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Best of Five MCQs for the Acute Medicine SCE
Best of Five MCQs
for the Acute Medicine SCE
Edited by
Nigel Lane
Consultant in Acute Medicine, North Bristol NHS Trust, UK
Louise Powter
Consultant in Acute Medicine, North Bristol NHS Trust, UK
Sam Patel
Consultant in Acute Medicine and Rheumatology,
Clinical Director, Medicine, North Bristol NHS Trust
Training Programme Director, General (Internal) Medicine, Severn Deanery, UK
1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
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© Oxford University Press 2016
The moral rights of the authors have been asserted
First Edition published in 2016
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2015934703
ISBN 978–0–19–968026–9
Printed in Great Britain by
Ashford Colour Press Ltd, Gosport, Hampshire
Oxford University Press makes no representation, express or implied, that the
drug 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 publishers do not accept responsibility or legal liability for any errors in the
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adult who is not breast-feeding
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for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
CONTENTS
Abbreviations viii
Contributors xv
Introduction xvii
1 Cardiorespiratory arrest and shock

Questions 1
Answers 15
2 Gastroenterology
Questions 27
Answers 42
3 Respiratory
Questions 59
Answers 78
4 Cardiology
Questions 93
Answers 111
5 Diabetes and endocrinology

Questions 127
Answers 143
6 Elderly care and stroke

Questions 157
Answers 170
vi Contents
7 Renal medicine and urological problems

Questions 183
Answers 198
8 Neurology and ophthalmology

Questions 207
Answers 226
9 Musculoskeletal medicine
Questions 249
Answers 269
10 Oncology and palliative care

Questions 283
Answers 292
11 Haematology
Questions 301
Answers 306
12 Infectious diseases and HIV

Questions 313
Answers 330
13 Poisoning and pharmacology

Questions 351
Answers 363
14 Immunology and allergy

Questions 383
Answers 389
15 Dermatology
Questions 395
Answers 400
Contents vii
16 Psychiatry
Questions 403
Answers 410
Subject index 421

ABBREVIATIONS
a-NVH asymptomatic non-visible haematuria

AAFB acid and alcohol fast bacilli
ABPA allergic bronchopulmonary aspergillosis
AchR acetylcholine receptors
ACR American College of Rheumatology
ACS acute coronary syndrome
ACTH adrenocorticotropic hormone
ADA adenosine deaminase
AEDs anti-epileptic drugs
AESs anti-embolism stockings
AF atrial fibrillation
ALF acute liver failure
ALT alanine transaminase
ANA antinuclear antibody
ANCA antineutrophil cytoplasmic antibodies
anti-TNF anti-tumour necrosis factor
ARDS acute respiratory distress syndrome
AST aspartate transaminase
AVN avascular necrosis
BASDEC brief assessment schedule depression cards
BASHH British Society for Sexual Health and HIV
BAUS British Association of Urological Surgeons
bd two times daily
BHIVA British HIV Association
BMI body mass index
bpm beats per minute
BPPV benign paroxysmal positional vertigo
BTS British Thoracic Society
BSR British Society for Rheumatology
CAD coronary artery disease
CBDS common bile duct stones
CDI clostridium difficile infection
Abbreviations ix
CF cystic fibrosis
CHM Commission on Human Medicines
CI-AKI contrast-induced acute kidney injury
CINV chemotherapy-induced nausea and vomiting
CIS clinically isolated syndrome
CJD Creutzfeldt-Jakob disease
CMAP compound muscle action potential
CMT core medical training (in the UK)
CMV cytomegalovirus
CNS central nervous system
COMT catecol-O-methyl transferase
COPD chronic obstructive pulmonary disease
CPC cerebral performance category
CRP C-reactive protein
CSII continuous subcutaneous insulin infusions
CTPA computed tomography pulmonary angiogram
CVID common variable immunodeficiency
CVP central venous pressure
CYP450 cytochrome P450
DESMOND Diabetes Education and Self Management for Ongoing and Newly Diagnosed
DEXA dual-energy X-ray absorptiometry
DIC disseminated intravascular coagulation
DIOS distal intestinal obstruction syndrome
DKA diabetic ketoacidosis
DSs dissociative seizures
DTs delirium tremens
DVLA Driver and Vehicle Licensing Agency
DVT deep vein thrombosis
EBV Epstein–Barr virus
ECG electrocardiogram
EGDT early goal-directed therapy
EGPA eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss
Syndrome)
EMG electromyogram
EMR endomucosal resection
ENT ear, nose and throat
EPA Enduring Power of Attorney
ERCP endoscopic retrograde cholangiopancreatography
ESC European Society of Cardiology
ESR erythrocyte sedimentation rate
EULAR European League Against Rheumatism
x Abbreviations
EWS Early Warning Score

F1 foundation year 1 doctor (in the UK)
F2 foundation year 2 doctor (in the UK)
FAST focused assessment with sonography in trauma
FDIT faecal donor instillation therapy
FEV forced expiratory volume
FEV1 forced expiratory volume in 1 second
FMT faecal microbiota transplantation
FRAX Fracture Risk Assessment Tool
FSH follicle stimulating hormone
FVC forced vital capacity
GABA gamma-aminobutyric acid
GBM glomerular basement membrane
GBS Guillain–Barré syndrome
GCA giant cell arteritis
GCS Glasgow Coma Score
GCSF granulocyte colony stimulating factors
GDS geriatric depression scale
GI gastrointestinal; glycaemic index
GP general practitioner; glycoprotein
GRACE Global Registry of Acute Coronary Events
GTN glyceryl trinitrate
HADS hospital anxiety and depression scale
Hb haemoglobin
HHS hyperosmolar hyperglycaemic state
HIV human immunodeficiency virus
HONK hyperosmolar non-ketotic
HPV human papilloma virus
HRS hepatorenal syndrome
HSV herpes simplex virus
IABP intra-aortic balloon pump
ICD implantable cardioverter defibrillator
ICH intracerebral haemorrhage
ICS inhaled corticosteroid
IDA iron deficiency anaemia
IGRAs interferon gamma release assays
IIP interstitial idiopathic pneumonia
IMCA independent mental capacity advocate
INR international normalized ratio
IV intravenous
Abbreviations xi
IVIG intravenous immunoglobulin

LABA long-acting beta agonist
LAMA long-acting muscarinic antagonist
LEMS Lambert–Eaton myasthenic syndrome
LH luteinizing hormone
LMWH low molecular weight heparin
LPA Lasting Power of Attorney
LTOT long-term oxygen therapy
MAOI monoamine Oxidase Inhibitors
MASCC Multinational Association for Supportive Care in Cancer
MCM major congenital malformations
MDAC multiple-dose activated charcoal
MDR TB multi-drug resistant tuberculosis
MG myasthenia gravis
MND motor neurone disease
MOA-B monoamine oxidase B
MAOI monoamine oxidase inhibitor
MRCP magnetic resonance cholangiopancreatography
MS multiple sclerosis
MSCC metastatic spinal cord compression
MSU mid stream specimen of urine
MUST Malnutrition Universal Screening Tool
NEAD non-epileptic attack disorder
NHS National Health Service
NICE National Institute for Health and Care Excellence
NIHSS National Institutes of Health Stroke Scale
NIV non-invasive ventilation
NNT number needed to treat
NNTB number needed to treat to benefit
NOACs novel oral anticoagulation agents
NOGG National Osteoporosis Guideline Group
NPH normal pressure hydrocephalus
NPIS National Poisons Information Service
NSAIDs non-steroidal anti-inflammatory drugs
NSIP non-specific interstitial pneumonia
od once a day
OGTT oral glucose tolerance test
OH orthostatic hypotension
OR odds ratio
ORS oral rehydration solution
xii Abbreviations
OSAHS obstructive sleep apnoea/hypopnoea syndrome

PBC primary biliary cirrhosis
PCP pneumocystis pneumonia
PCR polymerase chain reaction
PD Parkinson’s disease
PE pulmonary embolism
PEFR peak expiratory flow rate
PFAPA periodic fever, aphthous pharyngitis, and cervical adenopathy
PICA posterior inferior cerebellar artery
PID pelvic inflammatory disease
PoTS postural tachycardia syndrome
PPI proton pump inhibitor
PsA psoriatic arthritis
PSA prostate-specific antigen
PSP primary spontaneous pneumothorax
PCC prothrombin complex concentrate
PTH parathyroid hormone
PE pulmonary embolism
qds four times daily
RA rheumatoid arthritis
RCT randomized controlled trial
RF rheumatoid factor
RR relative risk
SABA short-acting beta agonist
SAH subarachnoid haemorrhage
SBP spontaneous bacterial peritonitis
SDAC single-dose activated charcoal
SIADH syndrome of inappropriate antidiuretic hormone secretion
SIRS systemic inflammatory response syndrome
SLE systemic lupus erythematosus
SNRIs serotonin–norepinephrine reuptake inhibitors
SpA spondyloarthritis
SPECT single-photon emission computed tomography
SSA/Ro Sjögren’s-syndrome-related antigen A, also called Ro
SSB/La Sjögren’s-syndrome-related antigen B, also called La
SSP secondary spontaneous pneumothorax
SSRIs selective serotonin re-uptake inhibitors
sTfR serum transferrin receptor
SUDEP sudden unexpected death in epilepsy
SVCO superior vena cava obstructions
Abbreviations xiii
TAB temporal artery biopsy

