hepatology and Nutrition
Icahn School of Medicine at Mount Sinai University of Pittsburgh Medical Center
Mount Sinai Medical Center Pittsburgh, Pennsylvania
New York, New York
Jeffrey Stepan, MD, MSc
Ilana Roberts Krumm, MD Assistant Professor of Orthopedic Surgery and Rehabilitation
Fellow Medicine
Department of Pulmonary & Critical Care Department of Orthopedic Surgery
University of California, San Francisco The University of Chicago Medical Center
San Francisco, California Chicago, Illinois

Randall Lee, MD Eric Strand, MD

Fellow Chief, General Obstetrics and Gynecology
Department of Urology Professor, Department of Obstetrics and Gynecology
University of Southern California Associate Program Director, Residency, Obstetrics and
Los Angeles, California Gynecology
Washington University School of Medicine in St. Louis
Kathryn Leyens, MD Barnes–Jewish Hospital
Fellow St. Louis, Missouri
Department of Medicine-Pediatrics
University of Pittsburgh Medical Center Timothy Yau, MD
Pittsburgh, Pennsylvania Associate Professor of Medicine
Department of Internal Medicine (Nephrology)
Brianna Rossiter, MD, MS Washington University School of Medicine in St. Louis
Assistant Professor of Medicine Barnes–Jewish Hospital
Department of Internal Medicine St. Louis, Missouri
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

Resident Editors
Teresa Chen, MD Susrutha Puthanmadhom-Narayanan, MD
Department of Ophthalmology Department of Internal Medicine
UCLA Jules Stein Eye Institute University of Pittsburgh Medical Center
Los Angeles, California Pittsburgh, Pennsylvania

Ryan Halvorson, MD Matthew Williams, MD, MBA

Department of Orthopedic Surgery Department of Psychiatry
University of California, San Francisco University of California, San Francisco
San Francisco, California San Francisco, California

Sarah Mohamedaly, MD, MPH David Xiong, MD

Department of General Surgery Department of Dermatology
University of California, San Francisco University Hospitals Cleveland Medical Center/Case Western
San Francisco, California Reserve University
Cleveland, Ohio
Christopher Puchi, MD
Department of Otolaryngology – Head & Neck Surgery
Northwestern University Feinberg School of Medicine
Northwestern Medicine
Chicago, Illinois

Kramer_Feldman FM_pi_xxii.indd 13 08/06/23 5:00 PM

 Contributors
Uzoma Ahiarakwe, MS Henry Clay Carter, BS
Eastern Virginia Medical School University of California, San Francisco School of Medicine
Norfolk, Virginia San Francisco, California

Austin Anthony, MA Chloe Cattle, MD

University of Pittsburgh School of Medicine University of California, San Francisco
Pittsburgh, Pennsylvania San Francisco, California

Ellen Barry, MD Ingrid Lynn Chen, MD

University of Pittsburgh Medical Center (St. Margaret Hospital) Kaiser Permanente Oakland Medical Center
Pittsburgh, Pennsylvania Oakland, California

Hannah Beaman, MD Shulei Shelley Chen, MD, MS

New York University Langone Health San Mateo County Behavioral Health and Recovery Services
New York, New York San Mateo, California

Tierra Bender, BS Sarah Cohen, BS, MPH

University of Pittsburgh School of Medicine Washington University in St. Louis
Pittsburgh, Pennsylvania St. Louis, Missouri

Kathryn Bennett-Brown, MD Prisca C. Diala, BA

Kaiser Permanente Oakland Medical Center University of California, San Francisco
Oakland, California San Francisco, California

Ninad Bhat, MD Ronaldo C. Fabiano Filho, MD

University of California, San Francisco School of Medicine University of Pittsburgh Medical Center
San Francisco, California Pittsburgh, Pennsylvania

Anika Binner, MD Lauryn M. Falcone, MD, PhD

University of Pittsburgh Medical Center University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Pittsburgh, Pennsylvania

Shaila Bonanno, MD Oluleke Falade, BS

University of Washington School of Medicine University of Pittsburgh School of Medicine
Seattle Children’s Hospital Pittsburgh, Pennsylvania
Department of Pediatrics
Seattle, Washington
Vanessa F. Fernanda Ferreira, MD
Massachusetts General Hospital
Sonny Caplash, MD Harvard Medical School
University of Pittsburgh Medical Center Boston, Massachusetts
Pittsburgh, Pennsylvania

Luis Carrete, BS
University of California, San Francisco School of Medicine
San Francisco, California

Kramer_Feldman FM_pi_xxii.indd 15 08/06/23 5:00 PM

 xvi Contributors

Emily Flaherty, BA Arthur Lenahan, MD, MPH

University of Pittsburgh School of Medicine University of Washington School of Medicine
Pittsburgh, Pennsylvania Seattle Children’s Hospital
Department of Pediatrics
Seattle, Washington
David Fogg, BS
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Liza Leykina, BA
University of California, San Francisco School of Medicine
San Francisco, California
Jose V. Forero, MD
The Ohio State University Wexner Medical Center
Columbus, Ohio Carrie Li, MD
Massachusetts General Hospital
Harvard Medical School
Dylan Fortman, MD Boston, Massachusetts
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Audrey Lim, MD
University of Pittsburgh Medical Center
Gio Gemelga, MD Pittsburgh, Pennsylvania
St. Joseph’s Medical Center
Stockton, California Brandon Lippold, MD
Washington University School of Medicine in St. Louis
Natalie Griffin, MD Barnes-Jewish Hospital
University of Pittsburgh Medical Center St. Louis, Missouri
Pittsburgh, Pennsylvania
Grace Lisius, MD
Inderpreet Hayer, MS University of Pittsburgh Medical Center
University of California, Berkeley-San Francisco Joint Medical Pittsburgh, Pennsylvania
Program
Berkeley, California Sarah Lowenstein, MD
University of Washington School of Medicine
Alex Hedeya, MD Seattle Children’s Hospital
Heersink School of Medicine Department of Pediatrics
The University of Alabama at Birmingham Seattle, Washington
Birmingham, Alabama
Maxwell Marlowe, MD
Alexander Hedaya, MD University of Washington School of Medicine
The University of Alabama at Birmingham Seattle Children’s Hospital
Birmingham, Alabama Department of Pediatrics
Seattle, Washington
Zachary Hier, MD
University of Louisville Asher Mirvish, BA
Louisville, Kentucky University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Nuzhat Islam, MD
University of California, San Diego Health Alicia Mizes, MD
San Diego, California Memorial Sloan Kettering Cancer Center
New York, New York
Elizabeth Kairis, BS
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Eider Moreno, MD
Mayo Clinic
Daniel Kim, MD Phoenix, Arizona
Cedars-Sinai Medical Center
Los Angeles, California Arman Mosenia, MD
University of Texas, Austin Dell Medical School
Anisha Konanur, MD Austin, Texas
University of Washington Medical Center
Department of Otolaryngology–Head and Neck Surgery Snehal Murthy, MD, MS
Seattle, Washington University of California, San Francisco
San Francisco, California
Alan Kong, MD Benioff Children’s Hospital Oakland
University of California, Los Angeles Oakland, California
Los Angeles, California

