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 LEACH et al.
Problem Solving in
Respiratory Medicine
and Allergy

Solving in
Problem
Every doctor’s point-of-care companion for respiratory disorders, in
the consultation room or on the ward. A series of questions leads the
reader logically through a case presentation, work-up, diagnosis and

Respiratory Medicine and Allergy

discussion of recent literature. Each case is concisely presented,
including an algorithm where appropriate to show overall
management strategies. This is a user-friendly resource for quick
review and assessment of individual cases, covering the most common
yet challenging cases seen by respiratory doctors – an invaluable
reference and training resource for the hospital, clinic and GP’s
surgery.

Related titles:
Asthma: Atlas of Investigation and Management
S L J O H N S TO N
ISBN 978 1 904392 18 7

Paediatric Respiratory Disease – Airways and Infection: Atlas of

Problem Solving in
Investigation and Management
A B U S H , J D AV I E S
ISBN 978 1 904392 97 2
Respiratory
Paediatric Respiratory Disease – Parenchymal Diseases: Atlas of
Investigation and Management, Medicine and
Allergy
A B U S H , J D AV I E S
ISBN 978 1 84692 086 8

Therapeutic Strategies: Acute Exacerbations in COPD

M C A Z Z O L A , S S E T H I , F B L A S I , A A N Z U E TO
ISBN 978 1 904392 71 2 RICHARD M LEACH
CHRISTOPHER KOSKY
Therapeutic Strategies in Pulmonary Arterial Hypertension
A PEACOCK, J BARBERÀ ELIZABETH HADLEY
CLINICAL
PUBLISHING

ISBN 978 1 84692 053 0 BORIS LAMS

CLINICAL PUBLISHING
www.clinicalpublishing.co.uk C L I N I C A L P U B L I S H I N G
 Problem Solving in
Respiratory
Medicine & Allergy
Edited by

RICHARD LEACH, MD, FRCP

Consultant Physician and Clinical Director of Medicine
Guy’s and St Thomas’ NHS Foundation Trust
London, UK

CHRISTOPHER KOSKY, MBBS, FRACP

Consultant Physician, Respiratory, General and Sleep Medicine
Guy’s and St Thomas’ NHS Foundation Trust
Honorary Senior Lecturer
King’s College
London, UK

ELIZABETH HADLEY, MBBS Hons, BSc Hons, MRCP London

Consultant Respiratory and General Physician
Department of Respiratory Medicine
Barking, Havering and Redbridge Hospitals University NHS Trust
London, UK

BORIS LAMS, MBBS, MD, FRCP

Consultant Physician, Respiratory, General and Critical Care Medicine
Clinical Lead for Respiratory and Sleep Medicine
Guy’s and St Thomas’ NHS Foundation Trust
London, UK

CLINICAL PUBLISHING
OXFORD

00-PS Respiratory Medicine-prelims-cpp.indd 3 25/08/2011 15:28

 CLINICAL PUBLISHING
an imprint of Atlas Medical Publishing Ltd
Oxford Centre for Innovation
Mill Street, Oxford OX2 0JX, UK

Tel: +44 1865 811116

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© Atlas Medical Publishing Ltd 2011

First published 2011

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system, or transmitted, in any form or by any means, without the prior permission in
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Although every effort has been made to ensure that all owners of copyright material
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Clinical Publishing and Atlas Medical Publishing Ltd bear no responsibility for the
persistence or accuracy of URLs for external or third-party internet websites referred to
in this publication, and do not guarantee that any content on such websites is, or will
remain, accurate or appropriate.

A catalogue record for this book is available from the British Library.

ISBN 13 978 1 904392 86 6

ISBN e-book 978 1 84692 598 6

The publisher makes no representation, express or implied, that the dosages in this
book are correct. Readers must therefore always check the product information and
clinical procedures with the most up-to-date published product information and data
sheets provided by the manufacturers and the most recent codes of conduct and safety
regulations. The authors and the publisher do not accept any liability for any errors in
the text or for the misuse or misapplication of material in this work.

Project manager: Gavin Smith, GPS Publishing Solutions, Herts, UK

Typeset by Phoenix Photosetting, Chatham, UK
Printed by Marston Book Services, Abingdon, Oxon, UK

00-PS Respiratory Medicine-prelims-cpp.indd 4 25/08/2011 15:28

 Contents

Preface ix

Contributors xi

Abbreviations xiii

SECTION 1 Infection
1. Severe Pulmonary Tuberculosis, Oni Choudhury, Heather Milburn 1
2. Non-tuberculous Mycobacterial Disease, Ronan Breen, Richard Leach 8
3. Hospital-acquired Pneumonia, Richard Leach 15
4. Lemierre’s Disease, Boris Lams, Christopher Kosky 21
5. Haemoptysis due to Bronchiectasis, Burhan Khan, Richard Leach 25

SECTION 2 Obstructive Lung Disease/Small Airways

Disease
6. Stable Chronic Obstructive Pulmonary Disease (COPD), Burhan Khan,
Richard Leach 33
7. Acute Ventilatory Failure in Chronic Obstructive Pulmonary Disease,
Richard Leach, Craig Davidson 41
8. Difficult Asthma, Lynette Linkson, Richard Leach 47
9. Asthma and Pregnancy, Lynette Linkson, Richard Leach 53
10. Allergic Bronchopulmonary Aspergillosis, Kate Brignall 55
11. Chronic Cough, Jimstan Periselneris, Richard Leach 62
12. Aspiration Syndrome, Boris Lams, Richard Leach 67

SECTION 3 Interstitial Lung Disease/Sarcoid

13. Classification of the Idiopathic Interstitial Pneumonias,
Richard Leach, John Rees 73
14. Treatment of Idiopathic Pulmonary Fibrosis/Usual Interstitial
Pneumonias, Lucy Schomberg, Richard Leach 81

00-PS Respiratory Medicine-prelims-cpp.indd 5 25/08/2011 15:28

 vi Contents

15. Acute Eosinophilic Pneumonia, Boris Lams, Christopher Kosky 88

16. Cryptogenic Organizing Pneumonia, Boris Lams, Christopher Kosky 93
17. Sarcoidosis (Radiographic Stage I), Anne Collett, Richard Leach 97
18. Sarcoidosis (Radiographic Stages II and III), Richard Leach 104
19. Hypersensitivity Pneumonitis, Elizabeth Hadley, Boris Lams 111
20. Amiodarone Pulmonary Toxicity, Elizabeth Hadley, Boris Lams,
Christopher Kosky 117

SECTION 4 Lung Cancer

21. Small Cell Lung Cancer (SCLC), Oni Choudhury, Richard Leach 121
22. Non-Small Cell Lung Cancer (NSCLC), Suma Kumar, Richard Leach 127
23. Pulmonary Nodules, Burhan Khan, Richard Leach 135
24. Mediastinal Mass: Bronchogenic Cyst, Elizabeth Hadley 139
25. Smoking Cessation, Suma Kumar, Richard Leach 142

SECTION 5 Pulmonary Vascular: Including PE and AVM

26. Pulmonary Hypertension, Bethia Bradley, Richard Leach 149
27. Massive Pulmonary Embolism, Elizabeth Hadley, Christopher Kosky 157
28. Sickle Cell Lung Disease, Elizabeth Hadley, Boris Lams, Christopher Kosky 161
29. Pulmonary Arteriovenous Malformation, Elizabeth Hadley 166

SECTION 6 Vasculitis/Rare Diseases

30. Wegener’s Granulomatosis and the Small Vessel Pulmonary Vasculitides,
Elizabeth Hadley, Richard Leach 171
31. Diffuse Alveolar Haemorrhage, Christopher Kosky 178

SECTION 7 Ventilatory Failure/Sleep

32. Obesity Hypoventilation Syndrome, Christopher Kosky, Boris Lams 183
33. Guillain-Barré Syndrome, Nicholas Hopkinson, Christopher Kosky 187

SECTION 8 Immunocompromised/HIV
34. Pneumocystis jirovecii Pneumonia, Elizabeth Hadley, Boris Lams 191
35. Lymphocytic Interstitial Pneumonia, Elizabeth Hadley, Boris Lams,
Christopher Kosky 195

00-PS Respiratory Medicine-prelims-cpp.indd 6 25/08/2011 15:28

 Contents vii

SECTION 9 Pleural Disease

36. Parapneumonic Effusion, Liju Ahmed, Richard Leach 199
37. Spontaneous Pneumothorax: Langerhans Cell Histiocytosis,
Eleanor Giddings, Boris Lams, Elizabeth Hadley 207
38. Mesothelioma and Asbestos-related Pleural Disease, Amina Aitsi-Selmi,
Charles Twort 213