TB tuberculosis
TCAs tricyclic antidepressants
TdP Torsades de Pointes
tds three times a day
TIMI Thrombolysis in Myocardial Infarction
TIPSS transjugular intrahepatic portsystemic shunt
TRALI transfusion-associated lung injury
TSH thyroid stimulating hormone
UC ulcerative colitis
UK United Kingdom
UPPP uvulopalatopharyngoplasty
US ultrasound
USA United States of America
UTI urinary tract infection
VATS video-assisted thoracic surgery
VKA vitamin K antagonist
VRII variable-rate insulin infusion
VT ventricular tachycardia
VTE venous thromboembolism
VVIR ventricular pacing, ventricular sensing, inhibited by a ventricular event, rate-respon-
sive pacemaker
vWF von-Willebrand factor
WHO World Health Organization
Contributors
Helen Alexander Consultant in General and Old Age Medicine, Gloucestershire Hospitals NHS
Foundation Trust, UK
Louise Beckham Specialty Registrar, Acute Medicine, Severn Deanery, UK
David de Berker Consultant Dermatologist, University Hospitals Bristol NHS Foundation Trust, UK
Begoña Bovill Consultant in Infectious Diseases and HIV, North Bristol NHS Trust, UK
Jeremy Braybrooke Consultant Medical Oncologist, University Hospitals Bristol NHS Founda-
tion Trust, UK
Andrew De Burgh-Thomas Consultant in Genito-urinary medicine and HIV, Gloucestershire
Hospitals NHS Foundation Trust, UK
Charlie Comins Consultant Clinical Oncologist, University Hospitals Bristol NHS Foundation
Trust, UK
Nerys Conway Speciality Registrar, Acute Medicine, Severn Deanery, UK
Ihab Diab Consultant Cardiologist, University Hospitals Bristol NHS Foundation Trust and
Weston Area NHS Trust, UK
Michelle Dharmasiri Consultant Stroke Physician, The Royal Bournemouth and Christchurch
Hospitals NHS Foundation Trust, UK
Sara Drinkwater Consultant Immunologist, Central Manchester University Hospitals NHS Foun-
dation Trust, UK
Tomaz Garcez Consultant Immunologist, Central Manchester University Hospitals NHS Founda-
tion Trust, UK
Matthew Hall Consultant Renal Physician, Nottingham University Hospitals NHS Trust, UK
Markus Hauser Consultant in Acute Medicine with an interest in Gastroenterology, Gloucester-
shire Hospitals NHS Foundation Trust, UK
Roland Jenkins Consultant in Respiratory Medicine, University Hospitals Bristol NHS Foundation
Trust, UK
Nigel Lane Consultant in Acute Medicine, North Bristol NHS Trust, UK
Rebecca Maxwell Consultant in Emergency Medicine, University Hospitals Bristol NHS Founda-
tion, Trust UK
Jim Moriarty Consultant Renal Physician, Gloucestershire Hospitals NHS Foundation Trust, UK
Fran Neuberger Specialty Registrar, Acute Medicine, Severn Deanery, UK
Anish Patel Consultant Liaison Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS
Trust, UK
Sam Patel Consultant in Acute Medicine and Rheumatology, North Bristol NHS Trust, UK
xvi Contributors
Justin Pearson Consultant Neurologist, North Bristol NHS Trust, UK

Suzanne Phillips Consultant in Endocrinology and Diabetes, Gloucestershire Hospitals NHS
Foundation Trust, UK
Louise Powter Consultant in Acute Medicine, North Bristol NHS Trust, UK
Paul Reavley Consultant in Emergency Medicine, University Hospitals Bristol NHS Foundation
Trust, UK
Philip Sedgwick Reader in Medical Statistics and Medical Education, St. George’s, University of
London, UK
Matthew Sephton Consultant Medical Oncologist, Yeovil District Hospital NHS Foundation
Trust, UK
Kanch Sharma Specialty Registrar, Neurology, Severn Deanery, UK
Matt Thomas Consultant in Intensive Care Medicine, North Bristol NHS Trust, Bristol, UK
Rosalind Ward Consultant in Old Age Psychiatry, Avon and Wiltshire Mental Health Partnership
NHS Trust, UK
Alastair Whiteway Consultant Haematologist, Southmead Hospital, North Bristol NHS Trust,
UK
INTRODUCTION
The acute medicine specialty certificate examination (SCE) is the exit exam for acute medicine
higher specialty trainees in the UK, which needs to be passed before trainees are awarded a Cer-
tificate of Completion of Training. It should be taken towards the end of your registrar training. It
consists of two papers, each with 100 questions. The questions are in ‘best of five’ format. You are
given a question stem, which is usually a clinical scenario, and then five possible answers from which
you need to choose the most correct one. The exam is computer based, and questions can be
flagged for later review. For each paper you have three hours, giving you about 1 minute 45 seconds
per question plus 5 minutes for review. Both papers are done on the same day, with a break for
lunch.
Nigel and Louise have passed the SCE (in 2012 and 2011 respectively). When it came to revising,
it was clear there was a lack of appropriate revision material, hence the need for this book. The
book covers the acute internal medicine curriculum (2012) and at the end of each answer you are
given relevant additional reading—for instance, national guidelines—so you can easily find additional
information. The book is divided into chapters according to subject to make it easier to revise. Of
course, in the exam, the questions are random, so you don’t know that you are answering a ques-
tion about cardiology, for example. You can pick questions randomly from the book to more reflect
the exam if you choose.
All the questions and answers were correct at the time of writing. However, acute medicine is ever-
changing, which is what makes it so exciting, so very new guidance may not be included.
The editors had a lot of help in writing this book from a wide variety of specialists to ensure the
questions are accurate and up to date. The editors would like to thank all of the individual chapter
editors for their contribution, without which it would not have been possible.
We hope you find this book useful. All that remains is to say good luck!
Nigel Lane, Louise Powter, and Sam Patel

CARDIORESPIRATORY ARREST
chapter
AND SHOCK
1 QUESTIONS
1. A 74-year-old man suffered a cardiorespiratory arrest on a surgical

ward four days after an elective sigmoid colectomy (with primary
anastomosis) for cancer. His past medical history included hypertension
and hypercholesterolaemia for which he took lisinopril, atenolol, and
atorvastatin.
He had been seen by the surgical foundation year 1 doctor (in the UK)
eight hours prior to his cardiorespiratory arrest after an episode of
nausea and vomiting. On examination at that time his temperature
was 38.0°C, pulse 105 beats per minute, blood pressure 95/40 mmHg,
and respiratory rate 28 breaths per minute, with peripheral oxygen
saturation of 94% on air. The doctor had noted abdominal tenderness,
prescribed intravenous fluids, paracetamol and ondansetron, and
performed peripheral blood cultures.
Which is the most likely cause of the cardiorespiratory arrest?
A. Anaphylaxis
B. Hyperkalaemia
C. Myocardial infarction
D. Peritonitis
E. Pulmonary embolus
2. A 69-year-old man was successfully defibrillated after an episode

of ventricular fibrillation secondary to an ST elevation myocardial
infarction (STEMI) and transferred to the cardiac catheter laboratory
for primary coronary intervention. After the procedure began he had a
further episode of ventricular fibrillation.
Regarding defibrillation, which is true?
A. A single direct current shock of 360 joules with a biphasic waveform is the most likely to
restore spontaneous circulation
B. Defibrillation is no more likely to be successful than a properly delivered praecordial thump
C. It is safe to continue with the coronary angiogram while the shock is delivered to the patient
D. Three shocks delivered with minimal interruptions should be given before any other intervention
E. Two minutes of chest compressions before defibrillation is recommended to optimize
coronary perfusion
2 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS
3. A 75-year-old man was admitted via the emergency department with

a two-day history of shortness of breath with a productive cough and
12 hours of nausea and vomiting. He had a history of chronic obstructive
pulmonary disease and usually took salmeterol and tiotropium inhalers.
His temperature was 39.3°C, heart rate 112 beats per minute, blood
pressure 116/72 mmHg, and respiratory rate 24 breaths per minute.
His oxygen saturation was 91% on 2 litres per minute of oxygen via nasal
cannulae.
A venous lactate was measured at 3.3 mmol per litre.
Which of the following is true?
A. Elevated lactate always represents tissue ischaemia
B. Elevated venous lactate identifies a high risk of death
C. Hyperlactataemia is diagnostic of severe sepsis
D. Venous and arterial lactate measurements are interchangeable
E. Venous lactate is not a suitable target for goal directed therapy
4. An 80-year-old woman was admitted to hospital for management of

chronic venous leg ulcers. While on the medical ward, she had an
asystolic cardiorespiratory arrest. Following resuscitation according
to Advanced Life Support guidelines ventricular fibrillation was seen
and defibrillation successfully restored spontaneous circulation after
15 minutes.
What is the patient’s chance of having a good neurological outcome?
A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
5. A 49-year-old woman was admitted to the intensive care unit after

suffering a massive subarachnoid haemorrhage. One week after
admission she remained unresponsive and the decision to perform
brainstem death tests was made. What preconditions must be met
before the tests are performed?
A. Coroner’s approval, known irreversible aetiology of coma, exclusion of reversible causes
of apnoea
B. Exclusion of reversible causes of apnoea, known irreversible aetiology of coma, exclusion
of reversible causes of coma
C. Exclusion of reversible causes of coma, 48 hours since onset of coma, structural brain
damage on CT scan
D. Known irreversible aetiology of coma, coroner’s approval, evidence of absence of cerebral
blood flow (e.g. with angiography)
E. Twenty-four hours since onset of coma, exclusion of reversible causes of apnoea, absence
of contraindications to organ donation
CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 3
6. A 55-year-old man was admitted to the acute medical unit with a four-
day history of increasing shortness of breath and cough productive of
green sputum. He was a smoker who took amlodipine for hypertension.
On examination his temperature was 35.8°C, pulse rate 85 beats per
minute, blood pressure 112/50 mmHg, and respiratory rate 26 breaths
per minute. Bronchial breath sounds were heard at the base of his right
lung. His capillary refill time was 4 seconds.
Investigations:
haemoglobin 143 g/L (130–180)
white cell count 13.9 × 109/L (4–11)
neutrophil count 10.1 × 109/L (1.5–7.0)
platelets 122 × 109/L (150–400)
serum sodium 144 mmol/L (137–144)
serum potassium 3.9 mmol/L (3.5–4.9)
serum urea 10.5 mmol/L (2.5–7.0)
serum creatinine 119 μmol/L (60–110)
arterial PO2 (air) 9.9 kPa (11.3–12.6)
arterial PCO2 4.5 kPa (4.7–6.0)
pH 7.33 (7.35–7.45)
lactate 3.3 mmol/L (0.5–1.6)
Which clinical syndrome does he have?
A. Acute kidney injury
B. Acute lung injury
C. Sepsis
D. Septic shock
E. Severe sepsis
7. A 40-year-old man known to have alcoholic liver disease presented with

