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PREGUNTAS HISTORIA DE LA MEDICINA 2013

1. Discuss the contributions of paleopathology to the history of disease.


The paleopathology is the study of the rest of the diseases, and the paleontology is the study of the prehistoric life and fossils. They are different disciplines that allow us to study the relationship between the diseases and the society as the time goes by. The paleopathology investigates with experimental methods the historical evolution of the living beings. This science demonstrates that diseases have been present from the beginning of times and they were always related to death if not treated. The initial moment that humans live in a complete harmony with nature is a principle that is present in many cultures. On the other line of thinking, the scientific thinking shows that this is only a myth, illusion, since every testimonies show that live and death are the two sides of the same coin. This comes from the paleontology and the paleopathology: the end of the myth of paradise. Disease is a universal phenomenon and permanent. In fact due to this presence in every human group determined the huge amount of diverse cultural patterns. The image of the body, health, disease, life or death have a totally different and concrete sense within the cultural contents of each region, and with a direct relationship with religious and cultural elements that have been growing and enriching in the proper history tradition. If we observe the present world we see that there are many differences of the reasons of dying, diseases, due to the plurality of society and cultural responses. This plurality of social and cultural responses in front of the universal phenomenon, disease and death give us to consider in a wide sense too many different sources of medical activity. In general, all societies, had to face the treat of disease. How they faced the diseases, is analyzed by paleontology (history of prehistoric life) and paleopathology (remains of diseases). We have limitations, we dont have documents or texts, and also orality is impossible, having just the remains to build the history. We can study the remains and the distribution of diseases thanks to the new technology. This is the oldest approach to the origins of the diseases, after giving up the theory of the paradise. To end up, is important to have into account that from this perspective, every idea, belief, valuation and behavioral pattern related to health and disease that, in each case, tradition has been socializing, is nothing more than the sediment and historic inheritance that have conformed the cultural tradition. For this reason, the occidental medicine inside the scientific community only represents one of the big quantities of human culture (but an important one).

2. Define historical epidemiology and epidemiological patterns


La epidemiologa histrica es la disciplina encargada del estudio de la distribucin de las enfermedades en los distintos grupos sociales en el pasado (importante, es la definicin de su ppt). Se encarga por tanto de determinar las diferentes enfermedades que han aparecido a lo largo de la historia, su peso especfico en cada poblacin y momento preciso de la historia y los determinantes que explican dicha distribucin. El principal problema de esta ciencia es la escasez e imprecisin de las fuentes que utiliza. De periodos muy antiguos, apenas podemos basarnos en la paleopatologa, que es la ciencia que estudia la enfermedad a partir de restos antiguos (por ejemplo un crneo prehistrico que nos indique a simple vista una determinada enfermedad sea, pero tambin tcnicas genticas o de imagen aplicables a estos restos). A esto hay que sumarle poco a poco trazas escritas o dibujadas y ya ms adelante verdaderos registros como los registros parroquiales de finales de la Edad Media o el Registro Civil (en Espaa en el ao 1875). A partir de todo ello, la epidemiologa histrica trata de definir las enfermedades socialmente dominantes, es decir aquellas que caracterizan a una sociedad, grupo social o territorio. Partiendo de este concepto, podemos definir un patrn epidemiolgico como el conjunto de enfermedades socialmente dominantes y su distribucin en una poblacin y periodo concretos. La epidemiologa histrica ha tratado pues de asociar periodos histricos con patrones epidemiolgicos concretos. Por ejemplo, el patrn epidemiolgico de finales del s. XIX y principios del s. XX corresponde a enfermedades infecto-contagiosas crnicas (como la tuberculosis o las enfermedades venreas) ligadas al proceso de industrializacin y a una sanidad pblica e higiene deficitarios.

3. Explain the different epidemiological patterns in the history


The epidemiological patterns show us the distribution of types of disease at any population. Along the history, we can differentiate five patterns: A. Great acute infectious-contagious epidemics/plagues. Firstly, infectious-contagious diseases refer to diseases that appear and disappear in short periods of time and cause high mortality rates. These diseases were present from the Antiquity until the end of the 19th century in Western, industrialised societies. However, nowadays they are present in poor countries. This period of time was marked by wars, plagues and famine (hambrunas) which resulted in the emergence of this type of diseases: Main social diseases: pest, yellow fever, small pox, choleraSome of them like pest became pandemics. B. Chronic infectious-contagious diseases Diseases closely linked to development of industrialisation and deficient public health facilities. Due to industrialization phenomena, rural exodus occurs (cities grow and villages begin to disappear). With the increased population in cities, health resources are shared between more people so, there is a deficit of health resources leading to the emergence of this type of diseases: Main social diseases: tuberculosis, malaria, typhoid fever, diphtheria, venereal diseases...) C. Health transition, demographic transition, transition of risks During the Inter-war Period ( 1st half of the 20th c). Main features Decrease of global mortality Decrease of infant and child mortality Increase of living expectancy Improvement of hygienic and working conditions Decrease of mortality in pregnant due to the medical assistance/help at delivery