General index 221

00-PS Respiratory Medicine-prelims-cpp.indd 7 25/08/2011 15:28

 Contributors

Consultant Respiratory Physicians, Guy’s and St Thomas’

NHS Foundation Trust, London, UK
Liju Ahmed Christopher Kosky John Rees
Ronan Breen Boris Lams Charles Twort
Anne Collett Richard Leach
Craig Davidson Heather Milburn

Consultant Respiratory and General Physician, Barking, Havering and

Redbridge Hospitals University NHS Trust, London, UK
Elizabeth Hadley

Consultant Respiratory Physician, Royal Brompton and

Harefield NHS Foundation Trust, London, UK
Nicholas Hopkinson

Consultant Respiratory Physician, Darent Valley Hospital,

Dartford and Gravesham NHS Trust, Dartford, Kent, UK
Burhan Khan

Consultant Respiratory Physician, Medway Maritime Hospital,

Medway, Kent, UK
Kate Brignall

Specialist Registrars in Respiratory Medicine, Guy’s and

St Thomas’ NHS Foundation Trust, London, UK
Bethia Bradley Lynette Linkson Lucy Schomberg
Eleanor Giddings Jimstan Periselneris

Previous Core Medical Trainees in Respiratory Medicine,

Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Oni Choudhury Suma Kumar Amina Aitsi-Selmi

00-PS Respiratory Medicine-prelims-cpp.indd 9 25/08/2011 15:28

 Abbreviations

ABG arterial blood gas BHL bihilar lymphadenopathy

ABPA allergic bronchopulmonary BM body mass
aspergillosis BMI body mass index
ACCP American College of Chest BMPR2 bone morphogenetic protein
Physicians receptor 2
ACE angiotensin converting enzyme BNP brain natriuretic peptide
ACE-I angiotensin converting enzyme BOOP bronchiolitis obliterans organizing
inhibitor pneumonia
AECOPD acute exacerbation of COPD BP blood pressure
AEP acute eosinophilic pneumonia BREATH-1 Bosentan Randomized trial of
AF Aspergillus fumigatus Endothelin Antagonist Therapy of
AFB acid-fast bacilli pulmonary Hypertension Study
AIDS acquired immune deficiency BTS British Thoracic Society
syndrome c-ANCA cytoplasmic anti-neutrophil
AIP acute interstitial pneumonia cytoplasmic antibody
ALK-1 activin receptor-like kinase 1 CAP community-acquired pneumonia
ALT alanine transaminase CAVE cyclophosphamide, doxorubicin,
ANA anti-nuclear antibody vincristine, etoposide
ANCA anti-neutrophil cytoplasmic CCB calcium channel blocker
antibody CF cystic fibrosis
ANNA-1 type 1 anti-neuronal nuclear antibody cGMP cyclic guanosine monophosphate
anti-Ber-EP4 anti-human epithelial antigen CHART continuous hyperfractionated
anti-CEA anti-carcino-embryonic antigen accelerated radiotherapy
anti-CK5/6 anti-cytokeratin 5/6 CHD congenital heart disease
anti-MPO anti-myeloperoxidase antibody CI confidence interval
anti-PR3 anti-proteinase 3 antibody CK7 cytokeratin 7
anti–TTF-1 anti-thyroid transcription factor 1 CNS central nervous system
anti-WT1 anti-Wilms tumour 1 COP cryptogenic organizing
APACHE Acute Physiology and Chronic pneumonia
Health Evaluation COPD chronic obstructive pulmonary
APAH associated pulmonary arterial disease
hypertension CPAP continuous positive airway
ARDS acute respiratory distress syndrome pressure
ASH Action on Smoking and Health CRP C-reactive protein
AST aspartate transaminase CSF cerebrospinal fluid
ATS American Thoracic Society CT computed tomography
AV arteriovenous CTD connective tissue disease
AVM arteriovenous malformation CTEPH chronic thromboembolic
BAL bronchoalveolar lavage pulmonary hypertension
BCG Bacillus Calmette-Guérin CTPA computed tomography pulmonary
BDP beclomethasone angiogram

00-PS Respiratory Medicine-prelims-cpp.indd 11 25/08/2011 15:28

 xii Abbreviations

CXR chest radiograph HHT hereditary haemorrhagic

DAD diffuse alveolar damage telangiectasia
DIC disseminated intravascular HIV human immunodeficiency virus
coagulation HLA human leukocyte antigen
DIP desquamative interstitial HP hypersensitivity pneumonitis
pneumonia HPAH heritable pulmonary arterial
DLCO carbon monoxide diffusing hypertension
capacity HRCT high-resolution computed
DOT directly observed therapy tomography
DPI dry powder inhalers HTLV-1 human T cell lymphotrophic virus
DPLD/ILD diffuse parenchymal (interstitial) type 1
lung disease IASLC International Association for the
DPT diffuse pleural thickening Study of Lung Cancer
DVT deep vein thrombosis ICS inhaled corticosteroid
EBUS endoscopic bronchial ultrasound ICU intensive care unit
ECG electrocardiogram IDSA Infectious Diseases Society of
ECV epirubicin, cyclophosphamide and America
vincristine IgA immunoglobulin A
ELISA enzyme-linked immunosorbent IgE immunoglobulin E
assay IgG immunoglobulin G
EMA epithelial membrane antigen IIP idiopathic interstitial pneumonia
EORTC European Organisation for IL-1 interleukin-1
Research and Treatment of Cancer IL-5 interleukin-5
EPAP expiratory positive airway pressure ILD interstitial lung disease
EPP extrapleuropneumonectomy IPAH idiopathic pulmonary arterial
ERS European Respiratory Society hypertension
ESR erythrocyte sedimentation rate IPAP inspiratory positive airway
ET-1 endothelin-1 pressure
ETS environmental tobacco smoke IPF idiopathic pulmonary fibrosis
F female ISOLDE Inhaled Steroids in Obstructive
18
FDG 18-fluorodeoxyglucose Lung Disease in Europe
FEV1 forced expiratory volume in 1 IU international unit
second Ig-1b interferon gamma-1b
FiO2 inspired oxygen concentration KCO transfer coefficient; carbon
FRC functional residual capacity monoxide gas transfer corrected
FU follow-up for alveolar volume
FVC forced vital capacity LABA long-acting b2 agonist
GBM glomerular basement membrane LAMA long-acting muscarinic antagonist
GBS Guillain-Barré syndrome LC Langerhans cell
GGO ground glass opacification LCH Langerhans cell histiocytosis
GI gastrointestinal LDH lactate dehydrogenase
GORD gastro-oesophageal reflux disease LFT liver function test
GP general practitioner LIP lymphocytic interstitial pneumonia
GSD glycogen storage disease LOS lower oesophageal sphincter
HAART highly active antiretroviral therapy LRT lower respiratory tract
HAP hospital-acquired pneumonia LRTI lower respiratory tract infection
HbSS homozygous sickle cell disease LTOT long-term oxygen therapy
HCAP health-care-associated pneumonia M male
HCO3 partial pressure of arterial MAC M. avium complex
bicarbonate MALT mucosal-associated lymphoid
HCRF hypercapnic respiratory failure tissue