upper gastrointestinal bleeding. While on the medical ward he had a
large haematemesis associated with a reduction in conscious level. He
had previously had banding of oesophageal varices. On examination
his temperature was 36.1°C, pulse rate 135 beats per minute, blood
pressure 73/43 mmHg, and respiratory rate 32 breaths per minute. His
Glasgow Coma Score was 9 (E3, V2, M5).
Investigations:
haemoglobin 59 g/L (130–180)
white cell count 14.2 × 109/L (4–11)
platelets 99 × 109/L (150–400)
international normalized ratio 1.5 (<1.4)
activated partial thromboplastin 42 s (30–40)
time
fibrinogen 2.9 g/L (1.8–5.4)
What is your first action in this situation?
A. Activate the massive haemorrhage protocol
B. Call ICU to arrange intubation
C. Give 1 mg of terlipressin intravenously
D. Give 2 litres of 0.9% saline stat
E. Insert a Sengstaken–Blakemore tube
8. A 60-year-old woman was admitted to the coronary care unit with acute
coronary syndrome for which she underwent percutaneous coronary
intervention. Her past medical history included type 2 diabetes mellitus,
hypertension, osteoarthritis, and a femoro-popliteal bypass six years
ago. She was taking metformin, ramipril, amlodipine, paracetamol,
codeine phosphate, and aspirin.
A urinary catheter was inserted during the procedure and over the next
12 hours she passed a total of 140 mL of urine.
On examination her pulse rate was 84 beats per minute, blood pressure
145/85 mmHg, jugular venous pressure 3 cm above the sternal notch,
respiratory rate 18 breaths per minute, and oxygen saturation 96%
on air. Auscultation of her chest revealed normal breath sounds with
occasional fine inspiratory crackles and heart sounds were dual with no
murmurs. There was no peripheral oedema and capillary refill time was
2 seconds.
A central venous catheter was inserted and the response to 250 mL of
0.9% saline was assessed:
Investigations:
Central venous pressure (mmHg):
Pre-treatment 5
Post-treatment 9
What is your action based on these results?
A. Insert arterial catheter
B. Repeat fluid challenge
C. Start dobutamine
D. Start furosemide
E. Take the central venous catheter out
9. A 62-year-old man suffered an out-of-hospital cardiac arrest. He was

successfully resuscitated in the emergency department and transferred
for percutaneous coronary intervention. Following stenting of the left
anterior descending artery an intra-aortic balloon pump (IABP) was
inserted and he was moved to the coronary care unit.
Two hours after the procedure the patient reported his breathing had
become more difficult. The nursing staff had noted that his oxygen
saturation had fallen from 96% to 91% on 2 litres per minute of oxygen
and that the waveform displayed on the IABP had changed (Figure 1.1).
It was switched from a 1:1 to 1:2 ratio for analysis.
Diastolic
Augmentation
Unassisted
Systole
Assisted Systole
Assisted Aortic
End Diastolic
Pressure
Figure 1.1 Intra-aortic balloon pump (IABP) waveform.
What is the problem with the intra-aortic balloon pump?

A. Early deflation
B. Early inflation
C. IABP kinked
D. Late deflation
E. Slow gas leak
10. An 18-year-old woman was admitted to the acute medical unit after
having a generalized seizure. While on the ward, she continued to have
fits at least hourly despite treatment with lorazepam, phenytoin, and
levetiracetam. Between seizures her Glasgow Coma Score ranged from
9 (E2, V2, M5) to 13 (E3, V4, M6). Transfer to the intensive care unit via
the CT scanner was arranged.
Which one of the following would not be considered essential for safe
transfer of this patient?
A. Adrenaline (epinephrine)
B. Intravenous access
C. Intubation
D. Pulse oximetry
E. Self-inflating bag
11. A 73-year-old man had a cardiac arrest. The rhythm was pulseless
electrical activity. Cardiopulmonary resuscitation was started at a rate
of 30 chest compressions to 2 ventilations.
What is the correct rate of chest compressions?
A. 80–100 per minute
B. 90–110 per minute
C. 100–120 per minute
D. 110–130 per minute
E. 120–140 per minute
12. A 64-year-old man had a cardiac arrest. The initial rhythm was pulseless
electrical activity. During cardiopulmonary resuscitation the rhythm on
the monitor was noted to change to VF.
What is the correct course of action?
A. Continue cardiopulmonary resuscitation until the two-minute period is completed
B. Deliver a DC shock then continue chest compressions until the two-minute period is
completed
C. Stop chest compressions and assess the rhythm
D. Stop chest compressions and check for a pulse
E. Stop chest compressions and deliver a DC shock
13. A 45-year-old man had a cardiac arrest. Chest compressions were in

progress. The anaesthetic trainee intubated the patient, secured the
tube at 27 cm at the teeth, and was ventilating the patient using a
self-inflating bag with high-flow oxygen. Waveform capnography was
attached to the tracheal tube but no end-tidal CO2 was detected.
What is the next step in airway management?
A. Auscultate the chest to check the tube position
B. Continue ventilation via the endo-tracheal tube
C. Remove the endo-tracheal tube and establish face-mask ventilation
D. Replace the waveform capnography with a new monitor
E. Withdraw the tube by 3 cm then re-secure and continue ventilation
14. A 45-year-old woman collapsed on the neurosurgical ward four days

after an elective craniotomy for a meningioma. She had no significant
past medical history and was taking paracetamol regularly for
post-operative analgesia.
On the arrival of the medical emergency team her temperature was
37.1°C, pulse rate 119 beats per minute, blood pressure 95/60 mmHg,
jugular venous pressure 4 cm above the sternal notch, and respiratory
rate 32 breaths per minute. Her Glasgow Coma Score was 13 (E3, V4,
M6) and her peripheries were cold. She was complaining of chest pain.
Investigations:
Arterial blood gas analysis (15 litres per minute oxygen via
face mask):
pH 7.19 (7.35–7.45)
PO2 8.5 kPa (11.3–12.6)
PCO2 2.9 kPa (4.7–6.0)
base excess –10.4 mmol/L (±2)
oxygen saturation 91% (94–98)
ECG showed sinus tachycardia.
The appropriate course of action is:
A. Focused echocardiography and thrombolysis if right ventricular dysfunction
B. Give low molecular weight heparin and arrange urgent coronary angiography
C. Measure D-dimer and troponin and start intravenous heparin
D. Start intravenous heparin and arrange urgent CT pulmonary angiography
E. Thrombolysis pending CT pulmonary angiography
15. An 18-year-old man was brought to the emergency department on New

Year’s Eve after an unwitnessed fall into a river on the way home from a
nightclub.
His temperature (rectal) was 28.1°C, pulse rate 31 beats per minute
with an irregular rhythm, blood pressure 60/45 mmHg, and respiratory
rate 9 breaths per minute. His Glasgow Coma Score was 3. There were
no injuries.
Which of the following is not appropriate for rewarming?
A. Continuous renal replacement therapy (CRRT)
B. Extracorporeal membrane oxygenation
C. Forced air warming blanket
D. Intravascular cooling device
E. Warmed humidified oxygen
16. A 75-year-old man was admitted to hospital for an elective revision of

a total knee replacement. He had type 2 diabetes and stage 2 chronic
kidney disease, and was taking gliclazide. On the orthopaedic ward eight
hours after the uneventful procedure he became suddenly unwell with
shortness of breath and agitation.
His temperature was 37.8°C, heart rate 142 beats per minute, blood
pressure 70/30 mmHg, and respiratory rate 30 breaths per minute.
On auscultation of his chest there were occasional wheezes heard. His
peripheries were warm and the capillary refill time was not prolonged.
Attached to his intravenous cannula was a 100 mL bag of 0.9% saline
containing flucloxacillin. On the bedside table was an empty bag of cell-
saver blood.
Investigations:
ECG: sinus tachycardia
CXR: normal
Which diagnosis and therapy is most likely and appropriate?

A. Anaphylaxis–adrenaline
B. Myocardial infarction–percutaneous coronary intervention
C. Pulmonary embolus–heparin
D. Sepsis–gentamicin
E. Transfusion reaction–hydrocortisone
17. A 49-year-old man presented to hospital with a two-day history of sore

throat and progressive dyspnoea. He was a heavy smoker but had no
other past medical history and took no regular medication.
On examination his temperature was 39.0°C, pulse rate 117 beats per
minute, blood pressure 155/84 mmHg, and respiratory rate 27 breaths
per minute. Oxygen saturations were 88% on room air. He appeared
distressed and was drooling. Inspiratory stridor was audible from the
end of the bed.
Which of the following is true:
A. Antibiotics should be given after tracheostomy
B. Immediate tracheostomy may be life-saving
C. Intubation is best attempted before transfer
D. Oxygen should not be given before intubation
E. Steroids and antibiotics are first-line therapy
18. A 45-year-old man with a history of idiopathic dilated cardiomyopathy

