First, do no harm

dr. Daniel Clinci

first
do
no
harm
a Medical English textbook
ovidius
university press
2020
Contents
Drugs, corpses & bodily fluids * an extremely brief history of medicine / 7
Let` s just talk about it... * the medical interview / 23
A bag of bones * the skeletal system / 32
Pumping iron * the muscular system / 39
The nervous breakdown * the nervous system / 44
Pour your heart out * the cardiovascular system/ 49
You leave me breathless * the respiratory system/ 55
You are what you eat * the digestive system/ 61
Let it all out * the urinary system/ 66
Here comes the stork * the reproductive system/ 70
We` re all in this together * social medicine/ 74
Who watches the watchers * autoimmunity/ 85
 Drugs, corpses & bodily fluids
*an extremely brief history of medicine*

The history of medicine might as well be only a long list of

discoveries and technological achievements that brought us from the
use of herbs to CRISPR technologies and “designer babies,” but it
also has something to do with the way various societies understood
life, disease, the body, the world, politics and so on. This history is
not necessarily an “evolution” or “progress.” It comprises epistemic
shifts and changes underlying the actual development of medicine as
we know it today. Sometimes, theories and practices were abandoned
when an epistemic shift occurred, prompted by some newly
discovered concept; sometimes, theories and practices were held in
high regard for centuries in spite of the new discoveries; and
sometimes new practices were invented, which actually prompted the
development of new concepts.
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 Drilling holes in people`s heads
Since prehistoric times humans have tried to find treatments for
medical conditions. Even though medicine as a field of research,
practice and training is a fairly recent development, the practices
associated with curing illnesses have a very long history. Throughout
the centuries, ideas were modified, concepts went in and out use, and
knowledge changed. This introduction will explain some aspects of
the history of medical thinking and the ways it evolved.
In prehistoric times, the practice of treating the ill had a
strong spiritual aspect. Illness was interpreted as possession by
spirits, either good or evil. Most of the medical knowledge centered
around plants or herbs (herbalism) and animal parts; medicine and
magic were indistinguishable. There are findings of prehistoric
medical procedures such as amputations, trepanning (drilling holes
in the cranium), and also some forms of dentistry.
Ancient Egyptian medicine made a huge leap forward in both
knowledge of human anatomy and pharmacology. The Ancient
Egyptians developed a kind of medical thinking in combination with
a mystical and magical one. They knew the importance of physical
examinations, they used diagnoses and specific forms of treatment.
Also, the Egyptians started to incorporate a theory of humors in their
medical knowledge.
“Examination of a woman aching in her legs and her calves after
walking
You should say of it 'it is discharges of the womb'.
You should treat it with a massage of her legs and calves with mud
until she is well.”
(extract from the Gynecological Papyrus, transl. by Stephen Quirke)
On the other side of the planet, the Chinese developed a huge
corpus of written medical texts, establishing a tradition known today
as Traditional Chinese Medicine (TCM). This medical practice was
still based on herbalism and was closely linked with very specific
philosophical perspective. TCM states that there is a primordial
substance of the world, qi, and life is the accumulation and
dispersion of this substance. “Evil qi” would cause disease, while
“healthy qi” would be beneficial.
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“Water and fire have no life though
they have qi; grass and tree have no
perception though they have life;
and birds and beasts have no
morality though they have
perception. A human being has qi,
life, perception and morality, and
therefore is the most privileged.”
(Hsun Tzu, in Jiuzhang & Lei, A
General Introduction to TCM, 58)
A bit later, TCM developed a new theory of the world, the body and
of disease, the dynamic balance and the oppositional unity of the yin
and the yang . These two principles, in turn, acted in two types of
organs: zang -organs (yin), like the heart, liver and kidneys, and fu-
organs (yang ), such as the stomach and the gall bladder. An
imbalance of these two principles would cause various forms of
disease, described by symptoms and syndromes. Eventually, the
Chinese also invented a “theory of the five elements,” which states
that everything is, in some measure or another, made of five essential
elements: wood, water, fire, metal and earth. Much like the Western
humors, these substances were linked to seasonal changes, fluids,
activities and so on. What is most interesting about Traditional
Chinese Medicine is its holistic spirit: the human body is, in itself,
integrated within the qi and the essential elements, but it is also
integrated within nature; the human being is a “psychosomatic
process,” an interplay between the yin and the yang , the various
forms of qi, or the five essential elements.
Another example of a holistic medical system is the ancient
Indian tradition of Ayurveda. Rather than conceptualizing health as
an absence of disease, in a similar manner to the Chinese tradition,
in Ayurveda health is considered a state of well-being (something
that Western biomedical medicine rhetorically recognized only in
1978). Ayurvedic medical knowledge is based on a balance between
three essences; however, it uses a personalized practice, because
every human being has a predominance of one such essence. Also,
environmental factors are taken into account. Ayurvedic treatment
does not focus on eliminating the cause of disease, but on restoring
the internal balance, something we might call today homeostasis.
9
“The exogenous diseases begin with pain, and then they bring about
disturbances in the equilibrium of the doşas. The endogenous
diseases on the other hand, begin with a disturbance in the
equilibrium of doşas and then bring about pain.”
(Charaka Samhita 1:20.7, in Fields, G., Religious Therapeutics, 69)
Primum non nocere
Hippocrates of Kos (460-370 BC) was the one who severed any link
medicine previously had with magic and religion, and focused
exclusively on finding somatic causes for illnesses. Hippocratic
knowledge was based on the “theory of the four humors,” which the
Ancient Greeks refined into a form that was to be used for the next
fifteen hundred years. Basically, the theory says that the human body
contains four fluids (or “humors”): black bile, yellow bile, blood and
phlegm. These four humors are in a tight balance; however, when
one of them falls out of balance, it is the doctor` s job to restore it.
“The human body contains blood, phlegm,
yellow bile and black bile. These are the
things that make up its constitution and
cause its pains and health. Health is
primarily that state in which these
constituent substances are in the correct
proportion to each other, both in strength
and quantity, and are well mixed. Pain
occurs when one of the substances
presents either a deficiency or an excess,
or is separated in the body and not mixed with the others.”
(Hippocratic Writings, 262)
The four humors were also linked with the seasons and also with
essential elements. For instance, phlegm was associated by the
Hippocratic school with winter, because phlegm was considered a
“cold humor”, thus causing “cold diseases” and an excess mucus that
people would blow from their noses during the winter; blood was of
course associated with warm weather and spring, during which the
most common condition was thought to be epistaxis (nose bleeds).
The treatment was, according to Hippocrates, supposed to be based
10
on the principle of opposition: diseases caused by excess blood were
to be cured by removing some blood to restore the balance; diseases
caused by eating too much were to be cured by fasting; disease
caused by working too much were cured by resting and so on. These
ideas paved the way to some interesting medical practices, such as
bloodletting.
“The application of leeches (Hirudo
medicinalis) has a history at least
as long as bloodletting. Their use
was particularly favoured in the
nineteenth century, to the extent
that several million leeches were
employed in Paris hospitals every
year. As late as the 1950s in at least
one London teaching hospital,
leeches were kept in the hospital
pharmacy and used occasionally. ”
(“The Demise of Bloodletting,” DP
Thomas)

The Hippocratic Corpus contains very powerful insights about

the nature of disease, some of which have only recently been
rediscovered by medicine and put to good use. For instance,
Hippocrates says that “some diseases are produced by the manner of
life that is followed” (HW, 266), in other words, by what we call
today “lifestyle”, the focus of “lifestyle medicine.” The Corpus also
mentions environmental causes of diseases and the fact that “when a
large number of people all catch the same disease at the same time,
the cause must be ascribed to something common to all and which
they all use” (HW, 266).
A very interesting text from the Corpus is “Airs, Waters,
Places.” It is in this essay that we can see the holistic tradition fully at
work in Hippocratic medicine. The author states that any
practitioner of medicine should study things like the effects of the
seasons, the winds, whether hot or cold, whether local or regional,
the quality of the water supply, even the setting of the town and the
habits of the locals, in short what we might call today the social

11
determinants of health. All these factors create predispositions to
various illnesses, according to Hippocrates; he also offers some
examples:

Description of the The locals Common medical

place conditions
- exposed to warm - heads full of phlegm - sickly women,
southern winds, which flows down and common miscarriages;
protected from the disturbs the internal - asthmatic children;
northern ones; organs; - men suffering from
- plentiful surface - not eating or diarrhoea, dysentery,
water, warm in the drinking well, prolonged fevers in
summer and cold in predisposed to the winter, skin
the winter; hangovers; diseases;
- weak constitution;
- exposed to cold - lean and strong; - abscesses; epistaxis
winds from the north, - prone to in the summer;
sheltered from the constipation; - the water causes the
southern ones; - eating plenty, but women to be sterile
- hard and cold water drinking little; and have issues with
supply; menstruation;
Interestingly enough, when Hippocrates goes on to talk about the
various peoples in Europe, Asia, Egypt and so on, he mentions the
people that live on the shores of the Black Sea. These Macrocephali
had the custom of shaping their babies` heads and making them
longer (something called artificial cranial deformation). Hippocrates
explains that “nature collaborates with tradition,” and this feature
had become an inherited trait. Amazingly as it may seem,
Hippocrates actually talks about heredity:
“The seed comes from all parts of the body, healthy from healthy
parents and sickly from the sickly. If therefore bald parents
usually have bald children, grey-eyed parents grey-eyed children, if
squinting parents have squinting children, why should not long-
headed parents have long-headed children?”
(HW, 162)
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 Hippocrates is perhaps mostly
remembered for his Oath, which lays
the principles governing medical
practice and acts as a foundation of
medical ethics. The Oath itself is first
and foremost a recognition that this
new profession, medicine, held great
power over the patients` lives. It also
proves that medical practice was
only accessible to the few, which
reinforces the idea that Hippocratic
medicine might have been a mystery
religion worshiping Apollo, Aescu-
lapius and other gods. Thus, the text
is organized around the idea of “do
no harm”: “I will [the selected few]
teach them the Science, if they desire
to learn it, without fee or contract
[…] and to none other. […] I will
abstain from harming or wronging
any man. […] I will not give a fatal draught to anyone if I am asked,
nor will I suggest any such thing. Neither will I give a woman means
to procure an abortion. […] I will not cut. […] I will not abuse my
position to indulge in sexual contacts with the bodies of women or of
men, whether they be freemen or slaves.” (HW, 67)
As we can see from the Hippocratic Oath, surgery was strictly
forbidden. This was a major hurdle for Galen of Pergamon (129-200
CE), a follower of Hippocrates who was very interested in anatomy.
Galen had to resort to experimenting on pigs and other animals also
because in the Roman Empire dissection of human corpses was
against the law. He wrote a great deal of treatises on anatomy and
medicine, and became the most influential figure for the next 1500
years. For instance, here is a part of Galen` s analysis of the beating
heart:
“Therefore the power of pulsation has its origin in the heart itself. It
would not have arisen if the organ had had the same nature as the
muscles throughout the whole animal. But the fact that the heart,
removed from the thorax, can be seen to move for a considerable
13
time is a definite indication that it does not need the nerves to
perform its own function. Those who think the heart a muscle seem
ignorant of these things […]”
(Singer, Ch., Galen on Anatomical Procedures, 184)
Galen used the same Hippocratic theory of the four humors in his
diagnosis, but knew a lot about bone structures, muscles, lungs, the
heart, the blood and the nervous system. He is also famous for
having made some errors in his anatomical analysis, such as the fact
that blood is produced by the liver and it is used as fuel by the
muscles. Because he could only work with animals, many of his
descriptions refer to animal organs, not human ones.
Roman medicine had very diverse interpretations of disease.
Of course, the authority of Galen and humorism remained
undisputed; however, other scholars had very interesting ideas. For
instance, Varro spoke of little creatures that cannot be seen, but
which float in the air and enter the body, causing disease. Vitruvius,
on the other hand, identified bad odors, miasmata, as the cause of
disease. All these theories remained in use until the 19 th century in
some form or another.
Monasteries, the Black Death & dog poop
Among other things, Galen noticed that the human body is so
amazing that it must have been designed by god. Also, he departed
from the Hippocratic holism regarding the human being and took a
more Platonic position, looking for the seat of the soul in the human
anatomy. This is was the beginning of a distinction that would haunt
Western medicine for the next 1800 years: the opposition between
the soul and the body.
After the fall of the Roman Empire, the most important
institution that was left standing to control and rule Europe was the
Church. The Christian Church imposed it own view on the human
being: the body was only a temporary shell in which that eternal soul
was housed; disease was a punishment from God for various sins,
and was treated with prayer and flogging. The Church eventually set
up “hospitals” within monasteries, where nuns would attend the ill,
not trying to treat them physically, but spiritually, to save their souls
from eternal damnation. The body was relegated to the ephemeral,
14
and was kept in such disregard that there are stories about saints
that bathed about once a year; the English considered that the
Vikings were obsessed with cleanliness because they took baths once
a week.
On the other side of the Mediterranean, the Arabs developed
an understanding of philosophy, math, astronomy, architecture,
medicine, chemistry etc. Arabic culture preserved the ancient Greek
and Roman knowledge through translations. Most famously, the
Persian Ibn-Sina (Avicenna) compiled his Canon of Medicine, which
consisted in medical knowledge from multiple traditions: Galenic,
Persian, Indian, Chinese. The five books of the canon contain
information on anatomy, pharmacology, etiology, the diagnosis and
treatment of diseases etc. Avicenna uses the same four humors as
Galen did, and promotes the same views in regard to anatomy; for
instance, blood is said to be contained in the liver. On the other
hand, he sometimes criticizes Galen, for instance, when it comes to
the seat of the soul, which Avicenna thinks is the heart, not the brain,
as Galen did. Among Avicenna` s medical treatments we may find
herbalism, bloodletting, surgery, but also the “soft” ones, like change
of lifestyle.
Galenic medical texts were eventually rediscovered by the
monks in European monasteries, who took on the arduous task of
translating, preserving and copying them. The Church became
particularly fond of Galen` s views, even if they were those of a pagan,
because of his opinions on the intelligent design of the human body.
Galenic medicine was recognized by the Church as the only
authoritative perspective on the human body and remained so for
another millenium. This created a certain stagnation in the
development of medical thought.
Medieval medicine was, on the other hand, very diverse. If
educated medical professionals were hired by the rich feudal lords,
regular citizens resorted to folk remedies and barber-surgeons. Folk
remedies were used by doctors or witches. “Leechbooks” contained
various forms of medical interventions using herbs and other
materials, but also incantations to be recited over the materia
medica. One of the most famous books in English medical practice
was “Bald` s Leechbook.” For instance, the treatment for neck pain,
like sore throat, swelling, tonsillitis etc., was album graecum, white
dog excrement, crushed and mixed with honey and then rubbed on
15
the spot. For shoulder pain, pig faeces were used in the same way.
For blisters, a mixture of dog urine and mouse blood was used; for
burns, goat dung and butter. Other leechbooks prescribed solutions
for conceiving a boy: a dried rabbit turned into a potion and drunk by
the couple; for difficult pregnancies, stepping three times on a grave.
“In case a man be a lunatic; take skin of a mereswine or porpoise [a
small Cetacean], work it into a whip, swinge the man therewith, soon
he will be well. Amen.”
(Bald`s Leechbook, III)
In 2015, a group of researchers recreated a recipe from Bald` s
Leechbook, using garlic, onion, wine and bile from a cow. They used
the recipe as designed and found that it is successful in treating one
of the most resistant pathogens, the methicillin-resistant staph
aureus, also known as MRSA.
A major event in Medieval history was the plague epidemic,
Pestilence, or the “Black Death” (1347-1351). Caused by a bacteria,
this disease was spread by fleas and rats throughout all of the Middle
East and Europe along the trade routes. The death count rose fast
and steady, and the reason for the plague was thought to be that God
had become angry. Physicians believed that the disease was spread
through bad odors, the miasmatic theory. In a few years, the Black
Death wiped out half of the population. One physician, Guy de
Chauliac, in Avignon, found that excising the pustules would help,
and recommended isolation, blood-
letting, purifying the air using fire and a
diet rich in fruit and other nice smelling
things. However, the fabric of Medieval
society had torn and the cities were left
unpopulated. To calm the wrath of God
and to avoid the Apocalypse, the
Christians started to punish the Jews,
the foreigners, the lepers, and also
began a witch hunt, identifying the
collaborators of the Devil, torturing
confessions out of the people and
burning them at the stake.

16
 Opening up some corpses
During the Renaissance, a sort of secularism started to become
manifest, a detachment from the power and authority of the Church.
For medicine, this meant that there was a detachment from the
authority of Galenic medicine. For general history, this meant the
birth of the scientific method of doubting, experimenting, observing
and concluding. All these probably sound very familiar and may lead
us to think about Descartes. However, before Descartes, Andreas
Vesalius was the one who not only dared to challenge Galen` s
anatomy, but also came up with some ideas about systematic doubt.
And all these happened because Vesalius was able to dissect some
corpses.
Galenic anatomy was not necessarily “human” anatomy. His
work on animals like pigs, dogs and monkeys resulted in some
mistakes that were propagated through the centuries because of the
interdiction to dissect human bodies. In both Ancient Rome and
Christian Europe it was forbidden to open up corpses. During the
Renaissance, however, because the Church had lost its power,
Vesalius was able to take freshly deceased criminals that had been
hanged and perform dissections. He famously did so at the
University of Padua, working with illustrators to create De humani
corporis fabrica, arguably the most important book in the history of
anatomy. Vesalius identified more than 200 mistakes in Galen` s
anatomy. Some examples include: the mandible is made of a single
part, not two (a result of Galen working on dogs), the liver has two
lobes, not five, the sternum has three segments, not seven, and so
on. But what is even more important than his anatomical findings is
the fact that Vesalius encouraged researchers to question the
established authority and experiment and think for themselves.
Another Padua alumnus was William Harvey. After years of
experiments on animal and human bodies, dissections and
vivisections, he came up with the strange idea that blood circulates
through the vessels. At first, he himself did not believe such a thing,
since it contradicted everything they knew about physiology from the
absolute authority that still was Galen. Eventually, in 1628 Harvey
published his work De motu cordis, in which he describes how the
blood circulates through the arteries and the veins in a closed loop,
pumped by the heart.
17
“These two motions, one of the ventricles, the other of the auricles,
take place consecutively, but in such a manner that there is a kind of
harmony or rhythm preserved between them, the two concurring in
such wise that but one motion is apparent […]. Nor is it for any other
reason than it is in a piece of machinery […].”
(De motu cordis V, “Of the motion, action and office of the heart”)
Both Harvey and Vesalius
promoted the scientific method in
their approach and we can surely
admit that their works were the
foundation of evidence-based
medicine. However, the under-
standing of the human body as a
machine constructed a new per-
spective on medicine, one which
still is prevalent in many parts of
the world, the biomedical model. Disease was nothing more than a
malfunction in a system of organs, and that was supposed to be
addressed by the physician who, using his educated gaze, would see
the signs of disease and eventually fix the machine.
The medical gaze
In The Birth of the Clinic, Michel Foucault describes the way in
which the patient became a subject of the physician` s “gaze.” Under
the trained eye, the patient was stripped of their individuality and the
living body became the object of clinical examination. In the 18 th
century, the clinic was the locus of a specific form of power that
dismantled the human being and reduced it to a malfunctioning
machine.
The act of seeing, the gaze, the direct observation were
actually the great methodological innovations of the Renaissance, as
Vesalius and Harvey clearly prove. Both of them identified the
objective truth that was hiding in the human body by cutting it open
and seeing whatever was to be seen. For Foucault, these practices
resemble a kind of spectacle. “The medical gaze” is the way in which
the biomedical tradition appeared after the dissolution of Ancient
holism. If the Middle Ages medical practices, however weird they
18
may seem today, had something to do with a tradition of thought
based on similarities and on the inter-connections between all
things, modern biomedical medicine leaves out all other factors –
social settings, environment, lifestyle – in favor of the cryptic signs
and symptoms of disease which would only be recognized and
interpreted by the doctor` s gaze. What is forgotten in modern
medicine, what is left behind, is not only Galenic and Hippocratic
misinterpretations about human anatomy and the theory of the four
humors, but also this wider, integrative view. We could easily say
that modern medicine is reductionist, since both the living body and
the dead one are subjected to a medical perspective that “sees”
organs and systems as if they were functioning independently.
Foucault describes the practice of nosology, the classification of
disease, and argues that the medical gaze is not even directed
towards the concrete body that is present, but towards negatives,
towards signs of the disease that are recognizable from theory and
experience.
Basically, all history of modern medicine is a practice of the
medical gaze. New technologies of seeing were invented, which
allowed physicians to hypothesize other, new objective truths; all
these technologies were ultimately based on direct observation and
experimentation, that is, on the scientific method developed by
Vesalius, Harvey, Descartes and others.
The ancient miasmatic theory of disease was superseded by
the germ theory, with contributions from scientists like van
Leeuwenhoek, who identified microscopic organisms he called
“animalcules,” Semmelweis` work in obstetrics, the famous John
Snow, Pasteur and Koch. The invention of anaesthesia meant that
patients undergoing surgery would finally survive the procedures.
Florence Nightingale established nursing as a legitimate medical
profession. Johns Hopkins Hospital in the US created practices such
as residencies and rounds. In the 20 th century, medical imaging was
invented, which meant that doctors did not need to cut the body
open to see whatever is on the inside anymore.
The medical gaze and the power exercised by the doctor over
the patient` s body lived on throughout the 20 th century. However, in
the second part of the 20 th century, the theory and practice of
consent started to be discussed and put into practice. After the
medical experiments on people in concentration camps during the
19
Second World War, the medical field developed the concept of
patient consent, that is, the patient has a right to agree or disagree to
be subjected to some medical procedure. In the 60s, informed
consent became the legal and ethical requirement. This means that
the patient receives information about their medical condition, about
the proposed management, outcomes, risks and side effects first and
then may or may not consent. During the 70s and the 80s the idea of
patient-centered medicine appeared, in opposition to doctor-
centered medicine, a practice that shifted some power away from the
doctor and offered it to the patient. In very broad terms, patient-
centered medicine means that the patient is supposed to be included
in all the stages of the medical process, that they are finally given a
voice.
Hippocratic medicine (or broadly speaking, non-Western
medical traditions) was rediscovered at the end of the 20 th century in
two major directions. The first one was established in 1978, when the
World Health Organization issued the Declaration of Alma-Ata, in
which it states that health is not merely the absence of disease, but a
state of general well-being, thus doing away with the whole
reductionist view of modern medicine. The second aspect is that of
lifestyle medicine. Around 1990, Ancient holism would once again
come to the fore as “the application of environmental, behavioral,
medical and motivational principles to the management of lifestyle
related health problems in a clinical setting.” Lifestyle medicine
focuses on things like diet, exercise, stress levels, habits and so on to
shape another kind of medical practice.
On the other hand, the
medical gaze lives on in
concepts and practices such as
the “Human Genome Project,”
which was completed in 2003
and managed to map the all
the human genes. Genomics,
the idea that our genes make
us who we are, is still debated, but technologies such as CRISPR,
manipulation of genes, are starting to take off in new, unpredictable
and oftentimes ethically dubious directions.