00-PS Respiratory Medicine-prelims-cpp.indd 12 25/08/2011 15:28

 Abbreviations xiii

MARS Mesothelioma and Radical Surgery PE pulmonary embolism

MDI metered dose inhalers PEC paclitaxel, etoposide, carboplatin
MDR multidrug resistant PEEP positive end-expiratory pressure
MHC major histocompatibility complex PEFR peak expiratory flow rate
MND motor neurone disease PET positron emission tomography
MPA microscopic polyangiitis PFT pulmonary function test
MPO myeloperoxidase PHT pulmonary hypertension
MRSA methicillin-resistant Staphylococcus PiO2 partial pressure of oxygen in
aureus airways
MS multiple sclerosis PJP Pneumocystis jirovecii pneumonia
99mTc technetium-99m PLCH pulmonary Langerhans cell
MV mechanical ventilation histiocytosis
6MW six-minute walks pMDI pressurized metered dose inhaler
NAC N-acetylcysteine PN pulmonary nodule
nAchR nicotinic acetylcholine receptors PPE parapneumonic effusion
Nd-Yag neodymium-yttrium aluminium PPHN persistent PHT in the newborn
garnet PPV positive predictive value
NHS National Health Service PSP primary spontaneous
NICE National Institute for Health and pneumothorax
Clinical Excellence QoL quality of life
NIPPV non-invasive positive pressure RAP right atrial pressure
ventilation RB respiratory bronchiolitis
NIV non-invasive ventilation RB-ILD respiratory bronchiolitis-associated
NRT nicotine replacement therapy interstitial lung disease
NSAID non-steroidal anti-inflammatory RCT randomized controlled trial
drugs REM rapid eye movement
NSCLC non-small cell lung cancer RHC right heart catheterization
NSIP non-specific interstitial pneumonia RR respiratory rate
NT nebulizer therapy RV residual volume
NTM non-tuberculous mycobacteria RVF right ventricular failure
NYHA New York Heart Association RVSP right ventricular systolic pressure
OC oral contraceptive Rx treatment
OHS obesity hypoventilation syndrome SABA short-acting b2 agonist
OP organizing pneumonia SAMA short-acting muscarinic antagonist
OR odds ratio SaO2 oxygen saturation of arterial blood
OSA obstructive sleep apnoea SCC squamous cell cancer
OT oxygen therapy SCD sickle cell disease
PaCO2 partial pressure of arterial carbon SCLC small cell lung cancer
dioxide SIADH syndrome of inappropriate
PAH pulmonary arterial hypertension antidiuretic hormone
p-ANCA perinuclear anti-neutrophil SIRS systemic inflammatory response
cytoplasmic antibody syndrome
PaO2 partial pressure of arterial oxygen SLE systemic lupus erythematosus
PAO2 alveolar oxygen pressure SPP secondary pneumothorax
PAP pulmonary artery pressure SVCO superior vena cava obstruction
PAS para-aminosalicylic acid TB tuberculosis
PASP pulmonary artery systolic pressure TBBx transbronchial biopsy
PCI prophylactic cranial irradiation Td deadspace
PCWP pulmonary capillary wedge Th1 helper T cell type 1
pressure Th2 helper T cell type 2
PE cisplatin and etoposide TLC total lung capacity

00-PS Respiratory Medicine-prelims-cpp.indd 13 25/08/2011 15:28

 xiv Abbreviations

TLCO carbon monoxide gas transfer V/Q ventilation-perfusion

TNF-a tumour necrosis factor alpha VA alveolar volume
TORCH Towards a Revolution in COPD VAP ventilator-associated pneumonia
Health VATS video-assisted thoracoscopy
TPMT thiopurine methyltransferase VC ital capacity
TTE transthoracic Doppler VCI inspiratory vital capacity
echocardiography VO2 oxygen consumption
TTF-1 thyroid transcription factor 1 WCC white cell count
Tv tidal volume WHO World Health Organization
UIP usual interstitial pneumonia WHO-FC World Health Organization
URTI upper respiratory tract infection functional class
USS ultrasound scan XR X-ray/radiograph

00-PS Respiratory Medicine-prelims-cpp.indd 14 25/08/2011 15:28

 SECTION ONE 01
Infection
01 Severe Pulmonary Tuberculosis
02 Non-tuberculous Mycobacterial Disease
03 Hospital-acquired Pneumonia
04 Lemierre’s Disease
05 Haemoptysis due to Bronchiectasis

PROBLEM

1 Severe Pulmonary Tuberculosis

Oni Choudhury, Heather Milburn

Case History
A 30-year-old, non-English-speaking Estonian man presented with a four-week history
of productive cough, haemoptysis, weight loss, fever and night sweats. He had recently
arrived in the UK and was working as a casual labourer. He had no past medical history
and was on no medication. He had not been treated for, vaccinated against (i.e. Bacillus
Calmette-Guérin [BCG]) or had any known tuberculosis (TB) contact. His alcohol intake
was excessive but he did not smoke. He lived in a hostel.
On examination he was unwell with fever (39.2°C) and tachypnoea (18 breaths/min)
and his oxygen saturation (SaO2) was 91% on air. There was no lymphadenopathy. Chest
examination revealed reduced breath sounds and bronchial breathing in the left lung. His
haemoglobin was 10.4 g/dl with a low white cell count (3.9 ¥ 109/l) and lymphocytosis.
The C-reactive protein (CRP; 194 mg/l) and erythrocyte sedimentation rate (ESR;
84 mm/h) were raised. Renal function was normal but liver function tests were slightly
elevated. The albumin was 21 g/dl. The chest radiograph (CXR) demonstrated dense left-
lung consolidation (Figure 1.1) and a left-sided pneumothorax occurred shortly after
admission. Acid-fast bacilli were isolated in sputum. Contact tracing revealed that his
partner, who was 11 weeks pregnant, had a strongly positive tuberculin skin test and her
CXR was consistent with early TB.

01-PS Respiratory Medicine-section 01-cpp.indd 1 25/08/2011 15:38

 2 §01 Infection

What factors would you take into account when you treat this patient?
How would you manage this patient?
What treatment adjustments are required in liver and renal disease?
When would you use steroid therapy in pulmonary tuberculosis?
How would you manage drug resistance in this patient?
How would you manage this patient’s pneumothorax?
How would you treat the pregnant partner of this patient?

Figure 1.1 Chest radiograph.

Background
Mycobacterium tuberculosis affects 9.4 million people and causes 1.7 million deaths a year
worldwide, despite being a curable disease1 and is one of the commonest causes of infectious
mortality. The incidence of tuberculosis (TB) is highest in sub-Saharan Africa but over 50%
of cases occur in Asia (i.e. India, China) due to the high population density and incidence is
increasing in Eastern Europe and Russia. About 10% of cases globally are multidrug resistant
(MDR), and around 10% of TB cases are co-infected with human immunodeficiency virus

01-PS Respiratory Medicine-section 01-cpp.indd 2 25/08/2011 15:38

 01 Severe pulmonary tuberculosis 3

(HIV). However, co-infection rates vary geographically, affecting 35%–40% of sub-Saharan

African cases, 2.7% of UK cases and 1%–2% of cases in China.
In the UK, 60% of TB occurs in the 15–44-year-old age group, 66% of patients are
non-UK born and >70% are from ethnic minority groups.2 In this case, age, ethnic origin
(associated with drug resistance, HIV co-infection), social factors (e.g. isolation, pov-
erty, homelessness) and alcohol consumption (i.e. non-compliance) must be taken into
account. The risk factors associated with non-compliance and factors associated with
resistant disease are listed in Table 1.1. Although treatment regimens for pulmonary
tuberculosis are evidence based,3,4 the management of complications such as extensive
lung damage and pneumothoraces is less clear.

Table 1.1 Risk factors for non-compliance with therapy and resistant disease in TB

a. Main risk factors for tuberculosis

1 Ethnic origin, sex and age
• Caucasian; >50 years old; M > F
• Asian/Chinese; <50 years old; M = F
• African; <40 years old; M = F
2 Medical factors
• Diabetes; renal and malignant disease
• Immunosuppression (chemotherapy, steroids)
• Immunomodulatory drugs (infliximab)
• Vitamin D deficiency
• Smoking
3 Poverty, poor nutrition, homelessness, social isolation
4 HIV/AIDS
5 Alcohol addiction

b. Risk factors for non-compliance with therapy

1 Alcohol addiction
2 Homelessness
3 Drug abuse
4 Mental illness

c. Factors associated with resistant disease

1 Contact with resistant disease
2 Treatment failure, inadequate previous anti-TB therapy
3 Adding a single drug to a failing regimen
4 Immigration from area of high resistance

AIDS, acquired immune deficiency syndrome, F, female; M, male.

Management of Mycobacterium tuberculosis

Patients with ‘open TB’ (i.e. sputum smear positive) should be isolated either at home or
in a hospital negative-pressure side room (i.e. vented to the outside air) and hospital staff
should wear face masks when attending the patient. After two weeks of TB therapy, HIV-
negative patients with sensitive organisms are considered non-infectious and although
bacilli may be seen in sputum these are usually dead.
The standard TB treatment regimen includes four drugs in the initial two months
(rifampicin, isoniazid, pyrazinamide, ethambutol) followed by two drugs for a further
four months (rifampicin, isoniazid).3,4 Initial therapy with four drugs has superseded
previous guidelines5 recommending three drugs because of increasing background isoni-
azid resistance. In this case, an initial four-drug regimen is essential as isoniazid resistance

01-PS Respiratory Medicine-section 01-cpp.indd 3 25/08/2011 15:38

 4 §01 Infection

is greater in immigrants, ethnic minority groups, HIV-positive patients and previously

treated patients. A three times weekly directly observed therapy (DOT) regimen for six
months is equally effective. Drug doses are calculated according to body weight (Table
1.2). Pyridoxine (vitamin B6) is given to most patients as their diets are often poor (e.g.
alcoholics) or they have diabetes, renal failure or HIV infection.
Central nervous system (CNS) TB requires twelve months’ treatment but non-CNS
TB usually responds to six months’ therapy. Baseline full blood count and renal and liver
function tests (LFTs) should be checked and if the patient is not at risk of adverse drug
reactions need not be rechecked unless symptoms develop. Steroid therapy may be con-
sidered (see below). Essential advice for patients is listed in Table 1.3.
The doctor making the diagnosis has a legal obligation to notify the public health
authorities (even if the diagnosis is made after death). This triggers appropriate contact
tracing and allows planning of treatment and screening services. As contact tracing is
undertaken by the community TB nursing services, they should also be informed about
all index cases.