was admitted after a cardiac arrest at home. The initial rhythm
recorded by the ambulance crew was ventricular fibrillation. There
was return of spontaneous circulation after 25 minutes of resuscitation
following Advanced Life Support guidelines and he was admitted to
the intensive care unit for further management including temperature
control and haemodynamic support.
Which of the following does not apply to the post-cardiac arrest
syndrome?
A. Intra-aortic balloon pumps may be used to support a failing myocardium
B. Intravascular volume depletion and vasodilatation mimic severe sepsis
C. Ischaemia-reperfusion injury leads to immunosuppression and coagulopathy
D. Oxygen saturations of 94% are acceptable to prevent secondary brain injury
E. Prophylactic phenytoin will reduce the incidence of seizures in the first week
Exploring the Variety of Random
Documents with Different Content
Madison was not alone in this ignorance. Monroe himself, still less
conscious than Madison of a war spirit, expected to reach the
Presidency by conciliating England. Even Robert Smith, to the
surprise of the world, posed as the victim of his hostility to France,
and hoped to become the centre of a combination of Smiths,
Clintons, Federalists, and Duane Pennsylvanians, who charged that
Madison was less friendly to England than he might have been. The
President suffered much annoyance from the Smiths because he
could not disprove their assertions or demonstrate his good-will for
Great Britain.
As soon as Madison learned through Senator Brent that Monroe
made no serious difficulty in accepting the State Department, he
sent for Robert Smith. A faithful account of the conversations that
followed would add vivacity to the story, for Madison seemed at
times to enjoy commenting not only on the acts of his opponents,
but also on their motives; while Robert Smith, being easily
disconcerted and slow in defence or attack, offered a tempting mark
for arrows of temper. The first interview took place March 23,[291]
and Madison made a long memorandum of what passed.
“I proceeded to state to him,” recorded Madison,[292] “that it had
long been felt and had at length become notorious that the
administration of the Executive department labored under a want of
the harmony and unity which were equally necessary to its energy
and its success; that I did not refer to the evil as infecting our Cabinet
consultations, where there had always been an apparent cordiality
and even a sufficient concurrence of opinion, but as showing itself in
language and conduct out of doors, counteracting what had been
understood within to be the course of the Administration and the
interest of the public; that truth obliged me to add that this practice,
as brought to my view, was exclusively chargeable on him; and that
he had not only counteracted what had been the result of
consultations apparently approved by himself, but had included myself
in representations calculated to diminish confidence in the
administration committed to me.”
Robert Smith protested, in his somewhat incoherent way, against
the truth of this charge; and the President, roused by resistance,
spoke with more preciseness, instancing Smith’s conduct in regard to
Macon’s bills in 1810, as evidence of the secretary’s bad faith.
“With respect to his motives for dissatisfaction, I acknowledged
that I had been, for the reasons given by him, much puzzled to divine
any natural ones, without looking deeper into human nature than I
was willing to do; ... that whatever talents he might possess, he did
not, as he must have found by experience, possess those adapted to
his station; ... that the business of the Department had not been
conducted in the systematic and punctual manner that was necessary,
particularly in the foreign correspondence, and that I had become
daily more dissatisfied with it.”
The man must have been easy-tempered who could listen to
these comments on conduct, motives, and abilities without sign of
offence; but Robert Smith showed no immediate resentment, for
when the President closed by offering to send him to St. Petersburg
to succeed J. Q. Adams, who was to take Justice Cushing’s place on
the Supreme Bench, Smith showed no unwillingness, although he
avowed his preference for the other vacancy on the bench soon to
be caused by Justice Chase’s death, or for the English mission left
vacant by Pinkney’s return. Madison declined to encourage these
ambitions, and Smith retired to consider the offer of St. Petersburg.
For several days the President supposed the arrangement to be
accepted; but meanwhile Robert Smith consulted his friends, who
held other views on the subject of his dignity and deserts. When he
next saw the President he declined the mission, declaring that
acceptance would be only indirect removal from office, the result of
“a most shameful intrigue.” After trying in vain the characteristic task
of convincing him that he altogether exaggerated his own
consequence, Madison accepted his resignation and left him to carry
out his threat of appealing to the country. “He took his leave with a
cold formality,” concluded Madison, “and I did not see him
afterward.”
For ten years Robert Smith had been one of the most powerful
influences in politics, trusted with the highest responsibilities and
duties, seeming more than any other single Cabinet officer to affect
the course of public affairs; when at a breath from the President his
official life was snuffed out, his reputation for ability vanished, and
the Republican party, which had so long flattered him, suddenly
learned to belittle his name. Under the shadow of monarchical or
absolute governments such tales of artificial greatness were
common, and their moral was worn thin by ages of repetition; but in
the democratic United States, and from the bosom of Jefferson’s
political family, this experience of Robert Smith was a singular
symptom.
Never again did this genial gentleman sun himself in the rays of
Executive power, or recover the smallest share of influence. He
returned to Baltimore, where he lived thirty years longer without
distinguishing himself; but about three months after his retirement
from office, in the month of June, 1811, he published an Address to
the People, charging President Madison with offences more or less
grave, and surprising every one by representing himself as having
persistently but vainly opposed Madison’s fixed purpose of making a
virtual alliance with France. The evidence of the late Secretary of
State, who might reasonably be thought the best informed and most
competent judge, confirmed the Federalist and British theory that
Madison was under secret pledges to Napoleon. So gravely did it
compromise Madison that he caused Joel Barlow to write a semi-
official reply in the “National Intelligencer;” and although Barlow
wrote in a bad temper, Madison himself wrote privately in a worse.
“You will have noticed in the ‘National Intelligencer,’” he told
Jefferson July 8,[293] “that the wicked publication of Mr. Smith is not
to escape with impunity. It is impossible, however, that the whole
turpitude of his conduct can be understood without disclosures to be
made by myself alone, and of course, as he knows, not to be made at
all. Without these his infamy is daily fastening upon him, leaving no
other consolation than the malignant hope of revenging his own
ingratitude and guilt on others.”
Robert Smith hardly deserved such invective. If the taunts of
Madison, Barlow, and the Republican press and party at his
incompetence were well-founded, the party had only itself to blame
for putting such a man in so high a position. If triumphant in nothing
else, Smith overthrew both Madison and Barlow by the retort with
which he met their sneers, and retaliated the charge of
incompetence.
“This advocate,” replied Smith (in the “Baltimore American”) to
Barlow (in the Washington “Intelligencer”), “would have us believe
that many persons both in and out of Congress thought that Mr. Smith
from want of talents and integrity was quite unfit for the Department
of State, and that his appointment was the effect of an intrigue. Were
there any truth in this remark, it could not fail to convince every
person of the utter unfitness of Mr. Madison himself for his office. It in
plain English says that from the officious persuasion of a few
intriguers he had appointed to the most important and the highest
station in the government a person without talents and without
integrity; and this person not a stranger, respecting whom he might
have been misled, but one who had been his colleague in office
during the long term of eight years, and of whose fitness he of course
had better means of judging than any other person or persons
whatever; nay, more,—to this same person, without talents or
integrity, was offered by Mr. Madison not only the mission to Russia,
but the important office of the Treasury Department.”
CHAPTER XVIII.
April 1, 1811, Monroe took charge of the State Department. The
first person to claim his attention was the French Emperor, and
Monroe had reasons for knowing that diplomatists of reputed
sagacity found use for uninterrupted attention when they undertook
to deal with Napoleon.
Monroe stood in a situation of extreme difficulty, hampered not
only by the pledges of his own government, but still more by the
difficulty of dealing at all with the government of France. When
Armstrong quitted Paris in September, 1810, being obliged to fix
upon some American competent to take charge of the legation at
Paris, he chose Jonathan Russell. The selection was the best he
could make. Jonathan Russell possessed advantages over ordinary
ministers coming directly from America. A native of Rhode Island,
educated at Brown University, after leaving college he followed the
business of a merchant, and in November, 1809, sailed from Boston
in a ship of his own, which arrived at Tönning in Denmark only to be
at once sequestered under Napoleon’s Decrees. He passed several
months in efforts to recover the property, and acquired experience in
the process. About forty years old, and more or less acquainted with
the people, politics, and languages of Europe, he was better fitted
than any secretary of legation then abroad for the burden that
Armstrong had found intolerable; yet the oldest and ablest
diplomatist America ever sent to Europe might have despaired of
effecting any good result with such means as were at the disposal of
this temporary agent, who had not even the support of a direct
commission from the President.
Russell felt the embarrassment of the position he was called to
fill. Armstrong departed September 12, bearing Cadore’s promise
that the decrees should cease to operate November 1, and saying as
little as possible of a condition precedent. The 1st of November
came, and Russell asked the Duc de Cadore whether the revocation
had taken place; but a month passed without his receiving an
answer. December 4, 1810, Russell wrote to the Secretary of State,
[294]—
“No one here except the Emperor knows if the Berlin and Milan
Decrees be absolutely revoked or not; and no one dares inquire of
him concerning them. The general opinion of those with whom I have
conversed on the subject is that they are revoked. There are indeed
among those who entertain this opinion several counsellors of State;
but this is of little importance, as the construction which the Emperor
may choose to adopt will alone prevail.”
At about the same time Russell wrote to Pinkney at London a