Consequences New epidemiological pattern Demographic changes Aging of the population

D. Non infectious-contagious diseases and accidents

Industrialized societies 1945- 1980 (since the end of World War II until 1980). During this time infectious diseases seemed to be resolved due to the improvement of the conditions and quality of life. This period is characterized by non-infectious diaseases and accidents: Cancer, heart attacks, brain vascular accidents, traffic accidents, industrial accidents E. Globalization and new health problems (from 1980 to the present ) This period is characterized by the EMERGENCE of new epidemic diseases (virus like flu that became a pandemic) and new health problems such as toxicomanies, accidents and anorexia. In addition, there is a RE-EMERGENCE of previously controlled diseases like tuberculosis (chronic infectious-contagious disease) The characteristics of the new society are: Crisis in the systems of health due to lack of economic resources. Neo-liberalism + crisis of health care universality. o Neo-liberalism is a technocratic ideology that aims to minimize state intervention in economic and social aspects in order to create a macroeconomy and a free market capitalist because they believe that a growth will occur in the country. Therefore defend the privatization (think the private system is more efficient and productive) o Social democracy Population movements and inequalities related to the accessibility to the health care system. Climatic and ecologic change...with the global temperature change, there are more tropical insects in places where there was none before so, it can appear tropical diseases in other parts of the world.

To conclude, disease is a changing phenomenon that has evolved as humans. Therefore, it is very difficult to control the health in a perfect way, some diseases reemerge and other new diseases emerge as happens in the present days

4. Concept and types of medical system:


- Medical system definition: Any society has been always been conceived as a socio-cultural system, and it presents characteristic beliefs, lifestyles, traditions and way of thought. Those characteristics and more are what define the society itself. Before entering into the concept of medical system, we shall give a definition to what systems of knowledge are. A system or rgime of knowledge is the way of gaining knowledge which is followed massively in one society. It can be based mainly in the narration of myths, or either in the explanation from a naturalistic point of view (the one followed with the classical philosophies and modern societies). As a part of those characteristics, the facing of problems like the disease and the death are also based on the type of population of which we are talking about. These ways of understanding natural facts are the base which will characterise later on the type of medicine practised in this society. Of course, the objective of any medical system will be to fight against disease and will be formed of a social dimension (doctors themselves) and a cultural dimension (beliefs). The actual medical system imperant in nearly all the world is the scientific medicine, which is a consolidated medical system which has been evolving in time and including also characteristics of other medical systems. - Types of medical systems: There have been many medical systems along the history of medicine, but all of them can be classified into one of these two types of medical systems, acording to their beliefs and the society from where they are part: - Supernaturalistic medical systems: They are the ones which made their affirmations based on religious beliefs and empirical practises. They dont ask why a treatment works (empirism), and attribute it to a deity (religion). In this type can be included all the prehistoric, indigenous and popular (folkmedicine) medicine, and also all the archaic (Egyptian, Mesopotamial and Pre-columbians) medicines. - Naturalistic medical systems: They are the ones which search for a racional explanation of the human body physiology and what may have caused the disease, so we can discover how to cure it. In this group can be included the classical (Indian, Chinese and Hellenic) medicines, and also the modern (Western medicine, Naturism and Homeopathy) medicines. So, in the end, a medical system is what will determine all the aspects of the medicine that will be practised in a determined society, and will also condition its advance and development.

5. Main features of paleomedicine and indigenous medicine.


Medicine cannot be understood as an isolated issue, we have to understand it as a whole with the sociocultural and historical environment in which its being practiced. To understand the paleomedicine its important to know the main features of the society where it was developed, it is: Society was arranged in tribes where there was established a very strong hierarchy, and the patriarchal figure was a respected authority. The father in a family was the symbol of cohesion between their members. Subsistence economy. Religion, magic and empirism were very important in this time period. Tools and other material aspects: they used very rudimentary tools, usually with stones, but also ceramics, metals and similar. Intellectual aspect: knowledge was religion-based. Totemism, taboos were common, and rituals were usually practiced. Either good and bad things could come from nature, and the human being classified these things as good or bad according to several aspects, as for instance their power to heal/toxicity. Lexicon: vocabulary grew by the creation of words related with things they used/saw.