20
 You can`t always get what you want
The famous show House MD presents a tension between the modern
biomedical model and the postmodern, patient-centered one. In the
paper “The Afterbirth of the Clinic,” the authors analyze from a
Foucauldian perspective multiple aspects of this tension that is very
apparent in House, a useful discussion for a better understanding of
what the modern and postmodern models are and, of course, their
discontents.
The title character, Dr. Gregory House, is the finest example of
a physician that employs the medical gaze according to the
biomedical model of the 19 th and 20 th centuries. As we have already
seen, the medical gaze dehumanizes the patient and reduces the
complex medical practice to a rational clinical one that is based on
the scientific standards of objective truth. As Foucault explains in his
Birth of the Clinic, under the medical gaze the patient becomes a
“background of objectivity.” Gregory House does not engage in
bedside medicine and most often refuses to talk to patients under the
assumption that “everybody lies.” Thus, the patient is only a
subjective perspective, an unwanted glitch in the search for the cause
of disease. Obviously, the character focuses more on treating the
disease and not the patient. Essentially, the patient as a whole is the
enemy of objective truth and their body must be disassembled,
dismantled, dismembered, opened up to reveal the truth of the signs
and symptoms. Foucault also explains how using a cryptic, hermetic,
Latinized language complements the medical gaze. The
professionalization of medical practice in the 19 th century re-created
that Hippocratic hermetic sect, but this time it is a religion of
worshipers of objectivity, with their own initiation rituals and their
specific language and practices which are inaccessible to outsiders.
For House, the patient should remain silent.
On the other hand, against this hermetism, against the divine
authority of the physician and against the patient as an object,
postmodern medicine turns to a more inclusive practice, that of
patient-centeredness. The inclusion of the patient in the medical
decision-making process did not stop at this point. The capitalist
model of medical practice also includes medical insurance
companies, hospitals and medical professionals as service providers,
administrators and so on, all the faces of an economics of health care.
21
Thus, medical professionals become more and more subordinated to
stakeholders, and decision-making might not always have the
purpose of diagnosing and treating patients, but that of expanding
profit, that is, doing medicine as a business.
However, there are lots of studies that show how newer
patient-centered approaches are more effective. The inclusion of the
humanities in medicine, the so-called medical humanities, narrative
medicine, with its focus on patient (and doctor) stories are examples
of such practices.
In the end, the authors of the paper admit that House is a
show about the current dilemma in medicine. What is medicine? Is it
a natural science looking for objectivity that treats disease? Or is it a
human(istic) science that services broader socio-political purposes?
The question and the alternatives that are presented in the article
may be somewhat reductive. Are there any other possibilities of
imagining the future of medicine?

22
 Let` s just talk about it...
*the medical interview*

Imagine you` re a doctor. You receive patients, you talk to them, you
examine them, you diagnose, you probably prescribe some drugs or
maybe order some tests. All this process is an encounter between
patient and doctor, and maybe this is an easily overlooked aspect of
the busy life of a medical professional. Firstly, we will look at the
structure of this encounter which we will call “the medical process”
from a biomedical point of view, in order to set the stage for a
discussion on medical history-taking or “medical interview.”
An encounter between doctor and patient starts with “the
presenting complaint,” that is, the patient complains about
something, usually pain. Of course, the patient may also complain
about other things, like sore throat, nausea, fatigue etc. All these are
called symptoms and they are subjective accounts of a patient` s

23
experience. For instance, the intensity of pain can be assessed on a
scale of 1 to 10, but this description will vary from patient to patient,
because pain is a very subjective symptom; in other words,
symptoms are extremely important, but most of the time they are not
enough for the doctor to reach a proper diagnosis.
1. Presenting complaint
2. Medical interview
3. Physical exam
4. Other data (e.g. blood tests, imaging, urinalysis etc.)
5. Diagnosis
6. Management plan
7. Prognosis
An important aspect of contemporary medical practice is consent.
Obtaining consent from the patient is one of the first stages of any
medical encounter. For instance, consent is needed for any medical
procedure, including the medical interview. This is a relatively new
development in medical theory and practice and it has something to
do with the ethics of patient-centered medicine, that is, the patient is
supposed to be listened to and included in the medical decision-
making process. Sometimes, informed consent is necessary, which
means that the doctor will explain risks, possible outcomes and
complications, and then ask for consent.
After the patient presents their complaint, the doctor usually
asks a few questions. This stage is known as “medical interview” and
there are various models of history-taking. The conversation is
structured in a certain way so as to elicit as much information as
possible from the patient, from the history of the symptoms, to
family history, social history and drug history.
At this point, the doctor will start looking for signs; being
objective, signs are a more reliable basis for a diagnosis. Usually, the
doctor will perform a physical examination using some techniques
such as inspection, auscultation, palpation and percussion.
Inspection is the visual assessment of the body and can be very
effective. One example of using inspection, that is, just looking at the
patient, is the assessment of skin color.

24
What do you think determines a patient` s skin color?

normal
yellow
red
blue
white
Another technique is palpation, which means that the doctor uses
their hands to feel certain body parts. For instance, an upper
respiratory infection might be confirmed by feeling swollen lymph
nodes (adenopathy).
Percussion is a technique of tapping on the body surface to
determine whatever is beneath, much like playing a hand drum. It is
used to determine the size, placement and consistency of organs, but
also the presence or absence of fluid.
Auscultation means using a stethoscope to listen to the internal
sounds of the body, like the circulatory system or the respiratory
system.
If the information gathered up to this point is insufficient, the doctor
may order some specific tests, like an ECG, a complete blood count,
biopsy, x-rays, ultrasound etc.
All this wealth of information, symptoms, history, signs, test
results and so on, lead to the diagnosis. The doctor interprets the
information to determine a pathology, the internal causes of disease,
and an etiology. For instance, the pathology of a case of anemia may
be the fact that the hematopoietic bone marrow does not make
enough red blood cells; the etiology would be a lack of dietary iron.
Arguably, the most important role of the doctor (from a
biomedical point of view) is reaching the right diagnosis. This implies
the fact that the doctor is able to interpret all the information, based
on experience, knowledge and skills. Setting up a management plan
is usually a straightforward process (like drug therapy, physio-
therapy, surgery etc.). Prognosis is the ability of the doctor to predict
the course of a managed disease.

25
 The medical interview

However, contemporary medical practice is not all about the

hard, cold science of interpreting data and applying textbook
treatment. Fortunately, the latest developments in medicine world-
wide have promoted the importance of a human connection between
doctor and patient. This connection is established during the medical
interview. Basically, the medical interview is just a conversation
between doctor and patient, but the values and the sense of
humaneness that this conversation, when done right, enacts cannot
be overstated. Indeed, the medical interview is the foundation onto
which all medical procedures unfold.
Throughout the development of postwar medicine, doctors
and institutions have promoted various models for this interaction,
taking into account the psychological aspects that occur in the shared
space of the doctor` s office. Starting from the 50s and 60s, the
emphasis was placed on attentively listening to the patient. For
instance, the Balint model states that the discussion leads to the
possibility of finding new ways forward in the medical process.
However, what was needed in the 60s was a structured framework
for medical history-taking. In the 70s, the Byrne-Long model
provided some guidelines, such as establishing a rapport with the
patient, discovering the reasons for the visit, discussing the problem
and planning. This model was considered to be quite doctor-
centered, and is perhaps the one that we see in use most of the time
in this country. The Pendleton model of the 80s was designed to be
more patient-centered, including a well-defined sequence of stages:
the doctor would assess the patient` s reasons for the visit, the nature
and history of each complaint, and their consequences; then, the
doctor would discuss any social problems as risk factors; the patient
and doctor would collaborate to establish a management plan, and
the doctor would encourage the patient to assume some
responsibility for the issues at hand. Thus, the main goal of the
Pendleton model, from a psychological standpoint, was to create
trust and a long-lasting relationship between doctor and patient.
However, this approach may be quite time-consuming.
In 1998, the Calgary-Cambridge model was created.
Resembling the Pendleton model, the Calgary-Cambridge approach
is very patient-centered and also very practical. Its goals are to
26
provide a structure for the patient and to build a relationship by
using five stages. It has become the globally accepted way to perform
a medical interview.
Building a relationship: taking notes in a way that does not interfere
with the conversation, demonstrating empathy and sensitivity,
accepting the patient` s point of view.
Providing structure: giving clarity to the conversation by clearly
separating points that are made, reinforcing some ideas that may
come up.
1st stage
“Initiating the Session”: establishing rapport and the reasons for the
visit
2 nd stage
“Gathering Information”: exploring the problem using open and
closed questions, developing a structure, establishing ideas, concepts
and expectations
3 rd stage
“Physical Exam”
4th stage
“Explanation and Planning”: providing information and checking
that the patient understands it
5 th stage
“Closing the Session”: summarizing and making sure that the agreed
plan is clear
The traditional structure of the content to be discussed contains the
following aspects:
1. The presenting complaint (the symptoms)
2. History of the presenting complaint (the history and details
regarding the symptoms)
3. Past medical history (patient` s personal medical history, like past
diseases, past surgical operations, past medical treatment)
4. Family history (parents and siblings)
5. Social history (home environment, occupation, habits like
drinking, smoking, exercise, other lifestyle factors like diet etc.)
6. Drug and allergy history
7. Systems review
27
We can see from this list that building trust is essential in the
medical process. To get clear and honest answers from the patient, a
doctor needs to be non-judgmental, because the discussion includes
aspects of the patient` s private life, which may be perceived as
invasive. The Calgary-Cambridge framework offers ways to build a
comprehensive and effective pattern of communication, for instance,
by being aware of the patient` s attitude and non-verbal cues.

This is an example of a medical interview. Identify the

stages and notice the language the medical student uses.
Then, think about what the diagnosis and the immediate
treatment might be.