Kramer_Feldman FM_pi_xxii.indd 16 08/06/23 5:00 PM

 Contributors xvii

Jennifer Meylor, MD Raisa Lomanto Silva, MD

University of Washington School of Medicine University of Pittsburgh Medical Center
Seattle Children’s Hospital Pittsburgh, Pennsylvania
Department of Pediatrics
Seattle, Washington Scott Swartz, MS
University of California, San Francisco School of Medicine
Fiona Miller, BA San Francisco, California
University of California, San Francisco
San Francisco, California Alice Tang, BS
University of California, San Francisco School of Medicine
Blair Mockler, MD San Francisco, California
University of Washington School of Medicine
Seattle Children’s Hospital Avery Thompson, MD
Department of Pediatrics Brigham and Women’s Hospital
Seattle, Washington Boston, Massachusetts

Joshua Norman, MD Christopher Thompson, MD

Stanford University University of Pittsburgh Medical Center
Stanford, California Pittsburgh, Pennsylvania

Ryan Norris, MD Hannah Tierney, MPH

Kaiser Permanente Oakland Medical Center University of California, San Francisco School of Medicine
Oakland, California San Francisco, California

Breanna Nyugen, BA Savannah Tollefson, BS

University of Pittsburgh School of Medicine University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Pittsburgh, Pennsylvania

India Perez-Urbano, BA Adrienne Visani, MD

University of California, San Francisco Washington University School of Medicine in St Louis
San Francisco, California Barnes-Jewish Hospital
St. Louis, Missouri
Michael Raver, BS
University of Pittsburgh School of Medicine Nathan Vengalil, MD
Pittsburgh, Pennsylvania Washington University School of Medicine in St. Louis
Barnes-Jewish Hospital
Camille Rogine, MD St. Louis, Missouri
University of California, San Francisco School of Medicine
San Francisco, California Jordan Wallace, MD
University of Washington School of Medicine
Harriet Rothschild, BA Seattle Children’s Hospital
University of California, San Francisco Department of Pediatrics
San Francisco, California Seattle, Washington

Nikhil Sharma, MS Lucas Weiser, MD

University of Pittsburgh School of Medicine Cedars Sinai Medical Center
Pittsburgh, Pennsylvania Los Angeles, California

Monica Stretten, MD Yael Wollstein, BA

University of California, Los Angeles University of Pittsburgh School of Medicine
Los Angeles, California Pittsburgh, Pennsylvania

Fritz Steuer, BS Toby Zhu, BS

University of Pittsburgh School of Medicine University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Pittsburgh, Pennsylvania

Sukruth Shashikumar, SB Valerie Zike, BS

Washington University School of Medicine in St. Louis Washington University School of Medicine in St. Louis
St. Louis, Missouri St. Louis, Missouri

Kramer_Feldman FM_pi_xxii.indd 17 08/06/23 5:00 PM

 Introduction
Why should I use this book? algorithm, as well as the clinical vignette on the HYF page,
We are excited to introduce First Aid Clinical Algorithms for the should be studied to answer these questions.
USMLE Step 2 CK, a new and improved study tool to help you excel 2. “Treatment” questions ask you to identify the appropriate
on the Step 2 CK. Unlike other textbooks that present diseases by treatment for the described condition. Often you must first
shared pathology, this book organizes material by presenting symp- identify the condition based on the question stem. Studying
toms in algorithms meant to demonstrate the clinical reasoning the algorithms (and potentially further treatment steps on
that should be used to answer the questions on test day. HYF pages) should prepare you well for these questions.
Many chief complaints have broad differentials that are often 3. “Best next step” questions ask you to (implicitly) form
not helpful to consider in their entirety for any given patient. a differential and then decide the next step in either
Instead, a clinician or test-taker should notice a few initial clues diagnosis or treatment. Oftentimes the specific diagnosis is
to narrow the differential from, say, dizziness to vertigo or a car- not clear, but a management step must be chosen anyway.
diac arrhythmia. Before developing a differential diagnosis. In this The algorithm format is ideal for thinking through these
book, this step is organized by “meta-algorithms” that show the questions.
steps to reach a more specific chief complaint, for which there is an 4. “Complications” questions ask you to predict the
algorithm/HYF page from the broader chief complaint (dizziness treatment complication the patient is at risk for developing
to vertigo). These pages serve to describe frameworks for a chief based on the drug or procedure indicated once you know a
complaint and the initial salient features to note. diagnosis or treatment. Use the algorithm to determine the
Algorithms present in a visually clear way the most vital infor- diagnosis and then the complications are listed in the HYF
mation needed to discriminate between similarly presenting diag- page.
noses and the correct timing of different management steps. The 5. “Differentiate” questions ask what essential diagnostic test
benefit of this format is that it helps the reader to distill the “infor- will differentiate one diagnosis from another, closely related
mation overload” often present in Step 2 question stems to the diagnosis. The algorithm format is designed to focus on
salient information that is needed to answer the questions quickly these essential diagnostic steps.
and correctly without being bogged down in unnecessary details. 6. “Facts” questions ask for specifics on a disease once
The book is comprised of paired algorithms and “High-Yield you have identified it, such as epidemiology (often what
Facts” (HYF) pages so that, for a given chief complaint, the diseases populations are at risk) and pathophysiology. The highest-
that should be on your differential will be included in an algorithm yield facts are covered in the HYF page.
that provides a step-by-step method to guide you from the chief • The algorithms are best used alongside practice questions.
complaint to the correct diagnosis and initial treatment. Accompa- After you finish a practice exam or question set, use this book
nying each algorithm will be the HYF page, which lists the diseases as you review incorrect (and correct) answers. Identify the
from the algorithm and includes pertinent high-yield information chief complaint and turn to the corresponding meta-algorithm
that is not present in the algorithm, in particular, a brief clinical or primary algorithm. Alternately, as you glance through the
vignette, management steps, and potential complications. answer choices, identify the algorithm that best includes these.
Work your way down the algorithm using the data provided
How should I use this book? in the question stem. If you made a mistake in the workup or
• It will be most helpful to begin using this book early in your sequence of management, it should be clear where that mistake
clinical education as you prepare for and start clerkships. The was made based on the algorithm. If you answered correctly,
specialty-specific chapters are designed to be study tools for the tracing your steps down the algorithm will help to reinforce
shelf exams and will also provide frameworks for the patients your reasoning.
and diseases you encounter on the wards and in clinic. As you • The algorithms can also be used to help to understand clini-
work through the chapters on each clerkship, you will be well cal decision-making on the wards or to provide guides for brief
prepared to review the book as a whole when studying for the on-rounds teaching on the management of specific complaints.
Step 2 CK exam. However, it should be noted that in instances of conflict, this
• This book will help you to answer the 6 primary types of ques- book favors the “test correct” approach, and occasionally this
tions on the Step 2 CK (and shelf) exams: approach may differ from usual clinical practice.
1. “Diagnosis” questions simply ask you to diagnose the
condition based on a question stem and set of data. The