Medicine in each tribe had differential characteristics, but in all cases we find these common aspects: The sick person was considered differently depending on the disease: sometimes as linked to evil, sometimes as sinner or someone to be protected. Illnesses were explained in a mythological way, with a supernatural dimension. It was understood as a supernatural phenomenon with moral value. Its cause may be a possession, a loss of soul, an introduction of a strange body, or a bad influence of evil animals or objects, even witchcraft. As disease was understood that way, its logical that the treatment was also based in a supernatural diagnosis, fortune-telling and other magical elements. The treatment usually consisted in rituals and empirical remedies based on plants, diet and massages. The medicine man, the chaman was someone who cared for the achievement of health and spiritual equilibrium and perfection in the tribe. The title of chaman was usually inherited. They took care about the soul rather than the body, as they conceived illnesses as a spiritual, non-material problem. By this reason, several different rituals, as it has been already stated, were practiced (trepanation in alive or dead people).

So, basically there was a coexistence between mythical elements and naturalistic beliefs and practices with a little bit more complex underpinning. All this gathered together in a sociocultural framework with contributions from different elements such as astrology, zodiac, time measurement, mathematics or architecture, among others.

6. Explain the several meanings of cranial trepanation


Las trepanaciones craneales destacan en la paleomedicina, esta fue el sistema mdico existente durante la prehistoria y estaba basada en la combinacin de creencias mgicas, religiosas y prcticas empricas carentes de justificacin racional. El rea geogrfica de difusin de esta tcnica es muy amplia y no podemos decir que surgi en un lugar concreto en tiempo ni en espacio. Existen mltiples interpretaciones sobre las trepanaciones craneales, que se trata de una perforacin de los huesos de la cabeza. Ha sido llevada a cabo tanto por razones mdicas como msticas y de su prctica tenemos indicios desde la era neoltica. Se cree, por pinturas encontradas en cuevas que el hombre neoltico crea que este tipo de ciruga poda curar ataques de epilepsia, migraas (migraines) y desrdenes mentales pero la mayora de las trepanaciones se realizaban por motivos religiosos sin justificacin racional. Estas se podan realizar tanto en vida como post-mortem. Realizarlas en cada uno de los momentos tenan una simbologa muy marcada: En vida: o Aliviar dolores o Liberar a la persona de demonios (crean que podan estar causados por un espritu que deba salir de la cabeza). Post-monten: o Motivos religiosos: permitir el alma salir del cuerpo. o Estudios antropolgicos.

Como tcnica mdica poda realizarse de diferentes maneras como haciendo una incisin circular con una piedra, barrenando (scuttling) con varias piedras punzantes (piercing) o raspando (scraping) con una piedra abrasiva. A dems, tenemos constancia que estas tcnicas fueron en ocasiones realizadas con xito porque la formacin de tejido cicatrizado indica que muchos de los pacientes sobrevivieron a las operaciones, esto demuestra el conocimiento adelantado de la medicina.