letter[295] expressing the opinion that, as the decrees had not been
executed for one entire month against any vessel arriving in France,
this fact created a presumption that the decrees were repealed. He
could not be blamed for an opinion so cautious, yet he was mistaken
in committing himself even to that extent, for he learned a few days
afterward that two American vessels had been seized at Bordeaux,
and he found himself obliged to write the Duc de Cadore a strong
remonstrance on the ground that as this was the first case that had
occurred since November 1 to which the decrees could have applied,
the seizures created a presumption that the decrees were not
repealed.[296] Russell’s instructions from America, including the
President’s proclamation of November 2, arrived three days later,
December 13, requiring him to assume the revocation of the
decrees; but only two days after receiving them, he read in the
“Moniteur” of December 15 Cadore’s official report to the Emperor
declaring that the decrees would never be revoked as long as
England maintained her blockades; and again, December 17, he
found in the same newspaper the Count de Semonville’s official
address before the Senate, declaring that the Decrees of Berlin and
Milan should be the “palladium of the seas.”
Yet Russell’s position was not quite so desperate as it seemed.
Certainly the decrees were not revoked; but he had a fair hope of
obtaining some formal act warranting him in claiming their
revocation. Although Napoleon’s motives often seemed mysterious
except to men familiar with his mind, yet one may venture to guess,
since guess one must, that he had looked for little success from the
manœuvre of announcing the revocation of his decrees as concerned
the United States. Perhaps he dictated Cadore’s letter of August 5
rather in order to prevent America from declaring war against
himself than in the faith that a trick, that to his eye would have been
transparent, could effect what all his efforts for ten years past had
failed to bring about,—a war between the United States and Great
Britain. The Emperor showed certainly almost as lively surprise as
pleasure, when December 12 he received the President’s
proclamation of November 2, reviving the non-intercourse against
England. His pleasure was the greater when he learned that
President Madison had adopted his suggestion not only in this
instance, but also in requiring of England the withdrawal of Fox’s
blockade of 1806 as a sine qua non of any future renewal of
commerce. Delighted with his success, not only did the Emperor
take no offence at the President’s almost simultaneous proclamation
for the seizure of West Florida, but rather his first impulse was to
lose not a moment in fixing Madison in his new attitude. He wrote a
hurried letter[297] on the instant to Cadore, ordering him if possible
to send fresh instructions to Serurier, who was already on his way to
succeed Turreau as French minister at Washington:—
“Send me the draft of a despatch for M. Serurier, if he is still at
Bayonne.... You will show in this letter the satisfaction I have felt in
reading the last letters from America. You will give the assurance that
if the American government is decided to maintain the independence
of its flag, it will find every kind of aid and privileges in this country.
Your letter will of course be in cipher. In it you will make known that I
am in no way opposed to the Floridas as becoming an American
possession; that I desire, in general, whatever can favor the
independence of Spanish America. You will make the same
communication to the American chargé d’affaires, who will write in
cipher to his Government that I am favorable to the cause of
American independence; and that as we do not found our commerce
on exclusive pretensions, I shall see with pleasure the independence
of a great nation, provided it be not under the influence of England.”
This hasty note still throws out flashes of the fire that consumed
the world. Silent as to the single question that America wanted him
to answer, the Emperor not only resumed his old habit of dangling
the Floridas before the President’s eyes, but as though he were glad
to escape from every Spanish tie, he pressed on Madison the whole
of Spanish America. Once more one is reduced to guess at the
motive of this astonishing change. No one knew better than
Napoleon that the independence of Spanish America could benefit
England alone; that England had fought, intrigued, and traded for
centuries to bring this result about, and that the United States were
altogether unable to contest English influence at any point in Central
and South America. He knew, too, that the permanent interests of
France could only be injured by betraying again the Spanish empire,
and that nothing could exceed the extravagance of intriguing for the
revolt of Mexico and Peru while his armies were exhausting
themselves in the effort to make his own brother King of Spain. Such
sudden inconsistencies were no new thing in Napoleon’s career. The
story of the Floridas repeated the story of Louisiana. As in 1803
Napoleon, disgusted with his failure at St. Domingo, threw Louisiana
to Jefferson, so in 1810, disgusted with his failure at Madrid, he
threw Spanish America in a mass to Madison. What was more
serious still, as in 1803 Germany could foresee that she must pay on
the Rhine for the losses of France at St. Domingo and New Orleans,
so in 1810 the Czar Alexander already could divine that the
compensation which Napoleon would require for Mexico and Peru
would lie somewhere in the neighborhood of Poland. Thus much at
least had been gained for the United States and England. Napoleon
took no more interest in the roads to Lisbon and Cadiz, and studied
only those that led to Wilna, Moscow, and St. Petersburg.
Read in this sense, Napoleon’s instructions to Cadore and
Serurier told most interesting news; but on the point likely to prove
a matter of life and death to Madison, the Emperor spoke so
evasively as to show that he meant to yield nothing he could retain.
He ordered Cadore to talk with Jonathan Russell about commercial
matters:—
“Have a conference with this chargé d’affaires in order to
understand thoroughly what the American government wants. You will
tell him that I have subjected ships coming from America to certain
formalities; that these formalities consist of a letter in cipher, joined
with licenses, which prove that the ship comes from America and has
been loaded there, but that I cannot admit American ships coming
from London, since this would upset my system; that there is no way
of knowing the fact [of their American character], and that there are
shipowners who for mercantile objects foil the measures of the
American government; in short, that I have made a step; that I will
wait till February 2 to see what America will do, and that in the mean
time I will conduct myself according to circumstances, but so as to do
no harm to ships really coming from America; that the question is
difficult, but that he should give the positive assurance to his
Government of my wish to favor it in everything; that he knows,
moreover, that several ships coming from America since the last
measures were known have obtained permission to discharge their
cargoes in France; finally, that we cannot consider as American the
ships convoyed to the Baltic, which have double papers, etc. It would
be well if you could engage this chargé to answer you by a note, and
to agree that he disowns the American ships which navigate the
Baltic. This would be sent to Russia, and would be useful. In general,
employ all possible means of convincing this chargé d’affaires, who I
suppose speaks French, of the particularly favorable disposition I feel
toward the Americans; that the real embarrassment is to recognize
true Americans from those who serve the English; and that I consider
the step taken by the American government as a first step taken
toward a good result.”
When Napoleon used many words and became apologetic, he
was least interesting, because his motives became most evident. In
regard to America, he wished to elude an inconvenient inquiry
whether the Berlin and Milan Decrees were or were not revoked.
Consequently he did not mention those decrees, although credulity
itself could not have reconciled his pledge to wait until February 2,
with his official assertion of August 5 that the decrees would be
withdrawn on November 1. Such a course was fatal to Madison, for
it forced him to appear as accepting the Berlin and Milan Decrees
after so long protesting against them. So justly anxious was the
President to protect himself from this risk, that in sending to Russell
the Non-intercourse Proclamation of November 2 he warned the
chargé against the doctrine of a condition precedent involved in
Cadore’s “bien entendu.” The Emperor was to understand that the
United States acted on the ground that “bien entendu” did not mean
“condition precedent.”[298] “It is to be remarked, moreover, that in
issuing the Proclamation, it has been presumed that the requisition
... on the subject of the sequestered property will have been
satisfied.”
December 13, at the moment when Napoleon was writing his
instructions to Cadore, Jonathan Russell was reading the instructions
of President Madison. No diplomatist could have found common
ground on which to reconcile the two documents. Madison’s
knowledge of the Napoleonic idiom was certainly incomplete.
Whatever “bien entendu” meant in the dictionaries, it meant in
Napoleon’s mouth the words “on condition,”—and something more.
In further assuming that the sequestered property had been
restored, President Madison might with equal propriety have
assumed that it had never been seized. Russell did what he could to
satisfy Madison’s wishes, but he could not hope to succeed.
Bound by these instructions to communicate the President’s
proclamation in language far from according with Napoleon’s ideas,
Russell wrote to Cadore, December 17, a note,[299], in which he not
only repeated the President’s assumptions in regard to the
revocation of the decrees, but also ventured beyond the scope of his
instructions: he demanded an explanation of the language used by
Cadore himself in his report to the Emperor, and by Semonville in the
Senate. As though such a demand under such circumstances were
not indiscreet enough, Russell strengthened the formal and
perfunctory protests of the President by adding an assurance of his
own that the United States, after cutting off their own intercourse
with England, would not consent to “any commercial intercourse
whatever, under licenses or otherwise, between France and her
enemy.”
Russell’s note of December 17 was never answered by the French
government, and, as was equally natural, it was never published by
the President or made known to Congress. Fortunately for Russell,
the Emperor was in good humor, and Cadore was in haste to convey
his master’s wishes to the American chargé d’affaires. December 22
Russell was summoned to the minister, and a very interesting
interview took place. Cadore gently complained of the tone in which
Russell’s note had been written, but put into his hands, as its result
and answer, the two letters written by the ministers of Justice and
Finance,—which allowed American vessels to enter French ports,
subject only to provisional sequestration, until February 2, at which
time all vessels sequestered since November 1 would be restored.
“When I had read these letters,” reported Russell,[300] “I returned
them to the Duke of Cadore, and expressed to him my regret that
the general release of American vessels detained under the Berlin
and Milan Decrees should be deferred until the 2d of February, as
this delay might throw some doubt on the revocation of those
decrees.” Cadore replied that the time thus taken was intended to
afford an opportunity for forming some general rule by which the
character of the property could be decided. Russell then complained
that by assigning the second day of February,—the very day on
which the non-intercourse with England would be revived,—this
event was made to appear as a condition precedent to the
abrogation of the French edicts; and thereby the order in which the
measures of the two governments ought to stand was reversed. In
reply Cadore repeated the general assurances of the friendly
disposition of the Emperor, and that he was determined to favor the
trade of the United States so far as it did not cover or promote the
commerce of England. He said the Berlin and Milan Decrees,
“inasmuch as they related to the United States,” were at an end;
that the Emperor was pleased with what the United States had
already done, but that he could not “throw himself into their arms”
until they had accomplished their undertaking.
Nothing could be more gentle than this manner of saying that the
revocation of November 1 was and was not founded on a condition
precedent; that the decrees themselves were and were not revoked;
but when Russell still pressed for a categorical answer, Cadore
declared at last, “with some vivacity, that the Emperor was
determined to persevere in his system against England; that he had
overturned the world in adopting this system, and that he would
overturn it again to give it effect.” On the third point Cadore was
equally unyielding. Not a word could Russell wring from him in
regard to the confiscated property of American merchants. “His
omission to notice the last is more to be lamented, as I have reason
to believe that this conversation was meant to form the only answer
I am to receive to the communications which I have addressed to
him.”
The conduct of Cadore warranted Russell’s conclusion that “upon
the whole this interview was not calculated to increase my
confidence in the revocation of the decrees.” Although President
Madison reached a different conclusion, and on the strength of this
conference caused Congress to adopt the Non-Intercourse Act of
March 2, Russell’s opinion could not be disputed. At the end of
another week Cadore sent word that one of the American vessels,
the “Grace Ann Greene,” arrived at Marseilles since November 1, had
been released; and Russell wrote to Pinkney that this release might
be considered conclusive evidence of the revocation.[301] A month
afterward he wrote to the Secretary of State on the same subject in
a different tone,[302] saying that the United States had not yet much
cause to be satisfied; that no vessel arrived since November 1 had
been permitted to discharge her cargo, and that tedious delays were
constantly interposed. As for the property confiscated before
November 1, Russell avowed himself afraid to make the reclamation
ordered by the President: “I ascertained indirectly that a convention
to this effect would not be entered into at this moment; and I
thought it indiscreet to expose the United States, with all the right
on their side, to a refusal.” No action of the United States, he feared,
could redeem the unfortunate property.[303]
Failure on these points was accompanied by a promise of success
on others. The President had remonstrated against the Emperor’s
scheme of issuing licenses through the French consuls to vessels in
ports of the United States; and Russell wrote to Cadore, Jan. 12,
1811, that such consular superintendence was inadmissible, and
would not be permitted.[304] January 18 Cadore returned an answer,
evidently taken from the Emperor’s lips:[305]—
“I have read with much attention your note of January 12, relative
to the licenses intended to favor the commerce of the Americans in
France. This system had been conceived before the revocation of the
Decrees of Berlin and Milan had been resolved on. Now circumstances
are changed by the resolution taken by the United States to cause
their flag and their independence to be respected. That which has
been done before this last epoch can no longer serve as a rule under
actual circumstances.”
Although this letter said that the Berlin and Milan Decrees were
repealed,—not on Nov. 1, 1810, but at some indeterminate time
afterward, in consequence of the President’s proclamation of
November 2,—yet it officially declared that whatever the date might
be, on January 18, when Cadore wrote, the revocation was
complete. Russell sent the letter to the President, and the President
sent it nearly ten months afterward to Congress as proof that the
decrees were revoked. He could not send, for he could not know,
another letter written by Cadore to Serurier three weeks later, which
instructed him to the contrary:[306]—
“I send you the copy of a letter addressed by me to Mr. Russell,
January 18, on the permits that had been at first delivered to
American ships. I cannot assure you that the permits are no longer to
be issued, although this letter gives it to be understood in an explicit
manner. Continue to conduct yourself with the reserve heretofore
recommended to you, and compromise yourself by no step and by no
official promise. Circumstances are such that no engagement can be
taken in advance. It is at the date of February 2 that the United
States were to execute their act of non-intercourse against England;
but before being officially informed in France of what they have done
at that time, we cannot take here measures so decisive in favor of the
Americans as after news to February 2 shall have arrived from
America. This motive will serve to explain to you whatever uncertainty
may appear in the conduct of France toward the United States.”
From these official instructions the facts were easy to
understand. The decrees had not been revoked on Aug. 5 or Nov. 1,
1810; they were not revoked Jan. 18, 1811; they were not to be
revoked on February 2; but the Emperor would decide in the spring,
when news should arrive from America, whether he would make
permanent exceptions in favor of American commerce. In principle,
the decrees were not to be revoked at all.
For four years President Madison had strenuously protested that
France and England must withdraw their decrees as a condition
precedent to friendly relations with America. For four years Napoleon
had insisted that America should submit to his decrees as a
condition precedent to friendly relations with France. February 2,
1811, he carried his point. The decisive day passed without action
on his part. Six weeks followed, but March 15 Russell still wrote to
the Secretary of State as doubtfully as he wrote in the previous
December:[307] “The temper here varies in relation to us with every
rumor of the proceedings of our government. One day we are told
that the Emperor has learned that the Non-intercourse Law will be
severely executed,—that he is in good humor, and that everything
will go well; the next day it is stated that he has heard something
which has displeased him, and that the American property lately
arrived in this country is in the utmost jeopardy. Every general plan
here is evidently suspended until the course we may elect to pursue
be definite and certain.”
Russell made no further attempt to maintain the fact of
revocation. Indeed, if the decrees were revoked, American rights
were more lawlessly violated than before. As ship after ship arrived
from the United States, he saw each taken, under one pretext or
another, into the Emperor’s keeping:—
“To countenance delay, no doubt, a new order was issued to the
custom-houses on the 18th ult., that no vessels not having licenses,
coming from foreign countries, be admitted without the special
authority of the Emperor. This indeed makes the detention indefinite,
as when once a case is before the Emperor it can no longer be
inquired after, much less pressed, and it is impossible to say when it
may attract the Imperial attention. It is my belief that our property
will be kept within the control of this government until it be officially
known here that the Non-intercourse Act against England went into
operation with undiminished rigor on the 2d of February.”
Under such circumstances, the idea that the United States were
bound by a contract with France—the principle on which Congress
legislated in the month of February—had no meaning to Jonathan
Russell at Paris, where as late as April 1 not a step had yet been
taken toward making the contract complete. “I trust,” wrote Russell,
March 15, “that I shall not be understood in anything which I have
written in this letter to urge any obligation on the United States to
execute at all the Non-intercourse Law; this obligation is certainly
weakened, if not destroyed, by the conduct of the Government
here.”
Russell never misunderstood the situation or misled his
Government. Although Napoleon’s habit of deception was the theme
of every historian and moralist, the more remarkable trait was his
frequent effort to avoid or postpone an evidently necessary
falsehood, and, above all, his incapacity to adhere to any consistent
untruth. Napoleon was easily understood by men of his own stamp;
but he was not wholly misunderstood by men like Armstrong and
Russell. He did not choose to revoke the decrees, and he made no
secret of his reasons even to the American government.
In the spring of 1811 the Emperor was surrounded by difficulties
caused by his interference with trade. The financial storm which
overspread England in 1810 extended to France in the following
winter, and not only swept away credit and capital throughout the
empire, but also embarrassed Napoleon’s finances and roused fresh
resistance to his experiments on commerce. The resistance irritated
him, and he showed his anger repeatedly in public. At the Tuileries,
March 17, he addressed some deputies of the Hanseatic League in a
tone which still betrayed an effort at self-control:[308]—
“The Decrees of Berlin and Milan are the fundamental laws of my
empire. They cease to have effect only for nations that defend their
sovereignty and maintain the religion of their flag. England is in a
state of blockade for nations that submit to the decrees of 1806,
because the flags so subjected to English laws are denationalized;
they are English. Nations on the contrary that are sensible of their
dignity, and that find resources enough in their courage and strength
for disregarding the blockades by notice, commonly called paper
blockades, and enter the ports of my empire, other than those really
blockaded,—following the recognized usage and the stipulations of
the Treaty of Utrecht,—may communicate with England; for them
England is not blockaded. The Decrees of Berlin and Milan, founded
on the nature of things, will form the constant public law of my
empire during the whole time that England shall maintain her Orders
in Council of 1806 and 1807, and shall violate the stipulations of the
Treaty of Utrecht in that matter.”
The sudden appearance of the Treaty of Utrecht had an effect of
comedy; but the speech itself merely reasserted the rules of 1806
and 1807, which time had not made more acceptable to neutrals.
Again and again, by every means in his power and with every accent
of truth, Napoleon asserted that his decrees were not and never
should be revoked, nor should they be even suspended except for
the nations that conformed to them. Though America had rejected
this law in 1807, she might still if she chose accept it in 1811; but
certainly she could not charge Napoleon with deception or
concealment of his meaning. A week after the address to the
Hanseatic deputies, on Sunday, March 24, he made another and a
more emphatic speech. The principal bankers and merchants of Paris
came to the Tuileries to offer their congratulations on the birth of a
son. Napoleon harangued them for more than half an hour in the
tone he sometimes affected, of a subaltern of dragoons,—rude,
broken, and almost incoherent, but nervous and terrifying:—
“When I issued my Decrees of Berlin and Milan, England laughed;
you made fun of me; yet I know my business. I had maturely weighed
my situation with England; but people pretended that I did not know
what I was about,—that I was ill-advised. Yet see where England
stands to-day!... Within ten years I shall subject England. I want only
a maritime force. Is not the French empire brilliant enough for me? I
have taken Holland, Hamburg, etc., only to make my flag respected. I
consider the flag of a nation as a part of herself; she must be able to
carry it everywhere, or she is not free. That nation which does not
make her flag respected is not a nation in my eyes. The Americans—
we are going to see what they will do. No Power in Europe shall trade
with England. Six months sooner or later I shall catch up with it (je
l’attendrai),—my sword is long enough for that. I made peace at Tilsit
only because Russia undertook to make war on England. I was then
victorious. I might have gone to Wilna; nothing could stop me but this
engagement of Russia.... At present I am only moderately desirous of
peace with England. I have the means of making a navy; I have all
the products of the Rhine; I have timber, dock-yards, etc.; I have
already said that I have sailors. The English stop everything on the
ocean; I will stop everything I find of theirs on the Continent. Their
Miladies, their Milords,—we shall be quit! (Leurs Miladies, leurs Milords
—nous serons à deux de jeu!)”
This hurried talk, which was rather a conversation than a speech,
lasted until the Emperor’s voice began to fail him. He flung defiance
in the face of every nation in the Christian world, and announced in
no veiled terms the coming fate of Russia. His loquacity astounded
his hearers, and within a few days several reports of what he said,
differing in details, but agreeing in the main, were handed privately
about Paris, and were on their way to St. Petersburg, London, and
New York[309]. One account varied in regard to the words used
about America:—
“The Decrees of Berlin and Milan are the fundamental laws of my
empire,” began the second report. “As for neutral navigation, I regard
the flag as an extension of territory; the Power which lets it be
violated cannot be considered neutral. The lot of American commerce
will be soon decided. I will favor it if the United States conform to
those decrees; in the contrary case, their ships will be excluded from
the ports of my empire.”
Russell sent to Monroe these private accounts, adding a few
details to show more exactly the Emperor’s meaning. Writing April 4,
he said that no American vessel had been allowed an entry since
February 4 unless carrying a license; that a secret order had then
been given to the custom-house to make no reports on American
cases; that the Council of Prizes had suspended its decisions; and
that, notwithstanding Cadore’s promise, licenses were still issued. “If
the license system,” concluded Russell, “were concerned, as the
Duke of Cadore suggests, to favor American commerce during the
existence only of the Berlin and Milan Decrees, it is probably
necessary to infer from the excuse of that system the continuance of
those decrees.”
Left without powers or instructions, Russell could thenceforward
do nothing. Remonstrance was worse than useless. “A
representation of this kind,” he wrote, “however mildly it might
portray the unfriendly and faithless conduct of this Government,
might have hastened a crisis which it does not become me to urge.”
At length, April 25, despatches arrived from America enclosing
the Non-intercourse Act of March 2 and the secret Act for taking
possession of Florida. The President’s accompanying instructions[310]
ordered Russell to explain that the different dates fixed by the
Proclamation and by the Act for enforcing the non-intercourse
against England were owing to the different senses in which
Cadore’s letter had been construed in France and America,—the
President having assumed that the decrees would have been extinct
Nov. 1, 1810, while the French government, “as appears from its
official acts, admits only a suspension with a view to a subsequent
cessation.” These instructions, as well as Russell’s despatches for the
most part, were never communicated to Congress.
April 17, a week before these documents arrived, Napoleon made
a sudden change in his Cabinet, by dismissing Cadore and
appointing Hugues Maret, Duc de Bassano, as his Minister of Foreign
Affairs. No one knew the cause of Cadore’s fall. He was mild,
modest, and not given to display. He “lacked conversation,”
Napoleon complained. Probably his true offence consisted in leaning
toward Russia and in dislike for the commercial system, while Maret
owed promotion to opposite tendencies. Maret’s abilities were
undoubted; his political morality was no worse than that of his
master, and perhaps no better than that of Cadore or of Talleyrand
whom he hated.[311] He could hardly be more obedient than
Cadore; and as far us America was concerned, he could do no more
mischief.
When Russell repaired to the Foreign Office, April 28, he was
received by the new minister, who availed himself of his inexperience
to ask many questions and to answer none. Russell had a long
interview with no results; but this delay mattered little, for the
Emperor needed no information. No sooner had he received the
Non-intercourse Act of March 2 than he ordered his ministers to
make a report on the situation of American commerce.[312] The
order was due not so much to a wish of hearing what his ministers
had to say as of telling them what they were to report:—
“The United States have not declared war on England, but they
have recognized the Decrees of Berlin and Milan, since they have
authorized their citizens to trade with France, and have forbidden
them every relation with England. In strict public right, the Emperor
ought to exact that the United States should declare war against
England; but after all it is in some sort to make war when they
consent that the Decree of Berlin should be applied to ships which
shall have communicated with England. On this hypothesis, one would
say: ‘The Decrees of Berlin and Milan are withdrawn as regards the
United States; but as every ship which has touched in England, or is
bound thither, is a vagrant that the laws punish and confiscate, it may
be confiscated in France.’ If this reasoning could be established,
nothing would remain but to take precautions for admitting none but
American products on American ships.”
This view of the contract to which American faith was bound,