Table 1.2 Standard antituberculous drug doses

Drug Daily dose 3 ¥ weekly dose

Isoniazid 300 mg 15 mg/kg 3 ¥ weekly (maximum 1 g)
Rifampicin (BM <50 kg) 450 mg 600 mg
Rifampicin (BM >50 kg) 600 mg 900 mg
Pyrazinamide (BM <50 kg) 1.5 g 2.0 g
Pyrazinamide (BM >50 kg) 2.0 g 2.5 g
Ethambutol 15 mg/kg 30 mg/kg

BM, body mass.

Table 1.3 Essential advice for patients starting antituberculous therapy

• Red urine (due to rifampicin)

• Red contact lenses due to rifampicin
• Nausea – usually improves
• Abdominal pain, vomiting or jaundice – stop drugs and contact doctor
• Efficacy of oral contraceptive pill reduced – need alternative contraception
• Potential drug interactions
 Rifampicin decreases levels of warfarin, phenytoin, digoxin, methadone, sulphonylureas, steroids, theophylline,
ciclosporin
 Isoniazid increases levels of phenytoin, carbamazepine, warfarin, diazepam
• Visual acuity and colour vision loss with ethambutol – stop drugs and contact doctor

Treatment adjustments in liver and renal disease

Liver function tests are often slightly raised in alcoholics or new patients with TB (e.g.
hepatic TB). Antituberculous therapy should not be withheld in these patients as LFTs
usually improve with therapy or remain stable. Viral hepatitis should be excluded.
In chronic liver disease, baseline LFTs should be followed by regular monitoring (i.e.
weekly for two weeks then every two weeks). If aspartate transaminase (AST) and alanine
transaminase (ALT) are greater than twice normal, continue to monitor 1–2-weekly;

01-PS Respiratory Medicine-section 01-cpp.indd 4 25/08/2011 15:38

Other documents randomly have
different content
in India, and notably the conferring upon Ireland of a measure of
Home Rule more complete than any proposed by Gladstone.
Any one of these measures proposed before the war would have led
to heated discussion throughout the land. The case of Ireland is
perhaps the most significant of the changed temper of the nation
immediately after the great war. The conflict over Irish Home Rule
has now culminated in a treaty accepted by the nation as a whole
and acquiesced in by the most violent amongst its opponents.
But fiercer political passions were stirred up by the struggle between
parties over Ireland than by any political question of modern times.
The causes underlying the conflict dealt with two of the most
powerful motives which make the human heart throb—race and
religion. There was the old feud between Saxon and Gael extending
over at least seven centuries. It drenched the moors of Ireland with
the blood of both races before a keener edge was given to its
hatreds by the introduction of an acute religious quarrel.
After the Reformation the religious differences which rent Europe
with fratricidal wars added fresh fury to the racial enmities which
made poor Ireland a cauldron of perpetual strife. When Mr.
Gladstone proposed to settle this raging tumult by wresting
supremacy from a race which had been dominant in that island for
700 years and a faith which had been supreme there for 400 years
and transferring it to the race and religion which all that time had
been in a condition of servitude, and when in order to attain his
ends he had to secure the adhesion of men of the ruling blood and
creed to his proposals, the passions raised were deeper and angrier
than any witnessed in British politics for many a day. It led for the
first time in the history of parliament to scenes of physical violence
on the floor of the House. It shows what we may expect when there
are genuine divisions of opinion which profoundly move masses of
men and women in a democracy. Those who recall the tropical heat
of parliamentary debates in 1893 naturally regard their voyage
through the frigid proceedings of the last parliament as they would a
sail through Arctic seas. That voyage is now over, and there are
signs that the waters will soon be lashed into fury.
For years political controversy between parties has been suspended
in the presence of a common danger. Reaction was inevitable, and
the greater the suppression the more violent the rebound. That does
not, however, altogether account for the visible omens of a coming
struggle unprecedented in its gravity. Fundamental issues have been
raised of such moment to millions that they cannot be settled
without a struggle that will rock society.
The scene enacted in the Commons a few days ago was by no
means as exciting as that which some of us witnessed in 1893. But it
gave me an uneasy feeling that the period of calm is definitely over,
and that Parliament henceforth must expect gusts and gales—and
worse. Emotions are once more welling up, and there are signs of a
great stir coming in British politics.
The cause is easily explained. The sense of exhaustion is passing
away, and issues containing a serious challenge to the privileges and
rights of powerful classes in the community and vital to the interests
of all classes have been raised by one of the great political parties
that divide Britain. The momentous character of that challenge may
be gathered from the terms of the motion submitted by Mr. Philip
Snowden to the judgment of the House of Commons:—

"That in view of the failure of the capitalist system to

adequately utilise and organise natural resources and productive
power, or to provide the necessary standard of life for vast
numbers of the population, and believing that the cause of this
failure lies in the private ownership and control of the means of
production and distribution, this House declares that legislative
effort should be directed to the gradual supersession of the
capitalist system by an industrial and social order based on the
public ownership and democratic control of the instruments of
production and distribution."
This motion will receive the full support of every member of the
Labour party. A few men outside the Socialist party who have
acquainted themselves with the publications of that party were quite
prepared for this demand of a complete change in the organisation
of society. And as they saw that party grow with startling rapidity
they knew we should not have long to wait before these subversive
ideas would be formulated in the House of Commons. Still, even for
the students of Socialist literature, the actual tabling of the
resolution on behalf of the second largest party in the State came as
a surprise and a shock. Too much credit was given to the restraining
influence of the trade union section of the party. Sir Lynden
Macassey, in his informing book on "Labour Policy, False and True,"
points out that it was in 1885 that the avowed advocates of this
proposal for the abolition of private property and for the
nationalisation of all the means of production and distribution first
stood for Parliament. There were only two candidates standing on
this platform, and they polled 32 and 29 votes respectively. Last
election the aggregate Socialist poll reached the imposing figure of
4,251,011 votes. The party that secured a majority of members in
the House of Commons only polled 5,457,871 votes. Mr. Ramsay
MacDonald states categorically that he knows that the Independent
Liberal members—exclusive of their leaders—favour nationalisation
and the capital levy. If that be an accurate statement of the views of
the majority of these gentlemen, and of those who elect them,
nearly one-half the British electorate are already prepared to assent
to Socialism by easy stages—which is the purport of Mr. Philip
Snowden's motion.
On that assumption we are on the eve of greater and more
fundamental changes affecting the lives of every class and condition
of men and women than have yet been seen in this country. Hence
the new sense of struggle with which the political atmosphere is
palpitating. Capitalism is to be arraigned before the Supreme Court
of the Nation, condemned, sentenced, and executed by instalments
—Chinese fashion. The composition of that court is not to-day
favourable to the prosecution. But who will be the judge after the
next general election? It is customary in political controversy to state
that the election which is for the moment impending will be the most
epoch-making in history. Without exaggeration, the next British
election may well turn out to be so. The British people, with their
inherited political instinct, are beginning to realise that grave
decisions must then be taken. Hence the greater keenness shown by
the voters at by-elections—hence the new interest taken by the
public in the proceedings of Parliament. There is still a good deal of
apathy and indifference. The average comfortable citizen is still
inclined to think these Socialist schemes so crazy as to be
impossible. They cannot believe that 21,000,000 of sane people can
possibly contemplate giving their sanction to such fantasies.
There are two cardinal facts which are constantly overlooked by the
complacent. The men and women who have no property for the
State to seize constitute an overwhelming majority of the electors of
the country. The second fact to note is the great preponderance of
the industrial population over the steadier and more stolid
agricultural population. America, in spite of its gigantic
manufacturing and distributing industries, still retains 60 per cent. of
its population on the land. The same proportion of the French and
Italian populations is agrarian. Barely 10 per cent. of the British
workers are engaged in cultivating the soil. Most of our workers
breathe and have their being in the crowded and excitable
atmosphere of factories, workshops, and mines. The air is filled with
germs of all kinds, and isolation in these thronging areas is
impossible. Hence the rapidity with which the fever has spread.
Can it be arrested? Nothing will be done until the danger is visible to
every eye. To vary the metaphor, no one will believe in the flood
until it is upon us. Trained weather prophets who forecast its coming
will be laughed at or told they have a personal or party interest in
ark building. It is an old tale—as old as the dawn of history. "As in
the days before the flood, they were eating and drinking and knew
not until the flood came and took them all away."
The trouble can only be averted in two ways. One is the systematic
inculcation of sound doctrines of economic truth into the minds of
the working people of this country. The second, and the more
important, is the rooting out of the social evils which furnish the
revolutionary with striking and indisputable object-lessons of the
failure of the capitalistic system as an agent of human happiness.
Without the latter the former effort will be futile. Arguments in
favour of the existing order will be refuted by glaring and painful
facts. Meanwhile, let the champions of that order take note of the
efforts put forth by the Socialists to advertise their eagerness to
redress the wrongs of the ex-service men and to soften the
asperities of discipline for the soldier. The Socialist leaders have
shrewdly taken note of the causes that produced the overthrow of
their Italian brethren, and they mean to take such steps as will
ensure that if Fascism comes in Britain it will be an ally, and not a
foe.
London, April 16th, 1923.
 XXVI
SHOULD WE MAKE PEACE WITH RUSSIA?