7. Medicina Arcaica
INTRODUCCIN Las civilizaciones pertenecientes a la medicina arcaica son: Egipto (poca de faraones). Sociedades mesopotmicas (Asiria, Babilonia, Hititas, Fenicia, Hebreos, Persas). Culturas precolombinas (Mayas, Aztecas, Incas). Aspectos comunes a destacar: Primeras civilizaciones relacionadas con imperios: Desarrollo de sistema social jerrquico, con el emperador (dios) a la cabeza. Concepto de polis. Esclavitud. Origen geogrfico generalmente comn caucsico (zonas arias/indoeuropeas), a partir de mltiples migraciones. o 10,000 a.C. Migraciones mesolticas desde Mesopotamia, Egipto y este Mediterrneo. o 8,000 a.C. hasta 4,000 b.C. migraciones desde el norte de Europa en direccin sur (lo que explica que el finlands, vasco y hngaro no pertenezcan originariamente al rea geogrfica donde actualmente se habla). Encabezan la revolucin Neoltica: comercio, ganadera y agricultura. Contexto: 3er y 1er milenio a.C. en reas de clima clido inter-trpicos. Bsqueda de la mejora de las condiciones de vida: reas cercanas a ros y costas. Desarrollo de movimientos culturales e intelectuales ms complejos, pero todava coexiste la magia y la religin con un nuevo enfoque naturalista. 1. Cultura material: a. Perspectiva ambiental. Explotacin de recursos naturales. i. Agricultura, agrimensura (divisin de las tierras), sistemas hidrulicos (riego). Condujo a nuevas formas de alimentacin y mejora de la dieta y variedad textil. ii. Ganadera y domesticacin de animales. Tambin contribuy a la mejora de la dieta, pero a la vez propici la aparicin de plagas y zoonosis. b. Perspectiva urbana y social. Desarrollo arquitectnico y la organizacin social. i. Desarrollo arquitectnico. El desarrollo de las matemticas contribuy al desarrollo de la arquitectura y urbanismo. Construccin de numerosos edificios, monumentos y palacios (estandarizacin de la polis), pero tambin iglesias, templos y monumentos religiosos, debido a la fuerte influencia religiosa. ii. Organizacin social jerrquica con influencia religiosa, con el emperador (dios) a la cabeza y el esclavo en la base de la pirmide. Las polis alcanzan grandes dimensiones (ciudad estado) y se dan relaciones diplomticas o blicas entre ellas (negocios y guerras). Algunas aportaciones materiales en esta poca: rueda, piedra pulida, cermica, textil, monumentos megalticos y navegacin.

2. Cultura intelectual: a. Desarrollo de la escritura: pictogrfica, ideogrfica o jeroglfica. Primeras bibliotecas. b. Concepto cclico del tiempo (fases lunares, ciclos circadianos, incluso periodo menstrual), lo que, en contraposicin al concepto lineal caracterstico del cristianismo, explica la creencia religiosa de la transmutacin de las almas y la reencarnacin. c. Matemticas: aplicaciones en agrimensura, arquitectura, contabilidad, geometra, sistemas de medidas y pesos, sistema decimal y sexagesimal. d. Astrologa. Dada la concepcin de la naturaleza como una nica entidad, la lectura de los patrones estelares les permite realizar predicciones sobre el ser humano. La capacidad de predecir adquiere gran relevancia en este periodo. La lucha contra la enfermedad en esta poca: Se alcanza un grado de complejidad muy alejado del nivel primitivo. Si bien aparecen sanadores especializados y nuevas tcnicas teraputicas, la medicina sigue muy influenciada por el peso de las creencias mgicas y religiosas. Importancia de la toxicologa (pensamiento polar respecto a la capacidad de la naturaleza de proporcionar elementos nocivos y curativos). CULTURAS ARCAICAS 1. Egipto faranico. Desde 2,600 a 400 a.C. Atraviesa tres etapas: Antigua, Media y Nueva. Escritura jeroglfica. En cuanto al desarrollo del conocimiento mdico: Primeros textos mdicos en hiertico (jeroglfico simplificado) sobre papiro. Destacan: o Papiro Rhind. Aritmtica, geometra y formas de medida. o Papiro Edwin Smith. Procedimientos quirrgicos. Descripcin de casos clnicos con pocos elementos mgicos. o Papiro de Ebers. 20 metros de papiro. Conocimientos mdicos, pero con mayor cantidad de elementos mgicos y religiosos. Escasos conocimientos anatmicos. En las Casas de Vida tenan lugar las momificaciones (con la extirpacin de los cuatro rganos vitales: ), pero era parte de un ritual religioso. Influencia de la religin y creencia en el poder de fuerzas malignas para crear enfermedad. Mdicos. Tres clases: o Sacerdotes de la diosa de la salud Sekhmet. o Magos. o Mdicos-escribas, que aprendan la profesin copiando repetidamente los papiros. Explicacin de las enfermedades: alteracin del flujo de los lquidos orgnicos (que se mueven por vasos que parten del corazn), teora inspirada en el flujo de las aguas del Nilo, de las que dependa toda Egipto