Kramer_Feldman FM_pi_xxii.indd 19 08/06/23 5:00 PM

 xx Introduction

Anatomy of an Algorithm: more familiar with the format throughout the course of the
• The algorithms are designed to follow a similar structure across book, the meanings of these non-textual signifiers will become
the book. Information is embedded via the written text, as well second nature and not require frequent referencing of the key
as through colors, symbols, and shapes. As the reader becomes included below.

Temperature >38°C (100.4°F)

Immediate (within
Postoperative Postoperative Postoperative Postoperative
30 minutes of
days 1–2 days 3–5 days 4–6 days 5–7
anesthetic)

Hypercarbia, WIND: WATER: WALKING: WOUND:

tachycardia, Atelectasis vs. Urinary Tract Deep Vein SSTI vs. Deep
muscle rigidity
Pneumonia Infection Thrombosis Abscess

WONDER Respiratory
Remove catheter
Lower extremity Cardinal signs of Salmon-colored
DRUG: Malignant symptoms duplex ultrasound SSTI1 wound exudate
Hyperthermia

Urinalysis and Anticoagulation

Dantrolene Chest X-ray
culture or IVC filter
Wound
Dehiscence

↓ Lung
Consolidation Antibiotics
Skin and CT Local wound
volumes Soft Tissue abdomen/pelvis care, antibiotics
Infection

Skin open, exposing

Antibiotics Deep underlying contents
Atelectasis Pneumonia
Abscess

Incentive Antibiotics +
spirometry,
Antibiotics +
percutaneous
Wound
supplemental O2 Evisceration
out of bed drainage

Footnotes
The “5Ws” mnemonic for the causes of fever in the post-operative period is Wind,
Water, Wound, Walking, and Wonder Drugs. These 5 causes are time-dependent To OR for
and thus typically occur in a predictable sequence. emergent repair2
1. Cardinal signs of skin and soft tissue infection: Redness, warmth, swelling, pus.
2. Do NOT push eviscerated contents back into body cavity due to infection risk;
cover with sterile material before taking the patient to the OR.

Kramer_Feldman FM_pi_xxii.indd 20 08/06/23 5:00 PM

 Introduction xxi

Chief complaint: All algorithms start with a chief complaint that immediately see all the diagnoses present on a given algorithm (ie,
brings you to that algorithm. It can be either a symptom (cough), the differential diagnosis for that chief complaint).
sign (macular rash), or lab value (hyponatremia).
Workup: Gray box. Next will be a box with an element of the workup
that will help to discriminate the different pathways that will take Atelectasis
you to the correct and alternate diagnoses. This can be a lab test,
imaging test, physical exam finding, or element of the history.
Treatment: Blue box. Treatment steps will stand out from the
workup by the blue color of their boxes. They can be empiric treat-
Urinalysis and ment steps before you have reached the diagnosis or directed treat-
culture ment that are below/after the diagnosis.

Positive and negative branches: If that element of the workup is

Antibiotics +
positive, follow the + sign. If it is negative, follow the – sign. All supplemental O2
branches have arrows to indicate the direction of the clinical rea-
soning from chief complaint to diagnosis.
Symbols: In Workup and Findings boxes, the stethoscope symbol
indicates a physical exam maneuver or finding, the test tube symbol
indicates a lab test, and the microscope symbol indicates an imag-
Findings: Green box. Often, the element of the workup does not ing study.
have a binary answer (+/–). In this case, the finding from that
workup step will be the next box below.
Footnotes: Detailed information that is necessary for understand-
ing the algorithm but too lengthy to be suited for the graphic algo-
Hypercarbia, rithm is included in the footnotes with numbered superscripts to
tachycardia, link it to the appropriate place in the algorithm.
muscle rigidity
Images: Images are included when they are likely to show up on
Diagnosis: Gold hexagon. After several steps, you will have reached test questions as important pieces of data to narrow a differential,
the diagnosis. These are in a bright color and larger font, so you can such as classic radiology, pathology, or physical exam findings.

Kramer_Feldman FM_pi_xxii.indd 21 08/06/23 5:00 PM

 1
Internal Medicine:
Cardiology

Kramer-Feldman_Ch01_p001_052.indd 1 08/06/23 5:49 PM

 2 Chapter 1 Internal Medicine: Cardiology

1-1 Chest Pain

Chest Pain

Cardiac Non-Cardiac See pp. 9–11

Ischemic Non-Ischemic Pulmonary Causes

Gastrointestinal
Causes
Acute Coronary Stable/Chronic • Pericarditis
Syndrome Angina • Myocarditis
• Decompensated Musculoskeletal
Heart Failure Causes
• Prinzmetal Angina
• Valvular Disease
• Aortic Syndromes Other Causes
(Miscellaneous)