Medical Student: Hi there! I` m Stephanie, I` m a first year medical

student. Can I get your name?
Patient: Hi, Stephanie! I` m John.
MS: Very nice to meet you, John!
P: You too!
MS: I` m just going to take a brief history of why you` re here today.
Is that ok with you?
P: Yeah, it` s fine.
MS: Ok, first of all, can I get your age?
P: 50.
MS: 50, great. And why are you here today?
P: Well, last night I got this terrible pain in my stomach.
MS: Ok.
P: And I couldn` t get back to sleep and I got out of bed and walked
around, I just couldn` t get back to sleep.
MS: Ok, you couldn` t get back to sleep. Alright, and it was just last
night?
P: Yeah.
MS: Could you explain a little bit more about the pain?
P: It` s just this sort of pain that keeps getting bad and then it kind of
goes away, but it doesn` t totally go away and it` s making me feel
like crap.
MS: So, it` s a bit of a colicky pain.
P: Oh, yeah.
28
MS: Alright. On a scale of 1 to 10, how bad would you say it was?
P: i would say it was 8 or 9 last night, but at the moment it` s about 5,
I` d say.
MS: So, it` s still going on right now. Is this the first time this has
happened to you?
P: Yeah.
MS: Could you just point to me where it is?
P: It` s sort of here, under the ribcage.
MS: Is there anything that makes it worse or better?
P: No, it just seems to do what it wants to do.
MS: That` s not good at all.
P: Last night I took some Quick-relief, that didn` t do anything, then I
took some Aspirin at two o` clock, that didn` t do anything, and at
about five o` clock I took some Panadol and that didn` t do anything.
MS: So you haven` t had any luck treating it...
P: No...
MS: And do you have any symptoms, other than the pain?
P: I had a bit of nausea last night, but that` s about it.
MS: Have you had anything like this before in the past, the stomach
pain?
P: No.
MS: Nothing like that... And just about your past medical history, in
general, do you have any ongoing issues, like diabetes, any issues
with your heart, lungs, kidneys, nothing like that?
P: No, no...
MS: Ok. And have you had any surgeries in the past?
P: Well, I had a fractured ankle when I was fourteen, I stopped
playing football because it took too long to heal, and then,
apparently, I had an operation when I was a baby because I used to
project vomit across the room. When I was younger, in school, I had
some asthma, but I don` t get any problems with that now except
when I get a really bad cold, and it` s just a wheezy cough.
MS: Alright. Are you currently on any other medication, herbal
remedies, vitamins, supplements?
P: No.
MS: Are you allergic to anything?
P: What was it...? Tetracycline...
MS: Tetracycline. I` m just going to do a bit of a summary here, to
make sure I have everything. Last night you got a pain in your
29
stomach, and it woke you up, you were having a bit of a hard time
sleeping with that as well. Gave you a bit of a nausea, you` ve never
had anything like this before, you said the intensity was about 8 or 9,
so pretty serious. You said it was just under your ribs, and it` s a
colicky pain, so it comes and goes whenever it wants. And you tried
Aspirin and Panadol, ok... So, I` m just going to ask you about your
general history. In terms of your diet, how is that?
P: Well, used to be pretty good up until last night, it was my son` s
birthday, we had pizza and cake, and I ate a bit much, but that` s why
it was strange, because I got a bit nauseous, and I don` t usually get
nauseous.
MS: Ok, that` s a little bit odd. So, is that usually a part of your diet,
the pizza and cake type thing?
P: Well, lately I` ve been having a lot of take-away food, cause the
wife started a new job and she hasn` t been home to do the cooking.
MS: So, a little bit more fatty foods than usual. Ok, no problem. In
terms of exercise, how` s that, do you exercise regularly?
P: Ahh, the occasional walk home.
MS: Ok. And do you smoke at all?
P: Thirty a day for thirty years.
MS: Ok. And how often do you drink?
P: I probably have five or six beers on the weekend, and occasionally
I` d have a glass of wine.
MS: Ok, not too bad at all. And you said you were married, you have
a wife. How many children do you have?
P: Four. 17 to 9.
MS: So you` re a busy man...
P: Well, yeah.
MS: What do you do for a living, John?
P: I` m a car salesman. I` v been doing that for about 20 years and I
like it.
MS: Full time?
P: Yeah, yeah. Except for today...
MS: Do you think anything in your life is causing stress right now?
P: Well, yes, the wife and I haven` t been getting on too well, since
she started this job she` s gotten quite mean. My daughter, the oldest
one, she` s skipping classes and causes problems with the teachers...
MS: She` s being a teenager, then... So, in terms of your family
history, did anybody have something like this before in your family?
30
P: Not that I know of.
MS: Are your parents still around?
P: Nah, they` re both dead. My dad died of a stroke at 87 and my
mom died of a heart attack at 79.
MS: So they both had pretty full lives then...
P: Yeah...
MS: So, let me just sum that up for you, to see if I haven` t missed
anything. In terms of your diet, you generally eat ok, but you` ve been
eating a little more take-away than usual. Last night it was pizza and
cake, so you think that might have had something to do with the
pain. You smoke thirty cigarettes a day, and that` s been going on for
thirty years, you have five to six beers on average on weekends, not
too bad at all, and you have four children and a wife, which is great,
you` re a car salesman full-time and you had a little bit of stress lately
because of your daughter and your wife going back to work...
P: Yeah...
MS: Ok, is there anything else you wanted to add today?
P: Nothing I can thing of except that I want to get rid of this pain...
MS: Definitely. And can you think of anything that might have
caused it?
P: No, the only thing I can think of is that I ate too much at the party,
but it hasn` t bothered me before.
MS: I think that` s about it, thank you very much!

31
 A bag ofbones
*the skeletal system*

The adult human body has 206 bones.

There are 26 bones in the human foot.
The human hand, including the wrist, has 54 bones.
The femur is the longest and strongest bone of the skeleton.
Bones stop growing during puberty.
The only bone not connected to another one is the hyoid.
1. Fill in the gaps in the description with the following
words:
heart joints
marrow phosphorus
framework lungs
brain calcium
fat movement

32
The functions of the skeleton
One of the functions of the skeleton is to support soft tissues. It acts
as a __________. Another function is __________. The skeleton
provides attachment points for muscles. Their contraction allows the
bones to move at __________. Also, the skeleton protects our
internal organs, such as the __________ and the __________,
within the thorax, and the __________, inside the skull. Bones
store minerals, like __________ and __________, and can
release them when needed. Bones also store __________ in the
yellow bone __________. Some bones contain hematopoietic
marrow which produces blood cells.
2. The human skeleton can be divided into the axial
skeleton and the appendicular skeleton. Match these terms
with their definitions:
ethmoid
hyoid
stapes
lumbar
sternum
mandible
sacrum
neurocranium

a. part of the skull that

protects the brain
b. the largest and strongest
bone of the human face
c. long flat bone located in
the central part of the chest
d. a horseshoe-shaped bone
located in the anterior
midline of the neck
e. the smallest bone of the
human body

33
f. five vertebrae between the rib cage and the pelvis
g. large triangular bone at the base of the spine
h. bone that separates the nasal cavity from the brain
3. Match these technical terms with the non-technical ones:
tibia shin
patella ankle
scapula wrist
clavicle jawbone
tarsals backbone
carpals hip
pelvis knee-cap
metacarpals chestbone
vertebrae palm
metatarsals sole
mandible shoulder blade

4. Fill in the gaps with the

appropriate terms:
A long bone has two parts. The
__________ is a tubular shaft
that runs between the proximal
and distal ends of the bone. The
hollow part is called the
__________, which is filled
with yellow marrow. The wider
section at each end of the bone
is called the __________ and
is filled with spongy bone. The
outer surface of the bone is
covered with a membrane called
the __________. It contains
blood vessels, nerves and
lymphatic vessels that nourish
the bone.

34
5. Bones vary in their appearance, depending on their
location and function. Generally speaking, there are three
types of bone markings: articulations (joints), projections
and holes. Match these terms with their descriptions.
head prominence feature
process hole through bone
tubercle passage in bone
fossa prominent rounded surface
sulcus elongated basin
foramen flat surface
canal groove
facet small rounded process
Phrenology
“If the skull be loaded with fat and flesh, this is usually an
indication of a shallow mind: much more if, at the same time, it be
small and round; it denotes stupidity” (extract from The Pocket
Lavater).
In the 18 th century, the Swiss Johann Kaspar Lavater
introduced an idea that would become very popular: the shape of the
skull is connected to the individual` s personality. These ideas were
popularized and used in areas like criminology and anthropology,
usually to justify racism and inequality, well into the 20 th century.
Bone fractures
A bone fracture occurs when there is a partial or complete
break in the continuity of a bone. The medical field that specializes in
the diagnosis and management of fractures is called orthopedics.
Fractures can be classified according to multiple criteria. Here are
some types of fractures:
a. traumatic fractures are caused by sustained trauma, i.e. high force
impact or stress.
b. pathologic fractures are caused by weakness of the bone. There are
underlying conditions for this weakness, such as osteoporosis, bone
cancer or osteogenesis imperfecta.
c. closed fractures happen when the skin remains intact.
35
d. open fractures happen
when there is a wound
that exposes the bone,
carrying the risk of
infection.
e. linear fractures are
parallel to the bone` s
long axis.
f. spiral fractures happen
when the bone is twisted.
g. avulsions happen
when a fragment of bone
is separated from the
main mass.
h. comminuted fractures
happen when the bone is
broken into several
pieces.
i. incomplete fractures happen when the bone fragments are still
partially joined.
When dealing with fractures as a medical professional, in
order to set a diagnosis, you must rely on history taking, physical
examination, and medical tests and investigations.
History taking
When taking a history for a fracture, you need to focus on
aspects such as the symptoms (the presenting complaint), personal
history, family history, and social history. Identifying the cause and
the circumstances of a fracture is a pretty straightforward process
when it comes to traumatic fractures. However, it can get a bit
complicated when you deal with pathologic fractures.
The patient will most likely complaint about pain, swelling,
stiffness, weakness, instability and loss of function. The description
of pain will probably be something like sharp, sudden onset,
exacerbated by movement, relieved by rest and immobilization.

36
You should ask about the mechanism of injury, the time between the
injury and presentation, previous accident, illness, surgery and drug
use; also, about the patient` s job/work/occupation, what they do in
their free time, smoking and so on.
Clinical study: Foot fracture
A physical exam for foot fractures includes:
- an inspection of the injury for swelling, bruises, open wounds.
- compare the uninjured foot to the injured one.
- palpate for tenderness, swelling etc.
- test the range of motion and joint function, also in comparison with
the uninjured foot.
- explore all the open wounds and do a neurologic exam for motor
and sensory functions.
Testing for foot fractures is usually performed using regular x-rays.
Other imaging techniques may be used, if necessary.
The emergency management of foot fractures usually includes
application of ice, immobilization and elevation of the foot, and
providing analgesia. Antibiotics may be necessary in the case of open
fractures.
There are possible complications with foot fractures, such as
arthritis, infections, instability and posture disturbances.
Osteoporosis
Osteoporosis is a condition in which the bone mass is
weakened. It is usually caused by aging, and more common in
women, due to lower estrogen levels after menopause. Other risk
factors include alcoholism and thyroid dysfunction. Since
osteoporosis has no symptoms, it is often diagnosed as an underlying
condition of a fracture. However, many people, both male and
female, experience pain and a lower quality of life as a result of
osteoporosis.
Osteoporosis can be prevented by adequate calcium and
vitamin D intake, and by regular weight-bearing exercise (e.g.
walking, running). The lifestyle risk factors associated with osteo-
porosis can be modified, for instance, smoking, inactivity, alcohol
and caffeine intake.
37
 In addition to these lifestyle changes, osteoporosis can be
managed using various drugs, like estrogen therapy, calcium and
vitamin D supplements, synthetic equivalents of the parathyroid
hormone etc.

38
 Pumping iron
*the muscular system*

Muscles make up about 40% of the total body weight.

The strongest muscle, based on its size, is the masseter.
The smallest muscles in the body are in the inner ear.
The largest muscle in the body is the gluteus maximus.
The human body contains more than 600 muscles.
1. Fill in the gaps with the right terms:
Functions of muscles
The muscular system` s main function is to allow ________. When
muscles contract, they contribute to ________ and ________
movement. Most muscle movement is under ________ control, but
some movements are ________. Muscle tendons stretch over the
39
________ and contribute to stability. The tendons in the knee and
shoulder are essential for ________. Good posture relies on strong,
flexible muscles. The muscles in the arteries and veins play a role in
________, as they maintain blood pressure. Muscles such as the
________ are involved in breathing. The muscles of the digestive
system move food using a wave motion called ________. Another
important function of the muscles is ________ regulation. Almost
85% of the ________ comes from contracting muscles.
stabilization
fine
conscious
heat
movement
circulation
joints
peristalsis
temperature
gross
diaphragm
reflexive
2. Match the terms with the
definitions:
1. a band of tough fibrous tissue that
connects a muscle with its bony
attachment
2. a sheet or band of fibrous tissue
enveloping, separating or binding
together muscles
3. the point or mode of attachment of a
skeletal muscle to the bone or other body
part
4. the point of attachment of a muscle
that remains relatively fixed during
contraction
5. the cytoplasm of a striated muscle
fiber
40
6. a voluntary muscle made up of elongated, multinucleated,
transversely striated muscle fibers, usually with bony attachments
7. tissue that contracts without conscious control, in the form of thin
layers or sheets, found in the walls of internal organs
8. a muscle that extends or straightens a limb or body part
9. a muscle that bends a joint or limb
10. a muscle that moves limbs away from the center of the body
11. a muscle that moves limbs towards the center of the body
extensor
insertion
skeletal muscle
abductor
sarcoplasm
origin
adductor
flexor
tendon
smooth muscle
fascia
3. Fill in the gaps:
The basic unit of the muscle is called ________, which are arranged
in a stacked pattern through the muscle cells. There can be
thousands of these in a single cell. They contain many parallel
filaments. The thin ones are called ________, and the thick ones
are ________. The sliding interaction between these two proteins
creates shortening. The sliding filament theory claims that the
thicker filaments remain relatively constant in length, while the
thinner ones change their length. However, recent discoveries prove
that the thicker filaments can also be flexible and contract, requiring
the hydrolysis of ________, which breaks high-energy phosphate
bond to release energy.