2. Sociedades mesopotmicas. 3,000 a.C. Escritura cuneiforme. 50,000 tablillas de arcilla (clay tablets) grabadas con agujas, almacenadas en el Templo Nipur. Contenidos diversos: geometra, urbanismo, astrologa, agricultura, veterinaria, medicina En cuanto al desarrollo del conocimiento mdico: Cdigo Hammurabi. XVIII a.C. Texto mdico legal. Regulacin de los honorarios y penas estipuladas por mala praxis. Mdicos: o Sanadores ligados a la casa sacerdotal. Diagnosticaban y aplicaban tratamientos ligados al exorcismo. o Sanadores de rango secundario. Laicos. Cirujanos-barberos, sometidos a legislacin muy dura. Enfermedad: concepcin religiosa. Shertu = pecado y enfermedad al mismo tiempo. o Diagnstico. Interrogatorio para averiguar la impureza moral. o Tratamiento. Mtodos mgicos y religiosos: exorcismos, plegarias, penitencias, sacrificios Sin excluir empleo de frmacos, vegetales, baos, masajes, ciruga 3. Sociedades mesoamericanas. a. Civilizacin Maya. Periodo Clsico. Siglo III. i. Todos los aspectos de la cultura estn influidos por la religin (lder poltico y militar, moral, conocimiento, arquitectura, arte, calendarios, escritura ii. Desarrollo de conocimientos en astronoma, calendarios, numeracin vigesimal b. Pueblos Nahua. Civilizacin Azteca. Siglo XIV. Desde emperador Technochtitlan hasta Moztezuma II. i. Gran organizacin militar y poltica. ii. Agricultura, ingeniera hidrulica, arquitectura urbana, matemticas, astronoma iii. Se mantiene el concepto espiritual unitario de la naturaleza.

8. MAIN FEATURES OF FOLKMEDICINES.


La medicina que hay a nuestro alrededor es la cristalizacin histrica de la perspectiva cientfica occidental engendrada en la poca clsica. Pero junto a esa medicina claramente predominante como cultura mdica oficial en los ncleos urbanos y metropolitanos-, coexisten en las zonas rurales y en los arrabales de las grandes ciudades otras formas de carcter creencial o mtico, prcticas empricas ampliamente difundidas y todo un conjunto de elementos paracientficos que forman la llamada folkmedicina o medicina popular. Incorporan al elemento mtico una serie de prcticas empricas encaminadas a la curacin de la enfermedad, algunas de las cuales poseen un grado notable de efectividad teraputica. Las folkmedicinas surgen en sociedades con una riqueza manifiesta en elementos culturales y artsticos y son de algn modo evidencia de este acervo cultural. Estas sociedades poseen una visin mgico-religiosa de la realidad y, consecuentemente, tambin de la enfermedad y de la salud. En nuestro entorno cultural, el rasgo ms caracterstico es un omnipresente entrelazado de las formas tradicionales del pensamiento mtico con contenidos procedentes de la asimilacin popular de la religin cristiana.

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Las folkmedicinas estn conformadas por la supervivencia de antiguas ideas, conceptos, valores, actitudes y prcticas entre la poblacin secular. No hay que confundirlas con las supersticiones. Los rasgos principales de las folkmedicinas son: La influencia del pensamiento analgico en la concepcin popular de enfermar. Muchas veces est acompaado de la creencia en la existencia de simpatas mgicas o, con otras palabras, en la posibilidad de que las personas padezcan la influencia a distancia de fuerzas espirituales. Un ejemplo es que la no satisfaccin de un antojo durante el embarazo da lugar a la aparicin de una mancha en la piel del descendiente con la forma de lo antojado. Presencia de elementos religiosos y, en el caso valenciano especialmente, los ritos paganos se van cristianizando. La presencia de enfermedades espirituales o enfermedades no mdicas. El arquetipo ms conocido ser el mal de ojo.Esta enfermedad se configura a partir de una creencia ampliamente extendida en la capacidad de producir el mal mediante una fuerza presente en la mirada. Se trata de un maleficio o influencia negativa a distancia. Encontramos prcticas populares que puede realizar una pluralidad inmensa de curanderos, brujos o exorcistas. Un ejemplo valenciano es la prctica de trencar l'enfit. El diagnstico y la curacin del empacho es una prctica popular muy enraizada. Se basa en un rito mgico-religioso que busca delimitar el punto de localizacin del empacho, para hacer bajar a los alimentos parados convenientemente. La eficacia del proceso se supone limitada a los creyentes y la ceremonia es llevada a cabo por mujeres mediante dos herramientas: una cinta (para medir la localizacin del empacho) y oracin. Los herbolistas tambin representaban un papel fundamental en la teraputica.