See pp. 3–5 See p. 8

Chest pain is one of the most common reasons in which a patient presents for medical care. There are many etiologies of chest pain or discomfort,
and certain life-threatening pathologies cannot be missed. Acute chest pain or discomfort can be framed into 3 primary categories: Myocardial ischemia,
non-ischemic cardiac chest pain, and non-cardiac chest pain.
Myocardial ischemia usually presents with typical chest pain, which often consists of chest, arm, and/or jaw pain described as dull, heavy, tight, or crushing.
It may be accompanied by dyspnea, nausea, vomiting, abdominal pain, diaphoresis, as well as a sense of anxiety or uneasiness, and can be triggered or
exacerbated by physical exertion and stress. If ongoing myocardial ischemia is suspected, the patient should be evaluated with basic diagnostic tools like
EKG and cardiac biomarkers for acute coronary syndrome, a spectrum of clinical presentations caused by plaque disruption or coronary vasospasm
leading to inadequate oxygen delivery to meet the heart’s metabolic demands. If myocardial ischemia is severe or prolonged in duration, irreversible
ischemic injury occurs, leading to myocardial infarction.
Both non-ischemic cardiac chest pain and non-cardiac chest pain usually present with atypical chest pain, which is frequently described as epigastric or
back pain or pain that is sharp, stabbing, burning, or suggestive of indigestion. If the chest pain has these non-ischemic qualities, there is a 95% negative
predictive value. Non-ischemic causes of cardiac chest pain include acute inflammatory or infectious processes (eg, infective endocarditis), pericardial
disease, aortic dissection, valvular pathologies, and heart failure. The majority of patients that present with chest pain will have a non-cardiac etiology.
The most common etiologies of chest pain are pulmonary (eg, pulmonary embolism, pneumothorax), gastrointestinal (eg, GERD, dyspepsia), and
musculoskeletal (eg, costochondritis). We will discuss these etiologies in more depth in the following pages. In addition, some patients that present
with acute chest discomfort may have an underlying psychiatric condition (eg, panic disorder) and experience chest tightness associated with difficulty
breathing, anxiety, and heart palpitations.
When a patient presents with chest pain, the first step in management is obtaining vital signs, including pulse oximetry, and a thorough cardiopulmonary
examination. If the patient is hemodynamically unstable, follow the ACLS protocol. If hemodynamically stable, obtain a thorough history on the quality,
location (including radiation), and pattern (including onset, duration, and provoking or alleviating factors) of the pain. Obtaining a description of associated
symptoms (eg, dyspnea, palpitations, hemoptysis) and the patient’s prior medical history (eg, coronary artery disease, connective tissue disease, malignancy)
is also helpful. Pulmonary etiologies (eg, pulmonary embolism) are usually associated with dyspnea and/or an ↑ oxygen requirement, and the chest pain is
often pleuritic in nature. Acute aortic dissection often presents with a terrible, tearing chest pain. Musculoskeletal pain is often reproduced with certain
movements or upon palpation of a specific area. A burning quality or exacerbation with eating can be suggestive of a gastrointestinal etiology. All together,
the patient’s demographics and chest pain characteristics, as well as basic diagnostic tools like EKG, chest x-ray, and cardiac biomarkers, narrow the
differential and help guide management.

FIGURE 1.1

Kramer-Feldman_Ch01_p001_052.indd 2 08/06/23 5:49 PM

Discovering Diverse Content Through
Random Scribd Documents
performance, is as a whole only the intensification of this being-
human. Henceforward all that resists our sensations is not mere
resistance or thing or impression, as it is for animals and for children
also, but an expression as well. Not merely are things actually
contained in the world-around but also they possess meaning, as
phenomena in the world-view. Originally they possessed only a
relationship to men, but now there is also a relationship of men to
them. They have become emblems of his existence. And thus the
essence of every genuine—unconscious and inwardly necessary—
symbolism proceeds from the knowledge of death in which the
secret of space reveals itself. All symbolism implies a defensive; it is
the expression of a deep Scheu in the old double sense of the word,
[179]
and its form-language tells at once of hostility and of reverence.
Every thing-become is mortal. Not only peoples, languages, races
and Cultures are transient. In a few centuries from now there will no
more be a Western Culture, no more be German, English or French
than there were Romans in the time of Justinian. Not that the
sequence of human generations failed; it was the inner form of a
people, which had put together a number of these generations as a
single gesture, that was no longer there. The Civis Romanus, one of
the most powerful symbols of Classical being, had nevertheless, as
a form, only a duration of some centuries. But the primitive
phenomenon of the great Culture will itself have disappeared some
day, and with it the drama of world-history; aye, and man himself,
and beyond man the phenomenon of plant and animal existence on
the earth’s surface, the earth, the sun, the whole world of sun-
systems. All art is mortal, not merely the individual artifacts but the
arts themselves. One day the last portrait of Rembrandt and the last
bar of Mozart will have ceased to be—though possibly a coloured
canvas and a sheet of notes may remain—because the last eye and
the last ear accessible to their message will have gone. Every
thought, faith and science dies as soon as the spirits in whose
worlds their “eternal truths” were true and necessary are
extinguished. Dead, even, are the star-worlds which “appeared,” a
proper world to the proper eye, to the astronomers of the Nile and
the Euphrates, for our eye is different from theirs; and our eye in its
turn is mortal. All this we know. The beast does not know, and what
he does not know does not exist in his experienced world-around.
But if the image of the past vanishes, the longing to give a deeper
meaning to the passing vanishes also. And so it is with reference to
the purely human macrocosm that we apply the oft-quoted line,
which shall serve as motto for all that follows: Alles Vergängliche ist
nur ein Gleichnis.
From this we are led, without our noticing it, back to the space-
problem, though now it takes on a fresh and surprising form. Indeed,
it is as a corollary to these ideas that it appears for the first time as
capable of solution—or, to speak more modestly, of enunciation—
just as the time-problem was made more comprehensible by way of
the Destiny-idea. From the moment of our awakening, the fateful and
directed life appears in the phenomenal life as an experienced
depth. Everything extends itself, but it is not yet “space,” not
something established in itself but a self-extension continued from
the moving here to the moving there. World-experience is bound up
with the essence of depth (i.e., far-ness or distance). In the abstract
system of mathematics, “depth” is taken along with “length” and
“breadth” as a “third” dimension; but this trinity of elements of like
order is misleading from the outset, for in our impression of the
spatial world these elements are unquestionably not equivalents, let
alone homogeneous. Length and breadth are no doubt,
experientially, a unit and not a mere sum, but they are (the phrase is
used deliberately) simply a form of reception; they represent the
purely sensuous impression. But depth is a representation of
expression, of Nature, and with it begins the “world.”
This discrimination between the “third” and the other two
dimensions, so called, which needless to say is wholly alien to
mathematics, is inherent also in the opposition of the notions of
sensation and contemplation. Extension into depth converts the
former into the latter; in fact, depth is the first and genuine dimension
in the literal sense of the word.[180] In it the waking consciousness is
active, whereas in the others it is strictly passive. It is the symbolic
content of a particular order as understood by one particular Culture
that is expressed by this original fundamental and unanalysable
element. The experiencing of depth (this is a premiss upon which all
that follows is dependent) is an act, as entirely involuntary and
necessary as it is creative, whereby the ego keeps its world, so to
say, in subordination (zudiktiert erhält). Out of the rain of impressions
the ego fashions a formal unit, a cinematic picture, which as soon as
it is mastered by the understanding is subjected to law and the
causality principle; and therefore, as the projection of an individual
spirit it is transient and mortal.
There is no doubt, however reason may contest it, that this
extension is capable of infinite variety, and that it operates differently
not merely as between child and man, or nature-man and townsman,
or Chinese and Romans, but as between individual and individual
according as they experience their worlds contemplatively or alertly,
actively or placidly. Every artist has rendered “Nature” by line and by
tone, every physicist—Greek, Arabian or German—has dissected
“Nature” into ultimate elements, and how is it that they have not all
discovered the same? Because every one of them has had his own
Nature, though—with a naïveté that was really the salvation of his
world-idea and of his own self—every one believed that he had it in
common with all the rest. Nature is a possession which is saturated
through and through with the most personal connotations. Nature is
a function of the particular Culture.