though quite the opposite of Madison’s, was liberal compared with
its alternative:—
“Finally, if it should be impossible to trace out a good theory in this
system, the best would be to gain time, leaving the principles of the
matter a little obscure until we see the United States take sides; for it
appears that that Government cannot remain long in its actual
situation toward England, with whom it has also political discussions
concerning the affairs of Spanish America.”
The Emperor’s will was law. The Council set itself accordingly to
the task of “leaving the principles of the matter a little obscure” until
the United States should declare war against England; while the
Emperor, not without reason, assumed that America had recognized
the legality of his decrees.
CHAPTER XIX.
The Emperor’s decision was made known to the American
government by a letter[313] from Bassano to Russell, dated May 4,
1811, almost as curt as a declaration of war:—
“I hasten to announce to you that his Majesty the Emperor has
ordered his Minister of Finance to authorize the admission of the
American cargoes which had been provisionally placed in deposit on
their arrival in France. I have the honor to send you a list of the
vessels to which these cargoes belong; they will have to export their
value in national merchandise, of which two thirds will be in silks. I
have not lost a moment in communicating to you a measure perfectly
in accord with the sentiments of union and of friendship which exist
between the two Powers.”
This was all. No imperial decree of repeal was issued or
suggested. President Madison cared little for the released ships; he
cared only for the principle involved in the continued existence of the
decrees, and Bassano’s letter announced by silence, as distinctly as
it could have said in words, that the principle of the decrees was not
abandoned. Such were Napoleon’s orders; and in executing them
Bassano did not, like Cadore or Talleyrand, allow himself the license
of softening their bluntness. Russell knew the letter to be fatal to
any claim that the French decrees were withdrawn, but he could do
nothing else than send it to London as offering, perhaps, evidence of
the “actual relations growing out of the revocation of the Berlin and
Milan Decrees.”[314] He wrote to Bassano a letter asking the release
of the American vessels captured and brought into French ports as
prizes since November 1, but he obtained no answer.[315] A month
afterward he wrote again, remonstrating against the excessive tariff
duties and the requirement that American vessels should take two
thirds of their return cargoes in French silks; but this letter received
as little notice as the other. Russell had the mortification of knowing,
almost as well as Bassano himself, the motives that guided the
Emperor; and July 13 he recited them to the President in language
as strong as propriety allowed:[316]—
“The temper here toward us is professedly friendly, but
unfortunately it is not well proved to be so in practice. It is my
conviction, as I before wrote you, that the great object of the actual
policy is to entangle us in a war with England. They abstain therefore
from doing anything which would furnish clear and unequivocal
testimony of the revocation of their decrees, lest it should induce the
extinction of the British orders and thereby appease our irritation
against their enemy. Hence, of all the captured vessels since
November 1, the three which were liberated are precisely those which
had not violated the decrees. On the other hand, they take care, by
not executing these decrees against us, to divert our resentment from
themselves. I have very frankly told the Duke of Bassano that we are
not sufficiently dull to be deceived by this kind of management. He
indeed pretends that they are influenced by no such motive; and
whenever I speak to him on the subject, he reiterates the professions
of friendship, and promises to endeavor to obtain the release of the
remainder of our vessels captured since November 1. I fear, however,
that he will not succeed.”
Even in case of war with England, Russell warned the President