I am frankly delighted that negotiations between Lord Curzon and

the Soviet government seem to indicate a genuine desire on the part
of both parties to establish a more satisfactory understanding
between this country and Russia. The Bolshevist episode, like all
revolutionary terrors, has been at times a shrieking nightmare which
has made the world shudder. It did render one supreme service to
civilisation—it terrified democracy back into sanity just at the time
when the nervous excitability that followed the war was bordering
on mental instability. In our attitude towards the Soviet government
we must, however, constantly bear in mind one consideration. What
matters to us is not so much the Russian government as the people
of Russia, and for the moment the Bolshevist administration
represents the only medium for dealing with that mighty nation. As
long as it remains the only constituted authority in Russia, every act
of hostility against it injures Russia. As we discovered in 1919, you
cannot wage war against the government for the time being of a
country without devastating the land and alienating its people. You
cannot refuse to trade with it now without depriving its people of
commodities—and especially of equipments—essential to their well-
being. It is the people, therefore, who would suffer, and it is the
people who would ultimately resent that suffering. Governments
come and go, but the nation goes on for ever.
The Russian people deserve—especially at the hands of all the Allied
nations—every sympathetic consideration we can extend to them.
Not only because they have to endure the sway of a tyrannical
oligarchy imposing its will by ruthless violence, but even more for
the reasons that led to the establishment of that tyranny. If the fruit
is bitter we must bear in mind how the tree came to be planted in
the soil. It may sound like quoting ancient history to revert to the
events of eight or nine years ago, but no one can understand Russia,
or do justice to its unhappy people, without recalling the incidents
that led to the great catastrophe.
Those who denounce any dealings with the existing order seem to
have persuaded themselves that pre-revolutionary Russia was
governed by a gentle and beneficent despotism which conferred the
blessings of a tolerant and kindly fatherland upon a well-ruled
household. In no particular is this a true picture of the ancien
régime. The fortress of Peter and Paul was not erected, nor its
dungeons dug, by the Bolshevists. Siberia was not set up as a penal
settlement for political offenders for the first time—if at all—by the
Bolshevists. In 1906 alone 45,000 political offenders were deported
to endure the severities of Siberia. Persecution of suspected religious
leaders was not started by the Soviets. To them does not belong the
discredit of initiating the methods of Pogromism. Under the
"paternal" reign of the Tsars dissent from the Orthodox faith was
proscribed and persecuted, and the Jews were hunted like vermin.
Let us not forget also that beyond all these circumstances the
revolution was rendered inevitable by the ineptitude and corruption
of the old system, and especially by the terrible suffering and
humiliation which that state of things inflicted on Russia in the Great
War.
Any one who has read the Memoirs of an Ambassador, by M.
Paléologue, will find a complete explanation in its pages of the
savage hatred with which the Russian revolutionaries view all those
who were associated in any degree with the old order. He tells the
story of how the gallant army found itself at the critical hour without
ammunition, rifles, transport, and often without food. No braver or
more devoted men ever fought for their country than the young
peasants who made up the Russian armies of 1914-15-16. With little
and often no artillery support, they faced without faltering the best-
equipped heavy artillery in the world. They were mown down by
shell fire and machine guns by the million. Their aggregate
casualties up to September, 1916, even according to the reluctant
admissions of the Tsarist generals of the day, were five millions. In
reality they were much heavier. Often they went into action with
sticks, as the Russian War Office had no rifles with which to arm
them. They picked up as they advanced rifles dropped by fallen
comrades. There is nothing in the war comparable to the trustful
heroism of these poor peasants. We know now why there were no
rifles, or shells, or wagons. The wholesale corruption of the régime
has been exposed to the world by irrefutable documentary evidence.
Here are a few extracts from M. Paléologue's interesting book. One
extract from his diary reads:—

"The lack of ammunition means that the rôle of the artillery in

battle is necessarily insignificant. The whole burden of the
fighting falls on the infantry and the result is a ghastly
expenditure of human life. A day or two ago one of the Grand
Duke Sergius's collaborators, Colonel Englehardt, said to Major
Wehrlin, my second military attaché: 'We're paying for the
crimes of our administration with the blood of our men.'"

About the same date talking about the deplorable state of things,
the Grand Duke Sergius, who was Inspector-General of Artillery, said
to the French ambassador, "When I think that this exhibition of
impotence is all that our aristocratic system has to show, it makes
me want to be a Republican."
When a Grand Duke talked like that early in 1915, what must a
peasant soldier have thought by the spring of 1917, after many more
millions of his comrades had been slaughtered as a result of the
same "exhibition of impotence."
It is no use pointing to the fact that our army was also short of
ammunition at that date. The British army was a small army
organised on the basis of a maximum expeditionary force of six
divisions. The Russian army was a great conscript force organised on
the basis of a hundred divisions in the field.
I recollect well our own military reports from the Russian fronts.
They provided much distressing reading. They filled you with
compassion for the millions of gallant men who were the victims of
corruption and stupidity in high places. I recall one statement made
to our general which betrays the callous indifference with which men
in authority seemed to treat the appalling sacrifice of life amongst
loyal soldiers who were facing death without a murmur, because the
"Little Father" willed it. Whenever anxious inquiries were directed by
our officer as to the gigantic losses in men which filled him with
dismay as well as horror, the usual reply was, "Don't worry yourself.
Thank God, of men at all events we have enough." An answer which
sends a thrill of horror through you when you read it. That is why at
the end of two and a half years the patient men in the field at last
mutinied. That is why their parents and brothers in the fields
supported them. The "Little Father" had failed them, and his minions
had betrayed them. It is a sordid and horrid tale of peculation,
maladministration, and cruel treachery. Millions of British and French
money went in shameless and open bribery, whilst the soldiers in the
field, for need of what the money could buy, were opposing bare
breasts covering brave hearts to the most terrible artillery in the
world. If the rest of the money had been well spent, what was left
after providing for profuse graft would still have sufficed to save that
gallant army from destruction. But unhappily no real interest was
taken in anything beyond the amount and the payment of the
pocket-money. That seemed to be the main purpose of the
transaction. Nothing was well managed except the inevitable bribe.
There were honourable and upright men who did their duty by their
distracted and plundered country, but they were helpless in the
torrent of corruption.
No wonder a great Russian industrialist engaged in the ministry of
war, in dwelling on the sad failure of tsarism and its probable results
in June, 1905, predicted a revolution with "ten years of the most
frightful anarchy." "We shall," he added, "see the days of
Pugatchef[11] again and perhaps worse"—a striking prophecy
verified with appalling accuracy.
It is not pleasant to recall these dreadful episodes, which reveal the
betrayal of a devotion faithful unto death. But this story is essential
to the right appreciation of events. There is no savagery like that of
a trustful people which finds that its trust was being imposed upon
the whole time. Here the retribution has been hideous in all its
aspects. But the provocation was also revolting from every point of
view. To judge Russia fairly that must be taken into account.
I think the government are, therefore, taking the right view of their
responsibilities when through their foreign secretary they open
negotiations with the representative of the Soviet government in this
country. You can easily evoke resounding cheers amongst the
thoughtless by declaring melodramatically that you will never "shake
hands with murder." In practice this policy has always been a failure.
Mr. Pitt in a famous passage declined to assent to that doctrine when
he was attacked for trying to open negotiations with the "assassins"
of the French Revolution. He was driven out of this calm and rational
attitude by the inflammable rhetoric of Burke, aided by the
arrogance of the victorious revolutionaries. Nevertheless, the sequel
proved he was right. French Bolshevism was not defeated by foreign
armies, nor starved out by the British blockade. But it was driven
into the arms of Napoleon, and Europe suffered bitterly for the folly
of the hotheads on both sides. It would have been better for that
generation had it listened to the wise counsel of William Pitt.
If you decline to treat with Russia as long as its present rulers
remain in power, then you ought to place Turkey in the same
category. The military junta that governed Turkey has been guilty of
atrocities at least as vile as any committed by the Bolshevists. But at
Lausanne we ostentatiously stretched the friendly hand of Britain to
the authors of the Armenian massacres. And France, Italy—yes, and
America also—tendered the same warm handshake. I am not
criticising the offer of amity made as a condition of peace. We must
make peace in the world, and you cannot do so if you put whole
nations off your visiting list because of the misconduct of those who
govern them. Once you begin you are not quite sure where it will
end.
In these cases the innocent suffer the most. A refusal to trade with
Russia would not deprive the Soviet commissaries of a single
necessity or comfort of life. The Communists are quite strong
enough to take care of themselves. But the peasants—who are not
Communists—would continue to suffer, and their sufferings would
increase as their reserves of clothing and other essentials became
completely exhausted. And the people of this country who need the
produce of Russia for their own use would also suffer to a certain
extent. America can afford this exalted aloofness. She does not need
the Russian grain and timber. She is an exporter of those
commodities. But we cannot do as well without them, and we also
sadly need Russian flax for our linen industries, which are
languishing for the want of it. Last year there were quite
considerable imports of Russian produce into this country. This year
owing to the prospects of an improved harvest these imports will be
much larger. They are greatly needed here for our own consumption,
and they pay for exports of machinery and textiles which the
Russian on his part urgently requires.
But beyond and above all these material considerations, the world
needs peace. In the old days conveyancing attorneys in this country
kept a property transaction going by interminable requisitions on the
title of the other party. They exercised all their ingenuity and invoked
the added ingenuity of trained counsel to probe for defects in the
right of the vendor to deal. Those were leisurely days, and men
could afford to dawdle. Even then these exercises often ended in
ruinous litigation. To-day time presses and the atmosphere is
dangerous for the plying of irritating interrogatories. It is time we
made up our minds that the Soviets have come to stay, whether we
like it or no, and that one or other of the formidable men who rule
Russia to-day are likely to rule it for some time to come. The sooner
we have the courage to recognise this fact, the sooner will real
peace be established.
 FOOTNOTE
[11] Pugatchef was the Pretender who led a revolt of the peasants
in the reign of Catherine and spread rapine and carnage through the
provinces bordering the Volga and Ural.
 XXVII
PALESTINE AND THE JEWS