III

Kant believed that he had decided the great question of whether

this a priori element was pre-existent or obtained by experience, by
his celebrated formula that Space is the form of perception which
underlies all world impressions. But the “world” of the careless child
and the dreamer undeniably possess this form in an insecure and
hesitant way,[181] and it is only the tense, practical, technical
treatment of the world-around—imposed on the free-moving being
which, unlike the lilies of the fields, must care for its life—that lets
sensuous self-extension stiffen into rational tridimensionality. And it
is only the city-man of matured Cultures that really lives in this
glaring wakefulness, and only for his thought that there is a Space
wholly divorced from sensuous life, “absolute,” dead and alien to
Time; and it exists not as a form of the intuitively-perceived but as a
form of the rationally-comprehended. There is no manner of doubt
that the “space” which Kant saw all around him with such
unconditional certainty when he was thinking out his theory, did not
exist in anything like so rigorous a form for his Carolingian ancestors.
Kant’s greatness consists in his having created the idea of a "form a
priori," but not in the application that he gave it. We have already
seen that Time is not a “form of perception” nor for that matter a form
at all—forms exist only in the extended—and that there is no
possibility of defining it except as a counter-concept to Space. But
there is the further question—does this word “space” exactly cover
the formal content of the intuitively-perceived? And beyond all this
there is the plain fact that the “form of perception” alters with
distance. Every distant mountain range is “perceived” as a scenic
plane. No one will pretend that he sees the moon as a body; for the
eye it is a pure plane and it is only by the aid of the telescope—i.e.
when the distance is artificially reduced—that it progressively obtains
a spatial form. Obviously, then, the “form of perception” is a function
of distance. Moreover, when we reflect upon anything, we do not
exactly remember the impressions that we received at the time, but
“represent to ourselves” the picture of a space abstracted from them.
But this representation may and does deceive us regarding the living
actuality. Kant let himself be misled; he should certainly not have
permitted himself to distinguish between forms of perception and
forms of ratiocination, for his notion of Space in principle embraced
both.[182]
Just as Kant marred the Time-problem by bringing it into relation
with an essentially misunderstood arithmetic and—on that basis—
dealing with a phantom sort of time that lacks the life-quality of
direction and is therefore a mere spatial scheme, so also he marred
the Space-problem by relating it to a common-place geometry.
It befell that a few years after the completion of Kant’s main work
Gauss discovered the first of the Non-Euclidean geometries. These,
irreproachably demonstrated as regards their own internal validity,
enable it to be proved that there are several strictly mathematical
kinds of three-dimensional extension, all of which are a priori certain,
and none of which can be singled out to rank as the genuine “form of
perception.”
 It was a grave, and in a contemporary of Euler and Lagrange an
unpardonable, error to postulate that the Classical school-geometry
(for it was that which Kant always had in mind) was to be found
reproduced in the forms of Nature around us. In moments of
attentive observation at very short range, and in cases in which the
relations considered are sufficiently small, the living impressions and
the rules of customary geometry are certainly in approximate
agreement. But the exact conformity asserted by philosophy can be
demonstrated neither by the eye nor by measuring-instruments. Both
these must always stop short at a certain limit of accuracy which is
very far indeed below that which would be necessary, say, for
determining which of the Non-Euclidean geometries is the geometry
of “empirical” Space.[183] On the large scales and for great distances,
where the experience of depth completely dominates the perception-
picture (for example, looking on a broad landscape as against a
drawing) the form of perception is in fundamental contradiction with
mathematics. A glance down any avenue shows us that parallels
meet at the horizon. Western perspective and the otherwise quite
different perspective of Chinese painting are both alike based on this
fact, and the connexion of these perspectives with the root-problems
of their respective mathematics is unmistakable.
Experiential Depth, in the infinite variety of its modes, eludes every
sort of numerical definition. The whole of lyric poetry and music, the
entire painting of Egypt, China and the West by hypothesis deny any
strictly mathematical structure in space as felt and seen, and it is
only because all modern philosophers have been destitute of the
smallest understanding of painting that they have failed to note the
contradiction. The “horizon” in and by which every visual image
gradually passes into a definitive plane, is incapable of any
mathematical treatment. Every stroke of a landscape painter’s brush
refutes the assertions of conventional epistemology.
As mathematical magnitudes abstract from life, the “three
dimensions” have no natural limits. But when this proposition
becomes entangled with the surface-and-depth of experienced
impression, the original epistemological error leads to another, viz.,
that apprehended extension is also without limits, although in fact
our vision only comprises the illuminated portion of space and stops
at the light-limit of the particular moment, which may be the star-
heavens or merely the bright atmosphere. The “visual” world is the
totality of light-resistances, since vision depends on the presence of
radiated or reflected light. The Greeks took their stand on this and
stayed there. It is the Western world-feeling that has produced the
idea of a limitless universe of space—a space of infinite star-systems
and distances that far transcends all optical possibilities—and this
was a creation of the inner vision, incapable of all actualization
through the eye, and, even as an idea, alien to and unachievable by
the men of a differently-disposed Culture.