41
4. Pathology
Rhabdomyolysis is a very serious condition caused by direct
or indirect muscle injury. The death of the muscle fibers lead to the
release of their contents in the bloodstream, which can lead to renal
failure and, in some cases, even death. Various forms of trauma, such
as falling, car accident, lying on a hard surface, or snake venom or
severe burns can cause rhabdo. However, it can also be caused by the
use of heroin or cocaine, extreme muscle strain, high doses of statins
or antipsychotics, hypertermia, ketoacidosis, sepsis or seizures.
The symptoms of rhabdomyolysis are muscle pain in the
shoulders, thighs or lower back, muscle weakness, dark red or brown
urine or oliguria. Other signs include abdominal pain, nausea, fever,
tachycardia, dehydration, and syncope.
To diagnose rhabdomyolysis, blood tests for creatine kinase
and urine tests for myoglobin are used, since both of these proteins
indicate muscle tissue breakdown. Common complications of rhabdo
include dangerously high levels of potassium in the blood
(hyperkalemia), which can lead to cardiac arrest.
Treatment with IV fluids keep the patient hydrated and
prevent kidney failure. In extreme situations, dialysis may be needed.
Sometimes, rhabdomyolysis is only a manifestation of an underlying
condition, such as diabetes or a thyroid condition, which will have to
be addressed.
Polymyositis is a kind of myopathy (muscle disease). It is an
inflammation of the muscles and other tissues like blood vessels that
supply the muscles. The muscles in the shoulders, upper arms, hips
etc. display weakness. There can also be pain or tenderness, difficulty
swallowing, and inflammation of other muscle tissue, such as the
heart. Polymyositis is an autoimmune disorder, which means that
the immune system, for some unknown reason, attacks normal body
cells, causing inflammation. Since there is no known cause,
polymyositis is managed using drugs that suppress the action of the
immune system, called anti-inflammatories, corticosteroids such as
prednisone.

42
Explain the meaning of the following terms:
trauma
statins
hypertermia
sepsis
oliguria
hyperkalemia
myoglobin
dialysis
myositis
prednisone

43
 The nervous breakdown
*the nervous system*

There are more nerve cells than there are stars in the galaxy.
A newborn` s brain grows about three times during the
course of its first year.
The left side of the brain controls the right side of the body
and viceversa.
The nervous system cannot function properly without
potassium and sodium ions.
1. Fill in the gaps:
The human nervous system coordinates voluntary and involuntary
actions and transmits information between various parts. It is made
up of the ________ nervous system (CNS) and ________ nervous
system (PNS). The CNS contains the brain and the ________. The
PNS is made of nerves that connect the CNS to every part of the
body. It includes motor neurons, the ________ nervous system,
44
regulating involuntary
functions, and the
________ nervous
system, which controls
the gastrointestinal
system.
The brain is the part of
the CNS and it consists
of the ________ (large
brain), ________
(small brain), and the
brain stem. The large
brain is divided into two
hemispheres. Within it,
there is a system of four
interconnected
ventricles in which
________ fluid (CSF)
is produced.
cerebrum
peripheral
enteric
autonomic
cerebellum
spinal cord
cerebrospinal
central

45
2. Identify the terms for these definitions:
a. a cell that carries electrical impulses
b. a long projection that conducts electrical impulses away from the
cell` s body
c. branched extensions of the cell that propagate the impulse from
other cells
d. the spherical part of the cell that contains the nucleus
e. the site of transmission of electric impulses between two cells
f. an insulating layer that forms around some nerves, like the ones of
the CNS

Pathology
There are over 600 neurological disorders, but the common
ones include Alzheimer` s disease, Parkinson` s disease, brain
tumors, different forms of dementia and epilepsy. Symptoms of
neurological disorders include headaches, change in vision, weakness
of the extremities, dizziness, impaired speech, memory loss, tremors,
paralysis, seizures, loss of sensation.
When dealing with neurological disorders, a comprehensive
history is taken, because any detail can prove essential in the
diagnostic process. Also, attention should be given to the patient` s
appearance, posture, speech and any other physical or mental clue.
46
So, assessment of a neurological patient includes psychiatric mental
status, cranial nerve status, a motor exam, a sensory exam,
coordination and reflexes. A psychiatric mental status exam
evaluates things like emotional state and narrative thinking. A
neurological status exam tries to assess level of consciousness,
language, memory and visio-spatial orientation.
Alzheimer`s disease is a chronic neurodegenerative condition,
a form of dementia. The early symptom is loss of short-term
memory. As it progresses, other symptoms appear, such as language
dysfunctions, disorientation, mood swings, behavioral issues and
social withdrawal. It eventually leads to death due to the loss of
bodily functions. The life expectancy is three to nine years.
The causes for Alzheimer` s are not very well documented. For
a long time, it was thought to be a genetic disorder that was inherited
from the parents. However, head injuries, depression and high blood
pressure can contribute to the onset of the disease. According to
recent studies, poor air quality can contribute to dementia, so air
pollution is becoming a factor that is taken into account. Exposure to
pesticides is another factor that has recently been taken into account.
Alzheimer` s cannot be cured and the progression of cognitive
loss cannot be slowed down. However, there are a few drugs that can
treat the symptoms and thus improve the quality of life for the
patients.
Epilepsy is a spectrum disorder characterized by seizures,
during which brain activity becomes abnormal. There are many types
of seizures, from staring blankly for a number of seconds to twitching
and convulsing violently, with or without temporary loss of
awareness. There are some drugs that can control the seizures, called
anti-epileptic drugs. Recently, the use of medical cannabis for the
management of epilepsy has been considered, and CBD (cannabidiol)
drugs have been approved for use. CBD has no psychoactive effects
and some studies have found it to be useful. However, research is still
ongoing.

47
Find the meaning of these terms:
tonic seizure
clonic seizure
tonic-clonic seizure
myoclonic seizure
atonic seizure
absence seizure

48
 Pour your heart out
*the cardiovascular system*

Every year, the heart beats approximately 35 million times.

Blood makes up 7% of the total body weight.
A newborn baby has about one cup of blood in circulation.
An adult human has about four to five litres.
The heart pumps blood to almost all of the body` s 75 trillion
cells. The only cells that do not receive any blood are the
ones in the corneas.
The first heart pacemakers were plugged into wall sockets.
The cardiovascular system, or circulatory system, is made of the
heart and blood vessels. Its basic function is to transport blood
throughout the body. Blood transports nutrients, oxygen, carbon
dioxide, hormones, waste etc. to and from the cells.
49
1. Fill in the gaps in the text with the words below:
The heart pumps blood through the blood vessels. It is located
between the ________, and has four chambers, the two
________, which are receiving chambers, and the two ________,
which are discharging chambers. Between these, on each side of the
heart, there are connecting valves: the ________ on the right and
the ________ on the left. The structure of heart is made of
connective tissue and forms septums that separate the chambers.
There are three layers of heart: the epicardium, the myocardium and
the ________. The myocardium, or heart muscle, is made of two
types of cells: ________ and ________. It receives blood from the
________ circulation. The ________ node is a group of cells that
have the ability to produce an electric impulse, causing the heart to
contract and setting its rate.
muscle
mitral
pacemaker
atriums
lungs
sinoatrial
endocardium
tricuspid
ventricles
coronary

2. Match these descriptions

with the terms:
a. vessel that takes blood away from the heart
b. vessel that brings blood towards the heart
c. small blood vessels that supply large vessels
d. largest artery in the human body
e. arteries that supply the head and neck with oxygenated blood
f. vessels that carry oxygenated blood back to the heart
g. largest veins in the human body
h. vessels that take deoxygenated blood from the head

50
aorta
vasa vasorum
vein
jugular veins
venae cavae
carotid arteries
artery
pulmonary veins

For a very long time, it had been thought that the heart is the
most important organ of the body and that it contains the soul.
Aristotle described the heart as the seat of intelligence, motion and
sensation. Since it was considered a hot organ, the lungs and the
brain had the function of cooling it down. Both Hippocrates and
Galen thought that the heart was the organ most closely related to
the soul, even though they also described its anatomy. The systole
and diastole cycle meant that the heart was an intelligent organ.
These ideas were perpetuated in some form or another until the 17th
century, when William Harvey discovered the circulation of blood, a
fact that was not accepted immediately by the scientific community.
3. Read the text and answer the questions:
Blood is a fluid that transports oxygen and nutrients to the
cells and carries away carbon dioxide and other waste products. It is
made of plasma, a clear solution (more than 92% water) of sugar, fat,
protein and salt, and blood cells. Red blood cells (RBCs) are cells
without nuclei that make up about 45% of the total blood volume.
They contain hemoglobin, an iron-based protein that transports
oxygen molecules. White blood cells (WBCs) exist in various
numbers and types, and make up a small part of the blood` s volume.
They are involved in protection against pathogens like bacteria,
viruses and fungi. Also, they remove dead cells and other debris. The
platelets are cell fragments that clot (coagulate) blood, thereby
protecting wounds and damage of the blood vessels. Platelets also
stimulate the immune system. All blood cells are produced in the
bone marrow from stem cells.
51
 Thus, blood performs many functions: it supplies oxygen and
nutrients, such as glucose, amino acids or fatty acids, it removes
waste such as urea, carbon dioxide and lactic acid, it protects against
pathogens, it converts into a gel to protect damaged vessels, it
transports hormones, it regulates the core temperature etc.
The study, management and prevention of blood diseases
makes up the medical field of hematology. Complete blood count
(CBC) tests are used to aid in diagnosing a wide range of medical
conditions.
Anemia is a condition in which a patient has a lower count of
RBCs than normal. Symptoms may include fatigue, shortness of
breath, weakness, syncope (fainting), polydipsia (exaggerated thirst).
Anemia can be caused by blood loss (from trauma or internal
bleeding), insufficient red cell production or increased red cell
breakdown. Usually, the cause for anemia is iron defficieny, since
iron is the essential element in hemoglobin, due to a lack of sufficient
dietary iron intake; however, it may also be caused by genetic blood
disorders (thalassemia) and tumors of the bone marrow. It can also
be caused by infections or autoimmune conditions.
a. What are some functions of the plasma?
b. What are the functions of the red blood cells?
c. What is iron-deficiency anemia?
d. What are some waste products in the blood?
4. Discuss these questions:
a. What might be some causes of high RBC count?
b. What might be some causes of high WBC count?
5. A day in the life ofa cardiologist
My name is Emily and I` m a 2 nd year internal medicine
resident doctor. I just finished my first 24-hour shift in the
Cardiology department.
At 8 a.m. I got a patient who was being transferred to our
hospital because they were having a bad heart attack and they
needed to have an intervention. I contacted my colleague and let him
know that the patient is on their way, with an ST-elevation
52
myocardial infarction (STEMI).
A myocardial infarction, also
known as a heart attack, happens when
the blood vessels that supply the heart
with oxygen and nutrients (the
coronary arteries) get blocked. Part of
the heart stops receiving oxygen and it
starts to die. When heart cells become
damaged, they release a protein called
troponin. So, if I` m worried a patient is
having a heart attack, I check their
troponin levels and get an ECG. During
a heart attack, electricity doesn` t
conduct normally through the heart,
and I` ll see something called ST-
elevation on the ECG. That` s why we
call it an STEMI. Seeing a STEMI
makes me super concerned; we usually
say that time is muscle, so the longer
the blood vessel is blocked, the more
damaged the heart becomes. So it` s
critical to get the patient to the hospital
and open up that blockage.
After 15 minutes, the patient was being wheeled into the heart
investigation unit. With each minute, more damage was being done
to the heart. But the medical team moves quickly and efficiently. A
wire was threaded up an artery in either the groin or the wrist, all the
way up to the heart. The injected dye into the artery to see where the
blockage is. Then, they deployed a balloon to open it up, and a metal
stent was placed there to keep it open. Just like that, blood flow was
restored to the heart.
Finally, we brought the patient to the recovery room and did
the less exciting stuff, the paperwork.
Then, we headed into the ICU to ultrasound a patient` s heart,
looking for something called tamponade. That` s when there is fluid
around the heart that is building up a lot of pressure so it can` t pump
well. Fortunately, the patient did not have tamponade.
Then I moved on to my other patients. The first one had
tachycardia. I thought this had something to do with the pain and the
53
anxiety the patient is feeling. The second patient was complaining of
chest pain, and I thought it might be pericarditis, which is when the
sack around the heart gets inflamed. So I started the patient on anti-
inflammatories and I sent off bloodwork to look for causes of the
pericarditis.
I then got a message about a patient who was very nauseous,
one of the cardiac patients. Nausea and vomiting can be related to
the heart and a heart attack; however, it did not seem to be the case,
but I went to see the patient and make sure it` s nothing too serious,
maybe try to make them feel a little better.
Answer these questions:
a. What is a heart attack?
b. What is coronary artery disease?
c. What is pericarditis?
d. What is troponin?
e. How do you manage a heart attack?
f. What was the immediate treatment for pericarditis?
Research and explain these concepts:
a. atherosclerosis
b. ischemia
c. arteriosclerosis
d. thrombus
e. embolus