"What's his reason? I am a Jew."

The Merchant of Venice.

Of all the bigotries that savage the human temper there is none so
stupid as the anti-Semitic. It has no basis in reason; it is not rooted
in faith; it aspires to no ideal; it is just one of those dank and
unwholesome weeds that grow in the morass of racial hatred. How
utterly devoid of reason it is may be gathered from the fact that it is
almost entirely confined to nations who worship Jewish prophets and
apostles, revere the national literature of the Hebrews as the only
inspired message delivered by the deity to mankind, and whose only
hope of salvation rests on the precepts and promises of the great
teachers of Judah. Yet in the sight of these fanatics the Jews of to-
day can do nothing right. If they are rich they are birds of prey. If
they are poor they are vermin. If they are in favour of a war it is
because they want to exploit the bloody feuds of the Gentiles to
their own profit. If they are anxious for peace they are either
instinctive cowards or traitors. If they give generously—and there
are no more liberal givers than the Jews—they are doing it for some
selfish purpose of their own. If they do not give—then what could
one expect of a Jew but avarice? If labour is oppressed by great
capital, the greed of the Jew is held responsible. If labour revolts
against capital—as it did in Russia—the Jew is blamed for that also.
If he lives in a strange land he must be persecuted and pogrommed
out of it. If he wants to go back to his own he must be prevented.
Through the centuries in every land, whatever he does, or intends,
or fails to do, he has been pursued by the echo of the brutal cry of
the rabble of Jerusalem against the greatest of all Jews—"Crucify
Him!" No good has ever come of nations that crucified Jews. It is
poor and pusillanimous sport, lacking all the true qualities of
manliness, and those who indulge in it would be the first to run
away were there any element of danger in it. Jew-baiters are
generally of the type that found good reasons for evading military
service when their own country was in danger.
The latest exhibition of this wretched indulgence is the agitation
against settling poor Jews in the land their fathers made famous.
Palestine under Jewish rule once maintained a population of
5,000,000. Under the blighting rule of the Turk it barely supported a
population of 700,000. The land flowing with milk and honey is now
largely a stony and unsightly desert. To quote one of the ablest and
most far-sighted business men of to-day, "It is a land of immense
possibilities, in spite of the terrible neglect of its resources resulting
from Turkish misrule. It is a glorious estate let down by centuries of
neglect. The Turks cut down the forests and never troubled to
replant them. They slaughtered the cattle and never troubled to
replace them." It is one of the peculiarities of the Jew-hunter that he
adores the Turk.
If Palestine is to be restored to a condition even approximate to its
ancient prosperity, it must be by settling Jews on its soil. The
condition to which the land has been reduced by centuries of the
most devastating oppression in the world is such that restoration is
only possible by a race that is prepared for sentimental reasons to
make and endure sacrifices for the purpose. What is the history of
the Jewish settlement in Palestine? It did not begin with the Balfour
Declaration. A century ago there were barely 10,000 Jews in the
whole of Palestine. Before the war there were 100,000. The war
considerably reduced these numbers, and immigration since 1918
has barely filled up the gaps. At the present timorous rate of
progress it will be many years before it reaches 200,000. Jewish
settlement started practically seventy years ago, with Sir Moses
Montefiore's experiment in 1854—another war year. The Sultan had
good reasons for propitiating the Jews in that year, as the Allies had
in 1917. So the Jewish resettlement of Palestine began. From that
day onward it has proceeded slowly but steadily. The land available
was not of the best. Prejudices and fears had to be negotiated.
Anything in the nature of wholesale expropriation of Arab cultivators,
even for cash, had to be carefully avoided. The Jews were,
therefore, often driven to settle on barren sand dunes and malarial
swamps. The result can best be given by quoting from an article
written by Mrs. Fawcett, the famous woman leader. She visited
Palestine in 1921 and again in 1922, and this is her account of the
Jewish settlements:

"So far from the colonies and the colonists draining the country
of its resources they have created resources which were
previously non-existent; they have planted and skilfully
cultivated desert sands and converted them into fruitful
vineyards and orange and lemon orchards; in other parts they
have created valuable agricultural land out of what were
previously dismal swamps producing nothing but malaria and
other diseases. The colonists have not shrunk from the
tremendous work and the heavy sacrifices required. Many of the
early arrivals laid down their lives over their work; the survivors
went on bravely, draining the swamps, planting eucalyptus trees
by the hundred thousand so that at length the swamp became a
fruitful garden, and the desert once more blossomed like the
rose."