IV

The outcome, then, of Gauss’s discovery, which completely altered

the course of modern mathematics,[184] was the statement that there
are severally equally valid structures of three-dimensional extension.
That it should even be asked which of them corresponds to actual
perception shows that the problem was not in the least
comprehended. Mathematics, whether or not it employs visible
images and representations as working conveniences, concerns
itself with systems that are entirely emancipated from life, time and
distance, with form-worlds of pure numbers whose validity—not fact-
foundation—is timeless and like everything else that is “known” is
known by causal logic and not experienced.
With this, the difference between the living intuition-way and the
mathematical form-language became manifest and the secret of
spatial becoming opened out.
As becoming is the foundation of the become, continuous living
history that of fulfilled dead nature, the organic that of the
mechanical, destiny that of causal law and the causally-settled, so
too direction is the origin of extension. The secret of Life
accomplishing itself which is touched upon by the word Time forms
the foundation of that which, as accomplished, is understood by (or
rather indicated to an inner feeling in us by) the word Space. Every
extension that is actual has first been accomplished in and with an
experience of depth, and what is primarily indicated by the word
Time is just this process of extending, first sensuously (in the main,
visually) and only later intellectually, into depth and distance, i.e., the
step from the planar semi-impression to the macrocosmically
ordered world-picture with its mysterious-manifest kinesis. We feel—
and the feeling is what constitutes the state of all-round awareness
in us—that we are in an extension that encircles us; and it is only
necessary to follow out this original impression that we have of the
worldly to see that in reality there is only one true “dimension” of
space, which is direction from one’s self outwards into the distance,
the “there” and the future, and that the abstract system of three
dimensions is a mechanical representation and not a fact of life. By
the depth-experience sensation is expanded into the world. We have
seen already that the directedness that is in life wears the badge of
irreversibility, and there is something of this same hall-mark of Time
in our instinctive tendency to feel the depth that is in the world uni-
directionally also—viz., from ourselves outwards, and never from the
horizon inwards. The bodily mobility of man and beast is disposed in
this sense. We move forward—towards the Future, nearing with
every step not merely our aim but our old age—and we feel every
backward look as a glance at something that is past, that has
already become history.[185]
If we can describe the basic form of the understood, viz., causality,
as destiny become rigid, we may similarly speak of spatial depth as
a time become rigid. That which not only man but even the beast
feels operative around him as destiny, he perceives by touching,
looking, listening, scenting as movement, and under his intense
scrutiny it stiffens and becomes causal. We feel that it is drawing
towards spring and we feel in advance how the spring landscape
expands around us; but we know that the earth as it moves in space
revolves and that the duration of spring consists of ninety such
revolutions of the earth, or days. Time gives birth to Space, but
Space gives death to Time.
Had Kant been more precise, he would, instead of speaking of the
“two forms of perception,” have called time the form of perception
and space the form of the perceived, and then the connexion of the
two would probably have revealed itself to him. The logician,
mathematician, or scientist in his moments of intense thought, knows
only the Become—which has been detached from the singular event
by the very act of meditating upon it—and true systematic space—in
which everything possesses the property of a mathematically-
expressible “duration.” But it is just this that indicates to us how
space is continuously “becoming.” While we gaze into the distance
with our senses, it floats around us, but when we are startled, the
alert eye sees a tense and rigid space. This space is; the principle of
its existing at all is that it is, outside time and detached from it and
from life. In it duration, a piece of perished time, resides as a known
property of things. And, as we know ourselves too as being in this
space, we know that we also have a duration and a limit, of which
the moving finger of our clock ceaselessly warns us. But the rigid
Space itself is transient too—at the first relaxation of our intellectual
tension it vanishes from the many-coloured spread of our world-
around—and so it is a sign and symbol of the most elemental and
powerful symbol, of life itself.
For the involuntary and unqualified realization of depth, which
dominates the consciousness with the force of an elemental event
(simultaneously with the awakening of the inner life), marks the
frontier between child and ... Man. The symbolic experience of depth
is what is lacking in the child, who grasps at the moon and knows as
yet no meaning in the outer world but, like the soul of primitive man,
dawns in a dreamlike continuum of sensations (in traumhafter
Verbundenheit mit allem Empfindungshaften hindämmert). Of course
the child is not without experience of the extended, of a very simple
kind, but there is no world-perception; distance is felt, but it does not
yet speak to the soul. And with the soul’s awakening, direction, too,
first reaches living expression—Classical expression in steady
adherence to the near-present and exclusion of the distant and
future; Faustian in direction-energy which has an eye only for the
most distant horizons; Chinese, in free hither-and-thither wandering
that nevertheless goes to the goal; Egyptian in resolute march down
the path once entered. Thus the Destiny-idea manifests itself in
every line of a life. With it alone do we become members of a
particular Culture, whose members are connected by a common
world-feeling and a common world-form derived from it. A deep
identity unites the awakening of the soul, its birth into clear existence
in the name of a Culture, with the sudden realization of distance and
time, the birth of its outer world through the symbol of extension; and
thenceforth this symbol is and remains the prime symbol of that life,
imparting to it its specific style and the historical form in which it
progressively actualizes its inward possibilities. From the specific
directedness is derived the specific prime-symbol of extension,
namely, for the Classical world-view the near, strictly limited, self-
contained Body, for the Western infinitely wide and infinitely profound
three-dimensional Space, for the Arabian the world as a Cavern. And
therewith an old philosophical problem dissolves into nothing: this
prime form of the world is innate in so far as it is an original
possession of the soul of that Culture which is expressed by our life
as a whole, and acquired in so far that every individual soul re-
enacts for itself that creative act and unfolds in early childhood the
symbol of depth to which its existence is predestined, as the
emerging butterfly unfolds its wings. The first comprehension of
depth is an act of birth—the spiritual complement of the bodily.[186] In
it the Culture is born out of its mother-landscape, and the act is
repeated by every one of its individual souls throughout its life-
course. This is what Plato—connecting it with an early Hellenic belief
—called anamnesis. The definiteness of the world-form, which for
each dawning soul suddenly is, derives meaning from Becoming.
Kant the systematic, however, with his conception of the form a
priori, would approach the interpretation of this very riddle from a
dead result instead of along a living way.
From now on, we shall consider the kind of extension as the prime
symbol of a Culture. From it we are to deduce the entire form-
language of its actuality, its physiognomy as contrasted with the
physiognomy of every other Culture and still more with the almost
entire lack of physiognomy in primitive man’s world-around. For now
the interpretation of depth rises to acts, to formative expression in
works, to the trans-forming of actuality, not now merely in order to
subserve necessities of life (as in the case of the animals) but above
all to create a picture out of extensional elements of all sorts
(material, line, colour, tone, motion)—a picture, often, that re-
emerges with power to charm after lost centuries in the world-picture
of another Culture and tells new men of the way in which its authors
understood the world.
 But the prime symbol does not actualize itself; it is operative
through the form-sense of every man, every community, age and
epoch and dictates the style of every life-expression. It is inherent in
the form of the state, the religious myths and cults, the ethical ideals,
the forms of painting and music and poetry, the fundamental notions
of each science—but it is not presented by these. Consequently, it is
not presentable by words, for language and words are themselves
derived symbols. Every individual symbol tells of it, but only to the
inner feelings, not to the understanding. And when we say, as
henceforth we shall say, that the prime-symbol of the Classical soul
is the material and individual body, that of the Western pure infinite
space, it must always be with the reservation that concepts cannot
represent the inconceivable, and thus at the most a significative
feeling may be evoked by the sound of words.
Infinite space is the ideal that the Western soul has always striven
to find, and to see immediately actualized, in its world-around; and
hence it is that the countless space-theories of the last centuries
possess—over and above all ostensible “results”—a deep import as
symptoms of a world-feeling. In how far does unlimited extension
underlie all objective things? There is hardly a single problem that
has been more earnestly pondered than this; it would almost seem
as if every other world-question was dependent upon the one
problem of the nature of space. And is it not in fact so—for us? And
how, then, has it escaped notice that the whole Classical world never
expended one word on it, and indeed did not even possess a
word[187] by which the problem could be exactly outlined? Why had
the great pre-Socratics nothing to say on it? Did they overlook in
their world just that which appears to us the problem of all problems?
Ought we not, in fact, to have seen long ago that the answer is in the
very fact of their silence? How is it that according to our deepest
feeling the “world” is nothing but that world-of-space which is the true
offspring of our depth-experience, and whose grand emptiness is
corroborated by the star-systems lost in it? Could a “world” of this
sense have been made even comprehensible to a Classical thinker?
In short, we suddenly discover that the “eternal problem” that Kant,
in the name of humanity, tackled with a passion that itself is
symbolic, is a purely Western problem that simply does not arise in
the intellects of other Cultures.
What then was it that Classical man, whose insight into his own
world-around was certainly not less piercing than ours, regarded as
the prime problem of all being? It was the problem of ἀρχή, the
material origin and foundation of all sensuously-perceptible things. If
we grasp this we shall get close to the significance of the fact—not
the fact of space, but the fact that made it a necessity of destiny for
the space-problem to become the problem of the Western, and only
the Western, soul.[188] This very spatiality (Räumlichkeit) that is the
truest and sublimest element in the aspect of our universe, that
absorbs into itself and begets out of itself the substantiality of all