54
small intestine
esophagus
liver
stomach
pancreas
gall bladder
large intestine
epiglottis
oral cavity
a. the first part of the gastrointestinal tract
b. structures that mechanically break down food
c. a flap in the pharynx that prevents food from entering the trachea
d. glands that produce salivary amylase
e. an organ that produces bile
f. an organ located behind the
stomach
g. a small organ where bile is
stored
h. a muscular tube that
stretches between the
pharynx and the stomach
i. an organ made of the
duodenum, jejunum and
ileum
j. an organ that contains
hydrochloric acid
k. the last part of the
gastrointestinal tract
l. a tube through which food
and liquids travel

62
2. Match the technical terms with non-technical
equivalents:
esophagus
bile
gastro-esophagial reflux
cholecyst
intestines
pharynx
heartburn
gall bladder
gullet
gall
gut
throat

3. Read the text and answer the questions:

Gastritis is an inflammation, irritation or erosion of the lining of the
stomach because of high gastric acidity. It can be either acute or
chronic. It is caused by excessive alcohol use, stress or medication
such as aspirin and other anti-inflammatory drugs. It can also be
caused by an infection with the bacterium Helicobacter pylori, and
other pathogens.
The symptoms of gastritis include nausea, abdominal pain,
vomiting, indigestion, hiccups, loss of appetite and vomiting blood.
The diagnosis can be confirmed by using endoscopy, which is a
technique in which a long tube with a camera is passed through the
esophagus and into the stomach, so that the stomach mucosa can be
directly inspected.
The treatment for gastritis depends on the cause. However,
antacids can help decrease the gastric pH levels. If the cause is a
Helicobacter infection, the treatment will include antibiotics. Some
dietary changes will be made, such as avoiding spicy foods, dairy
products and wheat gluten.
Another bacterium that commonly infects the gastro-
intestinal tract is Escherichia coli. While various strands of E. coli
naturally live in our gut, some types can cause severe abdominal
63
cramps, bloody diarrhea, nausea and vomiting. E. coli is typically
ingested with contaminated water, raw or undercooked vegetables or
beef. The bacteria can also be transmitted from person to person,
when the infected ones do not wash their hands properly. Young
children are especially at risk of developing complications from the
infection.
There is no cure for an E. coli infection. The patient will be
advised to stay hydrated, rest, avoid dairy products, fatty and high-
fiber foods which can make the symptoms worse. It is not advised to
take anti-diarrheal medication because that is the way the body
eliminates the toxins.
a. What are the causes ofgastritis?
b. What are hiccups?
c. What are some lifestyle changes in the treatment of
gastritis?
d. How can one become infected with E. coli?
4. The microbiome
The human gastrointestinal microbiota, or gut flora, are the microbes
that live in the human gastrointestinal tract. Between 2007 and 2016,
the US National Institutes of Health employed the Human
Microbiome Project, an initiative that sought to identify and
understand the gut flora. The project focused on mapping the
metagenome and genomic sequencing. It appears that we have three
times more microbial cells than human cells in our bodies, and their
influence on physiology and pathology is still not entirely
understood. The gut flora develops in the first two years of life in a
symbiotic relationship with the intestinal mucosa. For instance,
human gut flora helps in fermenting dietary fGi
1. Identify the components of the urinary system:
renal artery
adrenal gland
common iliac vein and artery
urinary bladder
liver
ureter
kidney
ureter
pelvis
urethra
inferior vena cava
abdominal aorta
renal pelvis
large intestine

2. Fill in the gaps in the text:

Adult humans produce about 1-2 liters of urine every day, depending
on hydration levels, environmental factors, general health etc.
________ is the production of excessive urine (> 2.5 liters/day),
while ________ is the production of less than 400 milliliters per
day. The first stage in the production of urine is the filtration of blood
by the ________. Their basic structural unit is the ________,
whose function is to regulate the water concentration and substances
like sodium. It reabsorbs what is needed and excretes the rest as
urine. The urinary system is controlled by ________, such as the
parathyroid and the antidiuretic.
Urination happens when urine is expelled from the
________ through the ________. This process is under voluntary
control.
nephron
bladder
kidneys
polyuria
urethra
67
oliguria
hormones
In the Middle Ages, the examination of urine was the standard
diagnostic procedure, so much so that the image of the special round
flask used by physicians became a symbol of medical practice.
Medieval practitioners had urine color charts which they referred to
in assessing the patient` s health. In addition to color, smell and even
taste were relevant indicators. One English physician described the
urine of a diabetic patient as “wonderfully sweet as if it were imbued
with honey or sugar.” This practice was, obviously, based on the
Galenic theory of the four humors.
3. Read the text and answer the questions:
The most common conditions that affect the urinary system are
urinary tract infections. These may be lower urinary tract infections
(cystitis) or upper urinary tract infections (kidney infections). Lower
UTIs are less severe than kidney infections; their symptoms are
frequent urination, burning or stinging pain while urinating and an
urge to urinate even when the bladder is empty. Kidney infection
symptoms are similar, but may also include fever. The most common
pathogen is E. coli, but some fungi like Candida albicans can also
cause UTIs (“yeast infection”). Females are more prone to developing
UTIs due to a shorter urinary tract. Diagnosis is usually based on the
symptoms, and the treatment include antibiotics or antifungals,
depending on the cause.
Kidney stones (urolithiasis) are another common condition
affecting the urinary system. Urolithiasis happens when a solid piece
of material develops in the kidney and then move through the
urinary tract, eventually being expelled. If the stone is larger than 5
mm, it can block the ureter, causing severe back or abdominal pain.
Other symptoms may be hematuria (blood in urine), vomiting, and
dysuria (pain while urinating). The stones form due to genetic and
environmental factors. High calcium intake, improper hydration and
hyperparathyroidism may cause kidney stones. The diagnosis is
confirmed using imaging, and blood and urine tests. Treatment for
urolithiasis includes medication, shock wave lithotripsy, a technique
in which the stones are broken down with ultrasounds, and surgery
68
to remove the stones.
Chronic kidney disease occurs (CKD) when there is a loss in
kidney function. Symptoms of chronic kidney disease include fatigue,
vomiting, loss of appetite. Complications include heart disease, high
blood pressure, anemia. Kidney function is tested using urinalysis,
usually looking for protein or RBCs in the urine, and blood tests,
such as the blood urea nitrogen (BUN) test. Chronic kidney disease
cannot be cured, and the lost function cannot be recovered. The
normal kidney function can be replaced by dialysis or kidney
transplant.
a. What is cystitis?
b. What is a yeast infection and how is it treated?
c. What are kidney stones?
d. What are the causes of kidney stones?
e. What is lithotripsy?
f. What are some symptoms of CKD?

69
 Here comes the stork
*the reproductive system*

The male sperm is the smallest human cell, while the female
egg is the largest.
The earliest written record of contraception is found in the
Egyptian Gynecological Papyrus from about 4000 years ago.
For a long time, the descriptions of the female reproductive
system were done using the terms of an inverted male
reproductive system.
At some point in the evolution of life on this planet, sexual
reproduction appeared and was maintained in multicellular
eukaryotes, in opposition to the asexual reproduction of the
prokaryotes. According to the latest discussions, why this happens is
a mystery because sexual reproduction consumes more resources
than the asexual one.
70
The male reproduc-
tive system has one
function, which is to
produce sperm, the
male reproductive
cell. The female
reproductive system
has two functions, to
produce egg cells
(ova) and to protect
and feed the fetus
until birth.
1. Identify the terms for these definitions:
a. an external organ that also serves as part of the urinary tract
b. pouch-like structure that holds and protects the testes
c. tubes in which sperm cells mature
d. a tube that carries sperm cells into the ejaculatory duct
e. organ that releases an ovum (egg)
f. tubes that carry the egg into the uterus
e. the lower part of the uterus
g. the muscular part of the female genital tract

71
2. Fill in the gaps with the terms below:
Pregnancy is divided into three trimesters. The first one includes
conception, when the ________ fertilizes the ________. The
fertilized egg, or ________, travels down the ________, which
can take about a week, while cell division continues at a fast rate.
Then, the ________ attaches to the ________, a process known
as implantation. This phase is called ________, and it lasts for
about ten weeks. The cells begin to differentiate into various body
systems. Some structures to support the embryo develop, like the
________ and ________. After this stage, the embryo becomes a
________, with a clearly identifiable heartbeat and erratic
movement, and it continues to grow until birth.
fallopian tube
endometrium
blastocyst
sperm
fetus
egg
umbilical cord
embryogenesis
zygote
placenta
The search for sex
Historically, there have been multiple theories regarding sexual
differentiation, from the genetic approach, to the endocrine
approach, to combinations of these, to neuroscientific approaches.
For instance, Aristotle believed that the heat during intercourse
determined the sex of the future baby; if the man released more heat
than the woman, the baby would then be a male, and viceversa. As
weird as this may sound, this is an accurate description of how sex
differentiation works in reptiles: the temperature of the nest
influences the sex of the offspring. This environmental theory of sex
determination was widely used until the beginning of the 20 th
century, when two chromosomes were discovered, the X and the Y.
72
Two conflicting theories emerged: one said that the presence of the Y
chromosome determines the male sex, and the other said that sex
differences are scattered throughout the genome, and not exclusively
found in one (or two) chromosomes. The first one became the widely
accepted theory. Later on, the discovery of the SRY gene on the Y
chromosome prompted the theory that, for instance, people with
XYY chromosomes were aggressive males. At the same time,
maleness was described as a lack of a second X. Sexual
differentiation was then carried on by hormones, especially
testosterone.
What we all need to understand is the fact that until very
recently medicine in general and research in genetics and genomics
in particular were paternalistic, male-centered practices. Women
were not accepted in the scientific community, and research had a
very strong male bias. Today, however, things have changed, and we
know that the Y chromosome is an evolution of an X chromosome
that lost a lost of its genes, we know that the role of hormones or that
of the SRY gene are not the essence of masculinity. Moreover, today
we know that things are a lot more complicated when it comes to
sexual differentiation, and even the “male and female brains” are
actually very plastic organs that can change the way they work in
accordance to environmental stimuli and factors. The new theories of
epigenetics and post-genomics can elucidate some of the mystery
regarding sex, but it appears that there are a lot of things to look out
for.