Everywhere the Jew cultivator produces heavier and richer crops

than his Arab neighbour. He has introduced into Palestine more
scientific methods of cultivation, and his example is producing a
beneficent effect on the crude tillage of the Arab peasant. It will be
long ere Canaan becomes once more a land flowing with milk and
honey. The effects of the neglect and misrule of centuries cannot be
effaced by the issue of a declaration. The cutting down of the trees
has left the soil unprotected against the heavy rains and the rocks
which were once green with vineyards and olive groves have been
swept bare. The terraces which ages of patient industry built up
have been destroyed by a few generations of Turkish stupidity. They
cannot be restored in a single generation. Great irrigation works
must be constructed if settlement is to proceed on a satisfactory
scale. Palestine possesses in some respects advantages for the
modern settler which to its ancient inhabitants were a detriment. Its
one great river and its tributaries are rapid and have a great fall. For
power this is admirable. Whether for irrigation, or for the setting up
of new industries, this gift of nature to Palestine is capable of
exploitation only made possible by the scientific discoveries of the
last century. The tableland of Judea has a rainfall which if caught in
reservoirs at appropriate centres would make of the "desert of
Judea" a garden. If this be done Arab and Jew alike share in the
prosperity.
There are few countries on earth which have made less of their
possibilities. Take its special attractions for the tourist. I was amazed
to find that the visitors to Palestine in the whole course of a year
only aggregate 15,000. It contains the most famous shrines in the
world. Its history is of more absorbing interest to the richest peoples
on earth, and is better taught to their children, than even that of
their own country. Some of its smallest villages are better known to
countless millions than many a prosperous modern city. Hundreds of
thousands ought to be treading this sacred ground every year. Why
are they not doing so? The answer is: Turkish misrule scared away
the pilgrim. Those who went there came back disillusioned and
disappointed. The modern "spies" on their return did not carry with
them the luscious grapes of Escol to thrill the multitude with a desire
to follow their example. They brought home depressing tales of
squalor, discomfort, and exaction which dispelled the glamour and
discouraged further pilgrimages. Settled government gives the Holy
Land its first chance for 1900 years. But there is so much
undeveloped country demanding the attention of civilisation that
Palestine will lose that chance unless it is made the special charge of
some powerful influence. The Jews alone can redeem it from the
wilderness and restore its ancient glory.
In that trust there is no injustice to any other race. The Arabs have
neither the means, the energy, nor the ambition to discharge this
duty. The British Empire has too many burdens on its shoulders to
carry this experiment through successfully. The Jewish race with its
genius, its resourcefulness, its tenacity, and not least its wealth, can
alone perform this essential task. The Balfour Declaration is not an
expropriating but an enabling clause. It is only a charter of equality
for the Jews. Here are its terms:

"His Majesty's government view with favour the establishment in

Palestine of a National Home for the Jewish people, and will use
their best endeavours to facilitate the achievement of this
object, it being clearly understood that nothing shall be done
which may prejudice the civil and religious rights of existing
non-Jewish communities in Palestine, or the rights and political
status enjoyed by Jews in any other country."

The declaration was subsequently endorsed and adopted by

President Wilson and the French and Italian foreign ministers.
The Zionists ask for no more. It has been suggested by their
enemies that they are seeking to establish a Jewish oligarchy in
Palestine that will reduce the Arab inhabitant to a condition of
servitude to a favoured Hebrew minority. The best answer to that
charge is to be found in the memorandum submitted by the Zionist
Association to the League of Nations.

"The Jews demand no privilege, unless it be the privilege of

rebuilding by their own efforts and sacrifices a land which, once
the seat of a thriving and productive civilisation, has long been
suffered to remain derelict. They expect no favoured treatment
in the matter of political or religious rights. They assume, as a
matter of course, that all the inhabitants of Palestine, be they
Jews or non-Jews, will be in every respect on a footing of
perfect equality. They seek no share in the government beyond
that to which they may be entitled under the Constitution as
 citizens of the country. They solicit no favours. They ask, in
short, no more than an assured opportunity of peacefully
building up their national home by their own exertions and of
succeeding on their merits."

It is a modest request which these exiles from Zion propound to the

nations. And surely it is just that it should be conceded, and if
conceded then carried out in the way men of honour fulfil their
bond. There are fourteen millions of Jews in the world. They belong
to a race which for at least 1900 years has been subjected to
proscription, pillage, massacre, and the torments of endless derision
—a race that has endured persecution, which for the variety of
torture, physical, material and mental, inflicted on its victims, for the
virulence and malignity with which it has been sustained, for the
length of time it has lasted, and more than all for the fortitude and
patience with which it has been suffered, is without parallel in the
history of any other people. Is it too much to ask that those amongst
them whose sufferings are the worst shall be able to find refuge in
the land their fathers made holy by the splendour of their genius, by
the loftiness of their thoughts, by the consecration of their lives, and
by the inspiration of their message to mankind?
 XXVIII
THE TREATY OF LAUSANNE[12]

The vanquished have returned to their spiritual home at Angora

throwing their fezzes in the air. The victors have returned with their
tails well between their legs. All tragedies have their scenes of
comedy, and the Lausanne Conference is one of those amusing
episodes interpolated by fate to relieve the poignancy of one of its
greatest tragic pieces—the Turk and civilisation.
The Turk may be a bad ruler, but he is the prince of anglers. The
cunning and the patience with which he lands the most refractory
fish once he has hooked it is beyond compare. What inimitable play
we have witnessed for six months on the shores of Lake Leman!
Once the fish seemed to have broken the tackle—that was when the
first conference came to an abrupt end. It simply meant, however,
that the wily Oriental was giving out plenty of line. Time never
worries him, he can sit and wait. He knew the moment would come
when they would return with the hook well in their gullets, and the
play begin once more—the reeling in and the reeling out, the line
sometimes taut and strained but never snapping. Time and patience
rewarded him. At last the huge tarpon are all lying beached on the
banks—Britain, France, Italy, and the United States of America—high
and dry, landed and helpless, without a swish left in their tails,
glistening and gasping in the summer sun.
It is little wonder that Ismet had a smile on his face when all was
over. Reports from Angora state that the peace is hailed there as a
great Turkish triumph; and so it is. The Turk is truly a great
fisherman. If he could govern as well as he angles, his would be the
most formidable Empire in the world. Unfortunately he is the worst
of rulers, hence the trouble—his own and that of those who
unhappily have drawn him as governor in the lottery of life.
The able correspondent of the Daily Telegraph at the Lausanne
Conference has supplied us from time to time with vivid pen pictures
of the four greatest Powers of the world struggling in the toils of the
squalid and broken remains of an Empire with an aggregate
population equal to that of a couple of English counties that I could
name. This is what he wrote about this conference, which
constitutes one of the most humiliating incidents in the history of
Western civilisation:—

"The records of the present Conference present an even more

marvellous series of concessions and surrenders. What was
frayed before is threadbare now. The Allies have whittled away
their own rights with a lavish hand in the cause of peace. They
have also—and this is a graver matter, for which it seems they
will have to give an account in the not distant future—gone
back on their promises to small races, which are none the less
promises because the small races have not the power to enforce
their performance. The figure that the European delegates are
cutting in Lausanne, and the agents of the concessionnaires in
Angora—all alike representatives of the West—has been
rendered undignified as much by the manner as the matter of
their worsting."

Since those distressing words were written the Powers have sunk yet
deeper into the slough of humiliation.
The Times correspondent wiring after the agreement writes in a
strain of deep indignation at the blow inflicted on the prestige of the
West by this extraordinary Treaty. In order to gauge the extent of
the disaster to civilisation which this Treaty implies it is only
necessary to give a short summary of the war aims of the Allies in
Turkey.
They were stated by Mr. Asquith with his usual succinctness and
clarity in a speech which he delivered when Prime Minister at the
Guildhall on November 9th, 1914:—
 "It is not the Turkish people—it is the Ottoman Government that
has drawn the sword, and which, I venture to predict, will
perish by the sword. It is they and not we who have rung the
death-knell of Ottoman dominion, not only in Europe but in
Asia. With their disappearance will disappear as I, at least, hope
and believe, the blight which for generations past has withered
some of the fairest regions of the earth."