things, Classical humanity (which knows no word for, and therefore
has no idea of, space) with one accord cuts out as the nonent, τὸ μὴ
ὄν, that which is not. The pathos of this denial can scarcely be
exaggerated. The whole passion of the Classical soul is in this act of
excluding by symbolic negation that which it would not feel as actual,
that in which its own existence could not be expressed. A world of
other colour suddenly confronts us here. The Classical statue in its
splendid bodiliness—all structure and expressive surfaces and no
incorporeal arrière-pensée whatsoever—contains without remainder
all that Actuality is for the Classical eye. The material, the optically
definite, the comprehensible, the immediately present—this list
exhausts the characteristics of this kind of extension. The Classical
universe, the Cosmos or well-ordered aggregate of all near and
completely viewable things, is concluded by the corporeal vault of
heaven. More there is not. The need that is in us to think of “space”
as being behind as well as before this shell was wholly absent from
the Classical world-feeling. The Stoics went so far as to treat even
properties and relations of things as “bodies.” For Chrysippus, the
Divine Pneuma is a “body,” for Democritus seeing consists in our
being penetrated by material particles of the things seen. The State
is a body which is made up of all the bodies of its citizens, the law
knows only corporeal persons and material things. And the feeling
finds its last and noblest expression in the stone body of the
Classical temple. The windowless interior is carefully concealed by
the array of columns; but outside there is not one truly straight line to
be found. Every flight of steps has a slight sweep outward, every
step relatively to the next. The pediment, the roof-ridge, the sides are
all curved. Every column has a slight swell and none stand truly
vertical or truly equidistant from one another. But swell and
inclination and distance vary from the corners to the centres of the
sides in a carefully toned-off ratio, and so the whole corpus is given
a something that swings mysterious about a centre. The curvatures
are so fine that to a certain extent they are invisible to the eye and
only to be “sensed.” But it is just by these means that direction in
depth is eliminated. While the Gothic style soars, the Ionic swings.
The interior of the cathedral pulls up with primeval force, but the
temple is laid down in majestic rest. All this is equally true as relating
to the Faustian and Apollinian Deity, and likewise of the fundamental
ideas of the respective physics. To the principles of position, material
and form we have opposed those of straining movement, force and
mass, and we have defined the last-named as a constant ratio
between force and acceleration, nay, finally volatilized both in the
purely spatial elements of capacity and intensity. It was an obligatory
consequence also of this way of conceiving actuality that the
instrumental music of the great 18th-Century masters should emerge
as a master-art—for it is the only one of the arts whose form-world is
inwardly related to the contemplative vision of pure space. In it, as
opposed to the statues of Classical temple and forum, we have
bodiless realms of tone, tone-intervals, tone-seas. The orchestra
swells, breaks, and ebbs, it depicts distances, lights, shadows,
storms, driving clouds, lightning flashes, colours etherealized and
transcendent—think of the instrumentation of Gluck and Beethoven.
“Contemporary,” in our sense, with the Canon of Polycletus, the
treatise in which the great sculptor laid down the strict rules of
human body-build which remained authoritative till beyond Lysippus,
we find the strict canon (completed by Stamitz about 1740) of the
sonata-movement of four elements which begins to relax in late-
Beethoven quartets and symphonies and, finally, in the lonely, utterly
infinitesimal tone-world of the “Tristan” music, frees itself from all
earthly comprehensibleness. This prime feeling of a loosing,
Erlösung, solution, of the Soul in the Infinite, of a liberation from all
material heaviness which the highest moments of our music always
awaken, sets free also the energy of depth that is in the Faustian
soul: whereas the effect of the Classical art-work is to bind and to
bound, and the body-feeling secures, brings back the eye from
distance to a Near and Still that is saturated with beauty.
 V
Each of the great Cultures, then, has arrived at a secret language
of world-feeling that is only fully comprehensible by him whose soul
belongs to that Culture. We must not deceive ourselves. Perhaps we
can read a little way into the Classical soul, because its form-
language is almost the exact inversion of the Western; how far we
have succeeded or can ever succeed is a question which
necessarily forms the starting-point of all criticism of the
Renaissance, and it is a very difficult one. But when we are told that
probably (it is at best a doubtful venture to meditate upon so alien an
expression of Being) the Indians conceived numbers which
according to our ideas possessed neither value nor magnitude nor
relativity, and which only became positive and negative, great or
small units in virtue of position, we have to admit that it is impossible
for us exactly to re-experience what spiritually underlies this kind of
number. For us, 3 is always something, be it positive or negative; for
the Greeks it was unconditionally a positive magnitude, +3; but for
the Indian it indicates a possibility without existence, to which the
word “something” is not yet applicable, outside both existence and
non-existence which are properties to be introduced into it. +3, -3, ⅓,
are thus emanating actualities of subordinate rank which reside in
the mysterious substance (3) in some way that is entirely hidden
from us. It takes a Brahmanic soul to perceive these numbers as
self-evident, as ideal emblems of a self-complete world-form; to us
they are as unintelligible as is the Brahman Nirvana, for which, as
lying beyond life and death, sleep and waking, passion, compassion
and dispassion and yet somehow actual, words entirely fail us. Only
this spirituality could originate the grand conception of nothingness
as a true number, zero, and even then this zero is the Indian zero for
which existent and non-existent are equally external designations.[189]
Arabian thinkers of the ripest period—and they included minds of
the very first order like Alfarabi and Alkabi—in controverting the
ontology of Aristotle, proved that the body as such did not
necessarily assume space for existence, and deduced the essence
of this space—the Arabian kind of extension, that is—from the
characteristic of “one’s being in a position.”
But this does not prove that as against Aristotle and Kant they
were in error or that their thinking was muddled (as we so readily say
of what our own brains cannot take in). It shows that the Arabian
spirit possessed other world-categories than our own. They could
have rebutted Kant, or Kant them, with the same subtlety of proof—
and both disputants would have remained convinced of the
correctness of their respective standpoints.
When we talk of space to-day, we are all thinking more or less in
the same style, just as we are all using the same languages and
word-signs, whether we are considering mathematical space or
physical space or the space of painting or that of actuality, although
all philosophizing that insists (as it must) upon putting an identity of
understanding in the place of such kinship of significance-feeling
must remain somewhat questionable. But no Hellene or Egyptian or
Chinaman could re-experience any part of those feelings of ours,
and no artwork or thought-system could possibly convey to him
unequivocally what “space” means for us. Again, the prime
conceptions originated in the quite differently constituted soul of the
Greek, like ἀρχή, ὕλη, μορφἠ, comprise the whole content of his
world. But this world is differently constituted from ours. It is, for us,
alien and remote. We may take these words of Greek and translate
them by words of our own like “origin,” “matter” and “form,” but it is
mere imitation, a feeble effort to penetrate into a world of feeling in
which the finest and deepest elements, in spite of all we can do,
remain dumb; it is as though one tried to set the Parthenon
sculptures for a string quartet, or cast Voltaire’s God in bronze. The
master-traits of thought, life and world-consciousness are as
manifold and different as the features of individual men; in those
respects as in others there are distinctions of “races” and “peoples,”
and men are as unconscious of these distinctions as they are
ignorant of whether “red” and “yellow” do or do not mean the same
for others as for themselves. It is particularly the common symbolic
of language that nourishes the illusion of a homogeneous
constitution of human inner-life and an identical world-form; in this
respect the great thinkers of one and another Culture resemble the
colour-blind in that each is unaware of his own condition and smiles
at the errors of the rest.
And now I draw the conclusions. There is a plurality of prime
symbols. It is the depth-experience through which the world
becomes, through which perception extends itself to world. Its
signification is for the soul to which it belongs and only for that soul,
and it is different in waking and dreaming, acceptance and scrutiny,
as between young and old, townsmen and peasant, man and
woman. It actualizes for every high Culture the possibility of form
upon which that Culture’s existence rests and it does so of deep
necessity. All fundamentals words like our mass, substance,
material, thing, body, extension (and multitudes of words of the like
order in other culture-tongues) are emblems, obligatory and
determined by destiny, that out of the infinite abundance of world-
possibilities evoke in the name of the individual Culture those
possibilities that alone are significant and therefore necessary for it.
None of them is exactly transferable just as it is into the experiential
living and knowing of another Culture. And none of these prime
words ever recurs. The choice of prime symbol in the moment of the
Culture-soul’s awakening into self-consciousness on its own soil—a
moment that for one who can read world-history thus contains
something catastrophic—decides all.
Culture, as the soul’s total expression “become” and perceptible in
gestures and works, as its mortal transient body, obnoxious
to law, number and causality:
As the historical drama, a picture in the whole picture of world-
history:
As the sum of grand emblems of life, feeling and
understanding:
—this is the language through which alone a soul can tell of what it
undergoes.
The macrocosm, too, is a property of the individual soul; we can
never know how it stands with the soul of another. That which is
implied by “infinite space,” the space that “passeth all
understanding,” which is the creative interpretation of depth-
experience proper and peculiar to us men of the West—the kind of
extension that is nothingness to the Greeks, the Universe to us—
dyes our world in a colour that the Classical, the Indian and the
Egyptian souls had not on their palettes. One soul listens to the
world-experience in A flat major, another in F minor; one apprehends
it in the Euclidean spirit, another in the contrapuntal, a third in the
Magian spirit. From the purest analytical Space and from Nirvana to
the most somatic reality of Athens, there is a series of prime symbols
each of which is capable of forming a complete world out of itself.
And, as the idea of the Babylonian or that of the Indian world was
remote, strange and elusive for the men of the five or six Cultures
that followed, so also the Western world will be incomprehensible to
the men of Cultures yet unborn.
 CHAPTER VI