73
 We`re all*socialinmedicine*
this together

In 1978, the World Health Organization issued a statement,

the “Declaration of Alma-Ata,” in which governments and public
officials decided to make healthcare available for all people. This
Declaration is still probably the most important document of the
WHO in regard to its mission to universalize healthcare.
Governments and other public officials decided back then that, by
the year 2000, every person will have access to medical care.
Obviously, they failed.
Medicine under capitalism
Ah, capitalism! Sometimes we might feel that it has become
so ingrained in our lives that we can no longer think of it as a socio-
economic construct, but more as the state in which things were, are
74
and forever will be. If this is quite a depressing thought, rest assured
that it is not the case. When we think about capitalism we probably
think of brands, big business corporations and so on, but capitalism
is so much more. It transformed and it keeps transforming the very
fabric of our society, with its insistence on ideas like individualism,
free market and consumer culture. Of course, individualism and
individual responsibility are just nice ways of saying that we are
encouraged to be selfish; the free market, with its “natural” logic of
supply and demand, might also seem cute, but it eventually leads to
deep social inequalities. The promoters of modern-day neoliberal
capitalism seem to argue that crises are an integral aspect of
economic and social development, but somehow the rich
corporations keep being bailed out by the states.
What is probably more interesting is the way in which
capitalist discourse normalizes poverty and social inequality based
on the concept of “meritocracy.” Technically, this means that the rich
and middle class have “merit,” while the poor deserve to live in
poverty because they do not have this “merit.” This is by no means an
old idea. Actually, we have to thank or blame (depending on where
you stand) that famous short French guy. This mythical “merit” was
turned into government policy by Napoleon, who promoted the
transition from an aristocratic order (based on inherited social
standing) to one based on ability.
So how does capitalism influence medical practice? One
British doctor, for instance, says that general practitioners have
become suppliers of services for the National Health Service (NHS),
owning a “private business” from which the NHS purchases those
services. “This change of my identity – from an individual
professional to a business – is no random event. […] It reflects an
ideological shift […] in the name of the political and economic
movement known as neo-liberalism.” Modern-day medical systems
operate in terms of “competition,” “market,” “profit,” “efficiency.” Of
course, it is not merely a change in language, but one in the essence
of these systems; they are becoming commercial enterprises, giving
up their status as public services. The NHS, for instance, outsources
medical care to private companies; however, this does not mean
better medical care or shorter waiting times, only more money in
corporate accounts. Everything ends up being run like a business.
This model of medicine under capitalism also gives up
75
“patient-centered care” in favor of “consumerism.” The patient is no
longer a person in need of medical assistance; this is the age of
“consumer-driven health care.” And the customer is always right.
The special relationship between doctor and patient, based on
mutual trust, communication and understanding promoted by the
patient-centered model turns into a specific buyer-seller
relationship, leading to a loss in professionalism.
The market rationality under which medicine is operating
more and more can be observed in the big pharma business. As
patients, we are exposed to the pharmaceutical industry` s
advertising practices on a daily basis. However, that is not where the
big money are spent; in 2012, the pharmaceutical industry spent $3
billion on consumer advertising, but $24 billion on marketing to
physicians in the US alone (probably because elsewhere it is illegal to
advertise prescription drugs directly to consumers), in order to
influence their prescription choices. The doctors received further
incentives like gifts.
Medicine for the people: a bit ofcholera, some typhus and the
revolution
The concept and practice of social medicine stand as a form of
resistance in the face of the capitalist transformation of medicine
into a business. Usually, when we talk about social medicine, we refer
to its more obvious aspect, the social activist one. However, social
medicine has also something to do with “public health.”
1854, London. Having doubted the miasma theory, that said
that some diseases are caused by bad odors, and having published an
essay on cholera epidemics, stating that cholera was communicated
by pollute water and had a higher incidence in the crowded living
spaces of the poor, John Snow was very concerned about a recent
outbreak of the disease on Broad Street. By talking to the locals, he
decided that the source was a certain water pump, which was
subsequently deactivated by the local authorities. Snow did not yet
understand how cholera was propagated through water (the germ
theory was proposed in 1861), but his interventions managed to
promote better sanitation facilities.
1848, Upper Silesia (modern-day Poland). Rudolf Virchow,
later known as the founder of cellular pathology, was on a trip to
76
investigate the causes of a typhus outbreak. He found the diagnosis
to be “spotted fever” (actually, it is a bacterial infection), but that is
less relevant. What is more important is that he found the causes for
the epidemic: the famine that had struck the poor Polish peasants
because of crop failures due to bad weather. Virchow identified
poverty (associated with a lack of education) as caused by the
peasants` political and economic oppression. Thus, only by
eliminating social inequalities would further outbreaks be prevented.
He went on to become a political activist, a socialist, a revolutionary,
and he published a journal called Die Medicinische Reform, in which
he wrote his famous line: “medicine is a social science, and politics
nothing but medicine at a larger scale”; as a politician, he also
advocated for safe drinking water, sanitation, hygiene, vaccinations
and so on.
Social medicine is this two-fold practice: social activism not
only for health care, but also for improved housing, better quality of
life, better working conditions etc. These two directions were
explicitly developed in the 20 th century in Latin America, through the
interventions of doctors like Ernesto “Che” Guevara and Salvador
Allende. Guevara, the famous Argentinian revolutionary, employed
social medicine as a means of improving the lives of Cuban peasants;
this social medical pathology included access to medical care, but it
was built on a grander foundation of access to better food, electricity
and other services, housing etc. In Chile, Allende claimed that an
improvement in health care would only be possible if capitalist
exploitation was to come to an end. High-tech medical institutions,
claimed Allende, serve no one if only the rich can afford them.
Instead, medicine should serve the communities. We can easily see
how Virchow` s legacy was alive and well in these situations, and it is
only obvious that such a development occurred in one of the poorest
regions of the world. Latin America became the gold standard for
social medicine, both as political and social activism, and as an
interrogation into what we call today the “social determinants of
health.”
Slowly, but surely, social medicine found its way into the
mainstream. The famous World Health Organization “Declaration of
Alma-Ata” (1978) is, basically, the document that turned social
medicine into an official position: “[...] health, which is a state of
complete physical, mental and social wellbeing, and not merely the
77
absence of disease or infirmity, is a fundamental human right […].” It
goes on to notice the “gross inequality” that can only be solved
through “economic and social development” to reduce the gap
between various countries.
“Primary health care […] includes at least: education concerning
prevailing health problems and the methods of preventing and
controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and
child health care, including family planning; immunization against
the major infectious diseases; prevention and control of locally
endemic diseases; appropriate treatment of common diseases and
injuries; and provision of essential drugs.”
Health care, according to the Declaration, does not only consist in
actual medical practices, but has something to do with education,
food and water, immunization etc. The document also states that
large sums of money that were spent on military conflicts and
armament could be used instead for the development of universal
health care, which seemed like an attainable goal by the year 2000.
A socialist perspective, one might say. And as it is customary
to have an allergy to words like “social” and “socialism” in this part of
the world and in many others, the Alma-Ata declaration remains a
symbolic gesture. Market-oriented neoliberalism is incompatible
with a vision of universal health care and with social medicine. In a
gesture of utter hypocrisy, the almost 200 member states of the
WHO gathered in 2018 to allegedly reinstate the spirit of Alma-Ata in
a new declaration. The Declaration of Astana changed the focus from
the social aspects that were so prominent in Alma-Ata towards
different and more recent ones, such as “unhealthy lifestyles and
behaviors,” “insufficient physical activity and unhealthy diets,”
tobacco and alcohol use, but also mentioned some other factors like
wars, violence, epidemics, climate change and antimicrobial
resistance. However, there is a hint of neoliberalism that plagues the
Astana declaration. Firstly, there is no mention of the underlying
social conditions that affect medicine. Secondly, the solutions are
found to be investing money in health care and technology, which is
to say a support for corporations, empowerment of individuals,
which probably means individual responsibility in the face of disease,
78
and also a more “efficient” spending on medical care services. One
cannot help but feel that the ideals of Alma-Ata have been betrayed
and that the “new economic order” suggested in 1978 turned into
neoliberal capitalism in 2018.
Social determinants ofhealth
In 2003, the WHO published a report on the social
determinants of health in Virchowian tradition, noticing that the
poor have shorter life expectancies and more illnesses than the rich,
even in developed countries. The report analyzes some key aspects of
social life, like stress, social exclusion, working conditions,
unemployment and access to healthy food.
Stress
When people are worried, anxious, unable to cope with daily life and
insecure, they have a higher incidence of physical and mental issues,
and also premature death. In stressful situations, our bodies`
hormones and nervous systems react by triggering the “fight, flight
or freeze” response: elevating heart rates, diverting blood to the
muscles, increasing alertness. Chronic stress affects the
cardiovascular and immune systems, and might lead to infections,
diabetes, high blood pressure, heart attacks, strokes and depression.
Early life
Studies have found that adult health is influenced by early childhood
and even by intrauterine life. Slow growth leads to a lifetime of
physical issues. Deficiencies in nutrition during pregnancy and
maternal stress, maternal smoking and alcohol use influence the
baby` s development. Insecure emotional attachment leads to poor
educational outcomes and, eventually, social exclusion. Slow physical
growth is associated with cardiovascular, respiratory, pancreatic and
kidney development.
Social exclusion
Poverty, material deprivation, social exclusion and homelessness
have a great impact on a person` s health. Poverty means that a
person cannot afford decent housing, education, transport, food and
so on. Apart from premature death, social exclusion increases the
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risk of cardiovascular conditions.
Working conditions
Poor working conditions, job insecurity and the lack of social support
in the workplace, i.e. jobs with high demand and low pay lead to
cardiovascular conditions like coronary artery disease, and also to
low back pain and other musculoskeletal conditions, and mental
issues.
Unemployment
Being unemployed leads to chronic stress, anxiety and depression,
heart disease, and a much higher risk for premature death.
Social support
It has been shown that social integration and mortality are related.
Those that lack a social network and support system are more likely
to experience less well-being and more depression. In societies where
there is a high level of inequality there is also a low level of social
cohesion. Studies have found that the risk for developing coronary
artery disease is higher in people that do not have meaningful social
relations.
Addiction
Socio-economic disadvantage is linked to alcohol dependence,
smoking and illegal drug use. To escape the pain of difficult social
and economic conditions, poor people resort to the cheapest means
of having fun, that is, using alcohol and smoking. Of course, this
leads to increased poverty and a worsening health.
Food
Malnutrition refers to various forms of medical conditions caused by
poor diets. Food shortages can lead to deficiencies, but over-
consumption can also lead to cardiovascular conditions, cancer,
obesity and other illnesses. The poor are more at risk because they
tend to eat cheaper processed food, with high sugar and fat contents.