In pursuance of the policy thus declared by the British Premier on

behalf of the Allies a series of Agreements was entered into in the
early months of 1915 between France, Russia, and ourselves, by
which the greater part of Turkey, with its conglomerate population,
was to be partitioned at the end of the War. Cilicia and Syria were
allocated to France; Mesopotamia to Britain; Armenia and
Constantinople to Russia. Palestine was to be placed under the joint
control of Britain and France. Arabia was to be declared independent
and a territory carved largely out of the desert—but including some
famous cities of the East, Damascus, Homs and Aleppo—was to be
constituted into a new Arab State, partly under the protection of
France and partly of Britain. Smyrna and its precincts were to be
allotted to Greece if she joined her forces with those of the Allies in
the war. The Straits were to be demilitarised and garrisoned. When
Italy came into the war later on in 1915, it was stipulated that in the
event of the partition of Turkey being carried out in pursuance of
these agreements, territories in Southern Anatolia should be
assigned to Italy for development.
What was the justification for breaking up the Turkish Empire? The
portions to be cut out of Turkey have a population the majority of
which is non-Turkish. Cilicia and Southern Anatolia might constitute a
possible exception. In these territories massacres and
misgovernment had perhaps succeeded at last in turning the balance
in favour of the Turk. But in the main the distributed regions were
being cultivated and developed before the war by a population which
was Western and not Turanian in its origin and outlook. This
population represented the original inhabitants of the soil.
The experiences, more especially of the past century, had
demonstrated clearly that the Turk could no longer be entrusted with
the property, the honour, or the lives of any Christian race within his
dominions. Whole communities of Armenians had been massacred
under circumstances of the most appalling cruelty in lands which
their ancestors had occupied since the dawn of history. And even
after the war began 700,000 of these wretched people had been
done to death by these savages, to whom, it must be remembered,
the Great Powers so ostentatiously proffered the hand of friendship
at the first Lausanne conference. Even while the conference was in
session, and the handshaking was going on, the Turks were torturing
to death scores of thousands of young Greeks whom they deported
into the interior. As "a precautionary measure" 150,000 Greeks of
military age, of whom 30,000 were military prisoners, were last year
driven inland to the mountains of Anatolia. On the way they were
stripped of their clothes, and in this condition were herded across
the icy mountains. It is not surprising that when an agreement was
arrived at for the exchange of military prisoners, the Turks found the
greatest difficulty in producing 11,000, and of the total 150,000 it is
estimated that two-thirds perished. The Allied Powers had every
good reason for determining, as they hoped for all time, that this
barbarian should cease to shock the world by repeated exhibitions of
savagery against helpless and unarmed people committed to his
charge by a cruel fate.
Apart from these atrocities the fact that great tracts of country, once
the most fertile and populous in the world, have been reduced by
Turkish misrule and neglect to a condition which is indistinguishable
from the wilderness, alone proves that the Turk is a blight and a
curse wherever he pitches his tent, and that he ought in the
interests of humanity to be treated as such. When a race, which has
no title to its lands other than conquest, so mismanages the
territories it holds by violence as to deprive the world of an essential
contribution to its well-being, the nations have a right—nay, a duty—
to intervene in order to restore these devastated areas to civilisation.
This same duty constitutes the reason and justification for the white
settlers of America overriding the prior claims of the Indian to the
prairies and forests of the great West.
On the shores of the Mediterranean are two races with a surplus
population of hard-working, intelligent cultivators, both of them
belonging to countries which had themselves in the past been
responsible for the government of the doomed lands covered by the
Turkish Empire. Greece and Italy could claim that under their rule
this vast territory throve and prospered mightily. They now pour
their overflow of population into lands far away from the
motherland. Yet they are essentially Mediterranean peoples. The
history of the Mediterranean will for ever be associated with their
achievements on its shores and its waters. The derelict wastes of
Asia Minor need them. Valleys formerly crowded with tillers are now
practically abandoned to the desert weeds. Irrigation has been
destroyed or neglected. The Italian engineers are amongst the best
in the world, and once they were introduced into Asia Minor would
make cultivation again possible. There is plenty of scope in the
deserts of Anatolia for both Italian and Greek. I was hoping for a
peace that would set them both working. Had such a settlement
been attained, a generation hence would have witnessed gardens
thronging with happy men, women, and children, where now you
have a wilderness across which men, women, and children are
periodically hunted down into nameless horror.
Yet another reason for the Allied decision was the bitter resentment
that existed at the ingratitude displayed by the Turk towards Britain
and France. They were naturally indignant that he should have
joined their foes and slammed the gate of the Dardanelles in their
face, and by that means complicated and prolonged their campaign
and added enormously to their burdens, their losses, and their
dangers. But he had not the thankfulness even of the beast of prey
in the legend towards the man who had cured his wounded limb.
France and Britain had many a time extracted the thorn from the
Turkish paw when he was limping along in impotent misery. They
had done more. They had often saved the life of that Empire when
the Russian bear was on the point of crushing it out of existence;
and yet without provocation, without even a quarrel, he had
betrayed them to their enemies.
I have set out shortly what the war policy of the Allies was in
reference to Turkey. The Treaty of Sèvres considerably modified that
policy in many vital aspects. By that Treaty, Constantinople, Cilicia,
and Southern Anatolia were left to the Turk; Armenia was created
into an independent State. There were many objections which could
be raised to the original proposals of 1915, as it might be argued
that they contemplated handing over in Cilicia and Southern Anatolia
populations which in the main were Turkish and Moslem to Christian
rulers. But in substance the modified plan of Sèvres was sound, and
if carried out would have conduced to the well-being of the millions
to be liberated by its terms for ever from Turkish rule. The world at
large also would have benefited by the opportunity afforded to the
industrious and intelligent Armenian and Greek populations of Turkey
to renew the fertility of this land, once so bountiful in its gifts, thus
enriching man's store of good things. The barbarian invasion which
withered that fertility was pushed back into the interior by the Treaty
of Sèvres. The Treaty of Lausanne has extended and perpetuated its
sway from the Black Sea to the Mediterranean. I have explained the
why and wherefore of Sèvres. But why Lausanne? It is a long and
painful story—a compound of shortsightedness, disloyalty,
selfishness, and pusillanimity amongst nations and their statesmen.
And more than all, Fate happened to be in its grimmest mood when
dealing with this problem. The Russian Revolution eliminated that
great country from the solution of the problem on the lines of
protection for the oppressed races of Turkey, and instead cast its
might on the side of the oppressor. President Wilson was inclined to
recommend that the United States of America should undertake the
mandate for the Armenians. Had he succeeded, what a different
story would now have been told! What a different story the
generations to come would also tell! But his health broke down at
the vital moment and America would have none of his humanitarian
schemes. Then came the departure of Sonnino from the Quirinal.
With him went for a momentous while the old dreams of Italian
colonisation, which in the past had done so much to spread
civilisation in three continents. His successors were homelier men. I
have still my doubts as to whether they served Italy best by the less
adventurous and more domesticated policy they pursued. The future
may decide that issue. But whatever the decision, the time for action
passed away, and unless and until there is another break up in
Turkey, the chance Italy has lost since 1919 will not be recovered.
Will it ever come back?
There followed the French check in Cilicia, and the negotiations at
Angora with Mustapha Kemal, which were both single-handed and
under-handed; for the Allies were not even informed of what was
going on. This was a fatal step, for it broke up the unity which alone
would enable the Western Powers to deal effectively with the Turk.
This unity was never fully re-created. There can be no reunion
without confidence. There can be no trust in the West that is broken
in the East. Much of the recent mischief in the Entente came from
the clandestine negotiations at Angora.
The last fatal change was the Greek revolt against Venizelos. It is
often said that he is the greatest statesman thrown up by that race
since Pericles. In all he has undertaken he has never failed his
people. Disaster has always come to them when they refused to
follow his guidance. When King Alexander was killed by a monkey,
the Greeks were called upon to decide between Constantine and
Venizelos. Their choice was ruinous to their country. No greater evil
can befall a nation than to choose for its ruler a stubborn man with
no common sense. Before the advent of Constantine, Greece, with
no aid and little countenance from the Powers, was able to hold the
forces of Mustapha Kemal easily at bay and even to drive him back
into the fastnesses of Anatolia. In encounter after encounter the
Greek army, led by men chosen for their military gifts and sufficiently
well equipped, inflicted defeat after defeat on the armies of Angora.
But with Constantine came a change. In the Greek army, courtiers
were substituted for soldiers in the high command. French, British
and Italian public opinion, with the memory of Constantine's
treachery during the war still fresh in their minds, altered their
attitude towards the Greeks who had elevated him to the throne in
defiance of Allied sentiment. Indifferent Powers became hostile;
hostile Powers became active. The final catastrophe began with the
heroic but foolish march of the Greek army into the defiles of Asia
Minor, followed by the inevitable retreat. It was consummated when
Constantine for dynastic reasons appointed to the command of the
troops in Asia Minor a crazy general whose mental condition had
been under medical review. The Greeks fight valiantly when well led,
but like the French, once they know they are not well led,
confidence goes, and with confidence courage. Before the Kemalist
attack reached their lines the Greek army was beaten and in full
retreat. With attack came panic, with panic the complete destruction
of what was once a fine army. With the disappearance of that army
vanished the last hope for the salvation of Anatolia. That the history
of the East, and probably the West, should have been changed by
the bite of a monkey is just another grimace of the comic spirit
which bursts now and again into the pages of every great tragedy.
All that could be done afterwards was to save the remnants of a
great policy. Western civilisation put up its last fight against the
return of savagery into Europe, when in September and October of
last year British soldiers and sailors, deserted by allies and
associates alike, saved Constantinople from hideous carnage. The
Pact of Mudania was not Sèvres, but it certainly was better than
Lausanne. From Sèvres to Mudania was a retreat. From Mudania to
Lausanne is a rout.
What next? Lausanne is not a terminus, it is only a milestone. Where
is the next? No one claims that this Treaty is peace with honour. It is
not even peace. If one were dealing with a regenerated Turk, there
might be hope. But the burning of Smyrna, and the cold-blooded
murders of tens of thousands of young Greeks in the interior, prove
that the Turk is still unchanged. To quote again from the
correspondent of The Times at Lausanne:—
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