MAKROKOSMOS
II

APOLLINIAN, FAUSTIAN AND MAGIAN SOUL

 CHAPTER VI

MAKROKOSMOS
 II
APOLLINIAN, FAUSTIAN AND MAGIAN SOUL

Henceforth we shall designate the soul of the Classical Culture,

which chose the sensuously-present individual body as the ideal
type of the extended, by the name (familiarized by Nietzsche) of the
Apollinian. In opposition to it we have the Faustian soul, whose
prime-symbol is pure and limitless space, and whose “body” is the
Western Culture that blossomed forth with the birth of the
Romanesque style in the 10th century in the Northern plain between
the Elbe and the Tagus. The nude statue is Apollinian, the art of the
fugue Faustian. Apollinian are: mechanical statics, the sensuous cult
of the Olympian gods, the politically individual city-states of Greece,
the doom of Œdipus and the phallus-symbol. Faustian are: Galileian
dynamics, Catholic and Protestant dogmatics, the great dynasties of
the Baroque with their cabinet diplomacy, the destiny of Lear and the
Madonna-ideal from Dante’s Beatrice to the last line of Faust II. The
painting that defines the individual body by contours is Apollinian,
that which forms space by means of light and shade is Faustian—
this is the difference between the fresco of Polygnotus and the oil
painting of Rembrandt. The Apollinian existence is that of the Greek
who describes his ego as soma and who lacks all idea of an inner
development and therefore all real history, inward and outward; the
Faustian is an existence which is led with a deep consciousness and
introspection of the ego, and a resolutely personal culture evidenced
in memoirs, reflections, retrospects and prospects and conscience.
And in the time of Augustus, in the countries between Nile and Tigris,
Black Sea and South Arabia, there appears—aloof but able to speak
to us through forms borrowed, adopted and inherited—the Magian
soul of the Arabian Culture with its algebra, astrology and alchemy,
its mosaics and arabesques, its caliphates and mosques, and the
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