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 Medicine and the overheated planet
If there is one thing that the Declaration of Astana (2018) got
right, it is the fact that climate change is one of the major factors
affecting contemporary public health. Since climate change is the
main aspect of this supposedly new geological period, the
Anthropocene, we could safely assume that it is the most important
factor affecting medicine. Climate change affects every other social
determinant of health, but it also affects working in medicine. Some
Western medical schools even started to include aspects related to
climate change in their courses.
The very concept of climate change might be defined as a
release of carbon in the atmosphere (from the burning of fossil fuels),
which in turn creates a “greenhouse effect,” thus overheating the
planet very, very fast. Before the industrial revolution of the 19 th
century, the global temperatures were about 1 degree lower, so
researchers believe this warming is caused by human activity.
Following this rise in global temperatures, the ice caps start to melt
and sea levels begin to rise. But there are other anthropogenic causes
of climate change: deforestation, pollution, overpopulation, intensive
agriculture etc. The effects of all these factors are extreme weather
phenomena, changes in the patterns of seasons, diminished water
supplies, worsening air quality, extinction of species and a loss of
biodiversity etc.
We have yet to understand the effects climate change has on
medicine and health in general. What we do know is the fact that, for
instance, due to seasonal changes, the pollen and allergies season
lasts much longer, so the incidence of asthma is higher than in the
past. We also know that infections and communicable diseases are
influenced by climate change, especially those that are vector-borne.
A vector-borne disease is an infection in which the pathogen is
transmitted through a host – or vector – usually insects. These are
poikilotherm, or “cold-blooded,” animals, and their body
temperature depends on external factors such as temperature and
humidity. As a result of global warming, these insects change their
behavior and their habitat, moving further north (in the Northern
Hemisphere), and bringing pathogens with them. For instance,
Aedes aegypti (also Aedes albopictus), the yellow fever mosquito
that can spread a whole range of diseases that have been traditionally
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identified as “tropical”: the dengue virus, the chikungunya virus, the
Zika virus, the Mayaro virus, the yellow fever virus and many other
pathogens. Another example of a pathogen that is becoming more
common in temperate climates is the West Nile virus which is also
transmitted through mosquito bites. Malaria, a parasitic infection
(Plasmodium) can now affect people living at high altitudes in South
America, for instance. On the other hand, in the North Atlantic,
infected oysters that carry Vibrio parahaemolyticus bacteria caused
gastroenteritis. All these diseases are not endemic to these areas and
are triggered by the warming climate. Lyme disease, caused by the
bacteria Borrelia and carried by ticks, has been affecting more and
more people in northern areas like Canada or the UK.
In Europe, one in every twenty people over 65 suffer from
Alzheimer` s disease. Together with an aging population, this number
is expected to double in the following period in Western Europe. In
Eastern Europe it is expected to triple by 2040. New research
suggests that Alzheimer` s disease is associated with air pollution.
Generally speaking, air pollution is associated with cognitive decline;
the World Health Organization estimates that 91% of the world` s
population lives in places where the air pollution levels exceed
recommended guidelines. Particulate matter, abbreviated by
researchers as PM, contains various noxious chemicals such as
nitrogen and sulfur oxides, carbon monoxide, metals, carbon,
sulfates and so on. Ultrafine PM is able to reach the brain and cause
cognitive decline and dementia.
Due to climate change, the Arctic permafrost, in places like
Greenland or Siberia, is thawing. Whatever is frozen in that soil will
be released. If this sounds like a Hollywood-style dystopian movie, it
may well be so.
In 2014, reindeer and humans alike from some forgotten part
of Siberia died from an infection. Bacillus anthracis, also known as
anthrax, was released from the warming permafrost into the water
supplies. Anthrax spores can survive in a latent state for more than a
century. When the conditions become favorable, which is what
happens when the climate is getting warmer, they activate. The
anthrax case proves that there are bacteria and viruses that are
frozen in the permafrost, pathogens that medicine is not really ready
to deal with. There are even studies that show that some permafrost
bacteria already have antibiotic resistance genes.
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 Will there be any medicine in the Anthropocene?
The ideal of universal health care seems to be very distant
right now. In the circumstances of climate change, humans seem
attacked by all sorts of plagues. If there is something that social
medicine teaches us, it is a new form of holism, the fact that we are
not isolated individuals, but parts of the social fabric, parts of our
environment, and, in turn, society, the environment and the other
species are part of who we are. So this prompts the question whether
or not there will be any medicine in the Anthropocene, and if yes,
how will it look like?
Climate change causes the extinction of plant life in places
such as the Amazon. Since plants are essential for about 10% of our
pharmaceuticals, we must be aware that they will probably not be
available anymore, or they may not be as available as they are now.
The migrating disease vectors and the pathogens they carry, together
with the not-so-remote possibility of a post-antibiotic age paint a
gruesome picture of the difficulties to come for medicine. On the
other hand, living longer lives and having less children than in the
past, especially in the developed and overdeveloped countries, means
that age-specific diseases will be more common. Also, access to
medical care in the age of declining demographics might be more
difficult, since there will be less people to contribute to government
healthcare programs.
What do you think are the challenges medicine will have to face in
the coming decades?

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 Who watches the watchers?
*autoimmunity*

The story of autoimmunity is quite fascinating, from its discovery, to

the very physiology of these disease, which is not yet well understood
by the medical field. Autoimmune disorders appear as a result of the
immune system going haywire and attacking normal body cells. We
don` t actually know why this happens, but research is under way.
To understand what autoimmunity is, we need to look back at
the history of medicine, probably as far back as Hippocrates and
Galen, and the theory of the four humors. Or maybe start from the
Ancient miasmatic theory of disease? Or from the 19 th century germ
theory? All of these, actually...
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 In the 18 th century, an Englishman called John Fewster
realized that prior infection with cowpox would render the person
immune to smallpox, or variola, which killed about half a million of
Europeans every year. Edward Jenner, a physician, hypothesized
that the pus in the blisters of the milkmaids made them immune
against smallpox, and used the pus to inoculate some of his patients.
Noticing that this method works, i.e., infecting a patient with cowpox
to prevent smallpox, Jenner described this method as vaccination
(from the Latin vacca, cow), and quickly became the hero of all
Western Europe. Of course, Jenner didn` t actually know how this
whole thing works, in the absence of the germ theory. But it was way
better than blood letting and the occasional mercury that were used
at the time for basically any disease.
After the discoveries of Pasteur and Koch from the second half
of the 19 th century, the germ theory of disease was starting to be
more and more accepted, competing with the miasmatic/humoral
theory. The fact that pathogens were the cause of disease meant that
doctors would start looking for microbes to explain any medical
condition. For instance, Pasteur thought of immunity as microbes
thriving in certain nutritive environments, like today` s agar plates,
so health could be restored by basically starving the pathogens. We
can thus see the difference between the germ theory, which says that
disease comes from the outside in the form of microbes, always as an
infection, and the theory of the four humors, which says that there is
a humoral imbalance within the body. For instance, the researchers
at the end of the 19 th century looked for the pathogen that could
explain rheumatoid arthritis; the others, using the more traditional,
older perspective, were focused on neurological causes using the
theory of the four humors or the miasmatic theory, and referring to
most disorders as “nerve diseases.”
At the beginning of the 20 th century, Metchnikoff, a doctor
from Paris, came up with the idea that phagocytes swallow and digest
invaders: “When one accepts the concept that phagocytes fight
directly against pathogens, it becomes understandable that
inflammation is a defense mechanism against bacterial invasion.”
Koch, on the other hand, and perhaps surprinsingly, was a proponent
of humoralism and what he called “antibodies,” humoral elements
involved in immunity. The question was what exactly determines
immunity.
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 In 1902, a physician called Richet introduced the concept of
anaphylaxis as a reaction of the immune system to a foreign
substance, and in 1906 Pirquet came up with the concept of allergy,
as “the change in condition after contact with any organic poison, be
it inanimate or animate.” Both anaphylaxis and allergy were concepts
designed to explain what we refer to today as “autoimmunity.”
However, most physicians were not interested in discovering the
intricacies of the immune system, and believed that it was only a
defense mechanism. Thus, they explained asthma, for instance, as a
nervous or even mental condition. The point was to find the microbe
and kill it. This led to some very dubious practices, like the one in
Britain, where they vaccinated patients with pollen to prevent
allergies, treating pollen as a toxin.
In 1932, a researcher called Thomas Rivers was injecting some
emulsion made from the brain of rats into the brains of some rhesus
monkeys. At some point, noticing the strange behavior of some of his
monkeys, Rivers identified demyelinating encephalitis; he thought
that the body attacked its own tissue and destroyed the myelin
sheath. Eventually, he called the condition “experimental allergic
encephalomyelitis.” Rivers: “To me, it is a profound biological
phenomenon to learn that the tissues of a person or animal can
create antibodies that will result in disease or the death of that
person or animal.” As we can see, the term “allergy” was used to
denote a hyperactivity of the immune system.
This ambivalence towards autoimmunity went on throughout
the 40s and the 50s. In the 40s, the concept of autoimmunity started
to be employed in reference to systemic lupus erythematosus (SLE)
and rheumatoid arthritis, and autoimmunity began to be perceived
as a legitimate cause for disease, alongside germs; however, it was
still seen in terms of an allergic reaction, as “auto-allergy.” In 1948,
the link between lupus erythematosus (LE) cells and gamma globulin
(an antibody) was discovered, prompting the hypothesis that “the LE
factor could be an auto-antibody to nucleoprotein or DNA,” and thus
describing SLE cause as the immune system attacking DNA.
However, autoimmune diseases were only understood as
“rheumatic” disorders, that is, as connective tissue or collagen
disorders, which is why even today we refer to medical immunology
as “rheumatology.” All these diseases, from lupus to hemolytic
anemia, to Hashimoto` s thyroiditis and multiple sclerosis, were not
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only a medical issue, but a philosophical one. How was it that the
body worked against itself? The problem of how the immune system
recognizes foreign bodies became the question how does the body
recognize itself? Medicine was in need of a theory of subjectivity,
which it found in the theory of clonal deletion. Basically, the theory
says that some WBCs, the ones that recognize the self, are destroyed
through apoptosis (programmed cell death) before they can become
active.
The impact of autoimmune conditions on patients back in the
60s and 70s was devastating. There are many accounts of patients
suffering from the mental turmoil and struggling to accept the fact
that their bodies have turned against them. Even today, living with
autoimmunity means facing a lifelong battle not against some
pathogen, some foreign body, but a battle for living with oneself.
There is no cure for autoimmune conditions. However,
medication such as corticosteroids are used to suppress the action of
the immune system and help with the symptoms. According to newer
approaches, just by limiting some dietary intake of sugars,
carbohydrates and processed foods, and increasing the amount of
good oils and fatty acids might help to reduce the inflammation.
As we can see, the development of an understanding of
autoimmunity is a kind of return to the Hippocratic theory of the
four humors, to the idea that the cause of disease might be an
imbalance within the body. Likewise, it is a return to the
individualized and personalized medical care that Hippocrates used,
because there is no other way to deal with autoimmunity, which can
take so many forms and can have so many aspects that, in the end,
what works for one patient might not work for the next.

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