to look for no better treatment from Napoleon, who might then
consider America as “chained to the imperial car, and obliged to
follow whithersoever it leads.” He pointed out that concessions had
never produced any return from the Emperor except new exactions
and new pretensions. If war with England became inevitable, care
must be taken to guard against the danger that France should profit
by it. French trade was not worth pursuing. The tariff on imports,
reinforced by the restrictions on exports, created a practical non-
intercourse.
Napoleon’s writings furnish evidence that the Emperor’s chief
object was not so much to entangle America in war with England as
to maintain the decrees which he literally overturned the world to
enforce. When he suspended their enforcement against American
ships in his own ports, he did so only because his new customs’
regulations had been invented to attain by other means the object of
the decrees. When he affirmed and reaffirmed that these decrees
were the fundamental law of his empire, he told a truth which
neither England nor America believed, but to which he clung with
energy that cost him his empire.
Russell made no more efforts, but waited impatiently for the
arrival of Joel Barlow, while Napoleon bethought himself only of his
favorite means for quieting Madison’s anger. August 23 the Emperor
ordered[317] Bassano to give his minister at Washington instructions
calculated to sharpen the cupidity of the United States. Serurier was
to be active in effecting the independence of Spanish America, was
to concert measures for that purpose with the President, promise
arms and supplies, employ the American government and American
agents for his objects, and in all respects give careful attention to
what passed in the colonies; yet in regard to Florida, the only
Spanish colony in which Madison took personal interest, Napoleon
hinted other views to Bassano in a message[318] too curious for
omission.
“You spoke to me this morning,” he wrote August 28, “of
instructions received by the American chargé on the affair of Florida.
You might insinuate the following idea,—that in consideration of some
millions of piastres, Spain in her present condition of penury would
cede the Floridas. Insinuate this, while adding that though I do not
take it ill that America should seize the Floridas, I can in no way
interfere, since these countries do not belong to me.”
With this touch of character, the great Emperor turned from
American affairs to devote all his energies to matters about the
Baltic. Yet so deeply were American interests founded in the affairs
of Europe that even in the Baltic they were the rock on which
Napoleon’s destiny split; for the quarrels which in the summer of
1811 became violent between France and the two independent
Baltic Powers—Russia and Sweden—were chiefly due to those
omnipresent American ships, which throve under pillage and
challenged confiscation. Madison’s wisdom in sending a minister to
St. Petersburg was proved more quickly than he could have
expected. Between March 1 and Nov. 1, 1811, at one of the most
critical moments in the world’s history, President Madison had no
other full minister accredited in Europe than his envoy to Russia; but
whatever mortifications he suffered from Napoleon, were more than
repaid by means of this Russian mission.
The new minister to Russia, J. Q. Adams, sailed from Boston
August 5, 1809, and on arriving at Christiansand in Norway,
September 20, he found upward of thirty masters of American
vessels whose ships had been seized by Danish privateers between
April and August, and were suffering trial and condemnation in
Danish prize courts. He reported that the entire number of American
ships detained in Norway and Denmark was more than fifty, and
their value little less than five million dollars.[319] The Danes, ground
in the dust by England and France, had taken to piracy as their
support; and the Danish prize-courts, under the pressure of Davout,
the French general commanding at Hamburg, condemned their
captures without law or reason. Adams made what remonstrance he
could to the Danish government, and passed on to Cronstadt, where
he arrived Oct. 21, 1809. He found a condition of affairs in Russia
that seemed hopeless for the success of his mission. The alliance
between Russia and France had reached its closest point. Russia had
aided Napoleon to subdue Austria; Napoleon had aided Russia to
secure Finland. At his first interview with the Russian Foreign
Minister, Adams received official information of these events; and
when he called attention to the conduct of the Danish privateers,
Count Roumanzoff, while expressing strong disapprobation of their
proceedings, added that a more liberal system was a dream.[320]
The Foreign Minister of Russia, Count Roumanzoff, officially
known as Chancellor of the Empire, and its most powerful subject,
favored the French alliance. From him Adams could expect little
assistance in any case, and nothing but opposition wherever French
interests were involved. Friendly and even affectionate to America as
far as America was a rival of England, Roumanzoff could do nothing
for American interests where they clashed with those of France; and
Adams soon found that at St. Petersburg he was regarded by France
as an agent of England. He became conscious that French influence
was unceasingly at work to counteract his efforts in behalf of
American interests.
Adams’s surprise was the greater when, with the discovery of this
immense obstacle, he discovered also an equally covert influence at
work in his favor, and felt that the protection was stronger than the
enmity. Before many months had passed, he found himself winning
successes that could be explained only by the direct interposition of
the Czar against the resistance of Roumanzoff and the ambassador
of France. In the mysterious atmosphere of the Russian court, the
effect of wielding this astounding power might well have turned his
head; but Adams hardly realized his position. At the outset, obliged
to ask the Czar’s interference on behalf of the plundered American
merchants in Denmark, he could regard himself only as performing
an official duty without hope of more than a civil answer. This was in
fact the first result of the request; for when, Dec. 26, 1809, he
opened the subject to Roumanzoff, the chancellor gave him no
encouragement. The Danes, he said, had been forced by France to
do what they were doing. France viewed all these American ships as
British; and “as this was a measure emanating from the personal
disposition of the Emperor of France, he was apprehensive there
existed no influence in the world of sufficient efficacy to shake his
determination.”[321] Adams resigned himself to this friendly refusal
of a request made without instructions, and implying the personal
interference of the Czar with the most sensitive part of Napoleon’s
system.
Three days afterward, December 29, Adams saw Roumanzoff
again, who told him, with undisguised astonishment, that he had
reported to the Czar the American minister’s request for interference
in Denmark and his own refusal; and that the Czar had thought
differently, and had “ordered him immediately to represent to the
Danish government his wish that the examination might be
expedited, and the American property restored as soon as possible;
which order he had already executed.”[322]
If Adams had consciously intrigued for a rupture between France
and Russia, he could have invented no means so effective as to
cause the Czar’s interference with Napoleon’s control of Denmark;
but Adams’s favor was far from ending there. The winter of 1809–
1810 passed without serious incident, but when spring came and the
Baltic opened, the struggle between France and the United States at
St. Petersburg began in earnest. Adams found himself a person of
much consequence. The French ambassador, Caulaincourt,
possessed every advantage that Napoleon and Nature could give
him. Handsome, winning, and in all ways personally agreeable to the
Czar, master of an establishment more splendid in its display than
had been before known even at the splendid court of St. Petersburg,
he enjoyed the privilege, always attached to ambassadors, of
transacting business directly with the Czar; while the American
minister, of a lower diplomatic grade, far too poor to enter upon the
most modest social rivalry, labored under the diplomatic inferiority of
having to transact business only through the worse than neutral
medium of Roumanzoff. Caulaincourt made his demands and urged
his arguments in the secrecy that surrounded the personal relation
of the two Emperors, while Adams could not even learn, except
indirectly after much time, what Caulaincourt was doing or what
arguments he used.
Already in April, 1810, Adams reported[323] to his Government
that the commercial dispute threatened a rupture between France
and Russia. On one hand, Napoleon’s measures would prove
ineffectual if Russia admitted neutral vessels, carrying as they would
cargoes more or less to the advantage of England; on the other,
Russia must become avowedly bankrupt if denied exports and
restricted to imports of French luxuries, such as silks and
champagnes, to be paid in specie. Russia, at war with Turkey and
compelled to maintain an immense army with a depreciated
currency, must have foreign trade or perish.
Napoleon wanted nothing better than to cripple Russia as well as
England, and was not disposed to relax his system for the benefit of
Russian military strength. During the summer of 1810 he redoubled
his vigilance on the Baltic. Large numbers of vessels, either neutral
or pretending to be neutral, entered the Baltic under the protection
of the British fleet. Napoleon sent orders that no such vessels should
be admitted. June 15 Denmark issued an ordinance prohibiting its
ports to all American vessels of every description, and August 3
another to the same effect for the Duchy of Holstein. July 19 a
similar ordinance was published by Prussia, and July 29 Mecklenburg
followed the example. The same demand came from Caulaincourt to
the Czar, and the French ambassador pressed it without intermission
and without disguising the dangers which it involved to the peace of
Europe. Alexander’s reply never varied.
“I want to run no more risks,” he told Caulaincourt.[324] “To draw
nearer England I must separate from France and risk a new war with
her, which I regard as the most dangerous of all wars. And for what
object? To serve England; to support her maritime theories which are
not mine? It would be madness on my part!... I will remain faithful to
this policy. I will remain at war with England. I will keep my ports
closed to her,—to the extent, however, which I have made known,
and from which I cannot depart. In fact I cannot, as I have already
told you, prohibit all commerce to my subjects, or forbid them to deal
with the Americans.... We must keep to these terms, for I declare to
you, were war at our doors, in regard to commercial matters I cannot
go further.”
Thus the American trade became the apparent point of irritation

between Alexander and Napoleon. The Russians were amused by
Cadore’s letter to Armstrong of August 5, saying that the decrees
were revoked, and that Napoleon loved the Americans; for they
knew what Napoleon had done and was trying to do on the Baltic.
The Czar was embarrassed and harassed by the struggle; for the
American ships, finding themselves safe in Russian ports, flocked to
Archangel and Riga, clamoring for special permission to dispose of
their cargoes and to depart before navigation closed, while Napoleon
insisted on their seizure, and left no means untried of effecting it. He
took even the extravagant step of publicly repudiating the very
licenses he was then engaged in forcing American ships to carry.
July 10, 1810, the “Moniteur” published an official notice that the
certificates of French consuls in the United States carried by
American vessels in the Baltic were false, “and that the possessors
of them must be considered as forgers,” inasmuch as the French
consuls in America had some time before ceased to deliver any such
certificates; and not satisfied with this ministerial act, Napoleon
wrote with his own hand to the Czar that no true American trade
existed, and that not a single American ship, even though
guaranteed by his own licenses, could be received as neutral.
In the heat of this controversy Adams was obliged to ask, as a
favor to the United States, that special orders might be given on
behalf of the American vessels at Archangel. As before, Roumanzoff
refused; and once more the Czar directed that the special orders
should be given.[325] This repeated success of the American minister
in overriding the established rules of the government, backed by the
whole personal influence of Napoleon, made Roumanzoff uneasy.
Friendly and even confidential with Adams, he did not disguise his
anxiety; and while he warned the American minister that Cadore’s
letter of August 5 had made no real change in Napoleon’s methods
or objects, he added that the Americans had only one support, and
this was the Czar himself, but that as yet the Czar’s friendship was
unshaken. “Our attachment to the United States is obstinate,—more
obstinate than you are aware of.”[326]
Adams then saw the full bearing of the struggle in which he was
engaged; his sources of information were extended, his social
relations were more intimate, and he watched with keen interest the
effect of his remonstrances and efforts. He had every reason to be
anxious, for Napoleon used diplomatic weapons as energetically as
he used his army corps. Only ten days after Roumanzoff made his
significant remark about the Czar’s obstinacy, Napoleon sent orders
to Prussia, under threat of military occupation, to stop all British and
colonial merchandise; and the following week, October 23, he wrote
with his own hand to the Czar a letter of the gravest import:[327]—
“Six hundred English merchant-vessels which were wandering in
the Baltic have been refused admission into Mecklenburg and Prussia,
and have turned toward your Majesty’s States.... All this merchandise
is on English account. It depends on your Majesty to obtain peace
[with England] or to continue the war. Peace is and must be your
desire. Your Majesty is certain to obtain it by confiscating these six
hundred ships or their cargoes. Whatever papers they may have,
under whatever names they may be masked,—French, German,
Spanish, Danish, Russian, Swedish,—your Majesty may be sure that
they are English.”
If Napoleon aimed at crippling Russia by forcing her into the
alternative of bankruptcy for want of commerce or invasion as the
penalty of trade, he followed a clear and skilful plan. Roumanzoff
answered his appeal by pleading that Russia could not seize neutral
property, and would not harm England even by doing so. November
4, two days after President Madison proclaimed the revocation of the
French Decrees, Napoleon dictated his reply to Roumanzoff’s
argument:[328]—
“As for the principle advanced,—that though wishing war on
England we do not wish to wage it on neutrals,—this principle arises
from an error. The English want no neutrals and suffer none; they
allow the Americans to navigate, so far as they carry English
merchandise and sail on English account; all the certificates of French
consuls and all other papers with which they are furnished are false
papers. In short, there is to-day no neutral, because the English want
none, and stop every vessel not freighted on their account. Not a
single vessel has entered the ports of Russia with so-called American
papers which has not come really from England.”[329]
Armstrong, quitting Paris Sept. 10, 1810, wrote to Madison in his
last despatch a few significant words on the subject,[330] suggesting
that Napoleon’s true motive in reviving the energy of his restrictions
on commerce was, among others, the assistance it lent to his views
and influence on the Baltic. No other explanation was reasonable.
Napoleon intended to force Russia into a dilemma, and he
succeeded. The Czar, pressed beyond endurance, at last turned upon
Napoleon with an act of defiance that startled and delighted Russia.
December 1 Roumanzoff communicated to Caulaincourt the Czar’s
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Best of Five MCQS for the European Specialty Examination

The Art and Practice of Diagnosis in Chinese Medicine

MCQs in Internal Medicine 5th Edition Arup Kumar Kundu

The Harriet Lane Handbook: Mobile Medicine Series Johns

The Medical Legal Aspects of Acute Care Medicine A

Intensive Care Medicine MCQs Multiple Choice Questions

MCQs for the FRCS(Urol) and Postgraduate Urology

The Village Shop for Lonely Hearts Riverside Lane 1 1st

1 Cardiorespiratory arrest and shock

5 Diabetes and endocrinology

6 Elderly care and stroke

7 Renal medicine and urological problems

8 Neurology and ophthalmology

10 Oncology and palliative care

12 Infectious diseases and HIV

13 Poisoning and pharmacology

14 Immunology and allergy

Subject index  421

a-NVH asymptomatic non-visible haematuria

EWS Early Warning Score

IVIG intravenous immunoglobulin

OSAHS obstructive sleep apnoea/hypopnoea syndrome

TAB temporal artery biopsy

Justin Pearson Consultant Neurologist, North Bristol NHS Trust, UK

Nigel Lane, Louise Powter, and Sam Patel

1. A 74-year-old man suffered a cardiorespiratory arrest on a surgical

2. A 69-year-old man was successfully defibrillated after an episode

3. A 75-year-old man was admitted via the emergency department with

4. An 80-year-old woman was admitted to hospital for management of

5. A 49-year-old woman was admitted to the intensive care unit after

7. A 40-year-old man known to have alcoholic liver disease presented with

9. A 62-year-old man suffered an out-of-hospital cardiac arrest. He was

Figure 1.1 Intra-aortic balloon pump (IABP) waveform.

What is the problem with the intra-aortic balloon pump?

13. A 45-year-old man had a cardiac arrest. Chest compressions were in

14. A 45-year-old woman collapsed on the neurosurgical ward four days

15. An 18-year-old man was brought to the emergency department on New

16. A 75-year-old man was admitted to hospital for an elective revision of

Which diagnosis and therapy is most likely and appropriate?

17. A 49-year-old man presented to hospital with a two-day history of sore

18. A 45-year-old man with a history of idiopathic dilated cardiomyopathy

At about the same time Russell wrote to Pinkney at London a

This view of the contract to which American faith was bound,

Even in case of war with England, Russell warned the President

Thus the American trade became the apparent point of irritation

Let us accompany you on the journey of exploring knowledge and

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Subject index 421