Cabe diferenciar tres estratos cuando hablamos de la medicina popular:

El estrato profundo lo comparte con las otras medicinas emprico-creenciales de tradicin oral: paleomedicinas y medicinas de pueblos aborgenes, y tambin es comn a todas las medicinas populares. Incluye las creencias religiosas, el pensamiento analgico y las prcticas empricas antiguas junto con las tradiciones locales. Corresponde al fundamento ms consistente. El estrato superficial es distinto en cada pas y cultura, y tambin difiere segn el momento histrico. Encontramos los elementos que provienen de tradiciones mdicas histricas. Pueden ser tan antiguos como refranes, aunque tambin incluimos la astrologa proveniente de Mesopotamia, las alteraciones de los humores propias del galenismo o la observacin racional hipocrtica. En la medicina domstica se manifiesta de forma particular la aplicacin de mtodos aprendidos a travs de tradicin oral y de generacin en generacin, empleados para diagnstico y tratamiento. Refleja el conjunto de lo anterior sumado a las peculiaridades y actos cotidianos ms presentes.

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9. General characteristics of classical scientific medicines


Contexto histrico: Para situarnos temporalmente, estas culturas surgieron: Cultura China: 3.000 a.C. Cultura India: 1.000 a.C. Cultura Helnica: 1.000 a.C.

Las dos primeras se consideran las dos grandes culturas orientales y muchos de sus mtodos mdicos perduran hoy en da, la ltima fue la gran cultura occidental. Estas culturas tienen mucho en comn, todas ellas pretendan entender la naturaleza mediante la observacin y la comprensin humana. Estas culturas se diferencian de las que las preceden por el hecho de que dejan en un segundo plano las creencias religiosas, desbancadas por el raciocinio. Una vez ya hemos hecho una pequea introduccin vamos a tratar las caractersticas generales de las medicinas clsicas. A pesar de ser culturas diferentes tienen rasgos en comn. La caracterstica principal es el nacimiento de la Filosofa de la Naturaleza: La filosofa de la naturaleza trat de dar respuesta a los diferentes interrogantes mediante interpretaciones de la naturaleza. Todo se basaba en un mtodo filosfico que pretenda explicarlo todo mediante un punto de vista racional (tanto la enfermedad como la curacin) y nunca basarse en algo sobrenatural (Dios nos ha castigado envindonos esta plaga de peste). Unidad en la Naturaleza: Estas culturas crean que todo estaba interrelacionado. Crean que el Universo era un todo que comprenda a todos los individuos y que mediante la actuacin conjunta de las diferentes fuerzas se producan los diferentes acontecimientos. Por lo que defendan que podan explicar cualquier suceso mediante las fuerzas. Los antiguos filsofos defendan que podemos entender el mundo como un macrocosmos en el que estamos incluidos los individuos, el microcosmos, y que las diferentes fuerzas que rigen el macrocosmos se reproducen en los individuos. Armona en la Naturaleza basada en la polaridad/dualidad: La Naturaleza estaba formada por elementos duales que se complementan y que se encuentran en equilibrio. Cuando uno de los dos elementos predomina sobre el otro se produce el desequilibrio. La enfermedad se explica mediante esta dualidad. Cuando se produce un desequilibrio en el que los elementos que causan la enfermedad predominan sobre los que la previenen se produce enfermedad. Es como una balanza. Concepto de elemento: El elemento es la unidad ms simple y ms pequea que existe. Todo se reduca a los elementos y eran la base de todo. Pensaban en un elemento que lo compona todo, sin embargo no saban cual era. Es el precedente a la teora atmica, mediante la cual sabemos que toda la materia esta constituida por tomos. De esta concepcin de elemento derivan dos 12

modos de pensar que se darn en los filsofos de las tres culturas (presocrticos, Lao-Tse): o La mentalidad analtica: La cual busca establecer, de manera racional, los principios ms generales que organizan y orientan el conocimiento de la realidad, as como el sentido del obrar humano. o Los sistemas filosficos naturales: La filosofa natural pretende explicar la concepcin del mundo mediante leyes cientficas. Deja de lado basarse en la explicacin divina. Ejemplo: la filosofa natural dira que el palo se cae por la gravedad (este ejemplo no es de la poca antigua, Newton y la gravedad son del s XVII), mientras que la naturaleza teolgica dira que es porque Dios lo quiere as. Concepto circular del tiempo: El concepto que tenan del tiempo se basaba en una secuencia de sucesos que se repeta. Constituan un circulo cerrado y va muy relacionado con la dualidad de elementos. Ejemplo: El da y la noche, son elementos duales, que se van alternando en el tiempo de manera repetida.

Todas estas caractersticas las comparten las tres culturas que hemos nombrado. Las culturas no estaban en contacto, crecieron de forma autnoma aunque si tuvieron un poco d influencias entre s (Las relaciones comerciales, como la Ruta de la Seda, que provocaba el contacto entre personas de las diferentes culturas).

10. Natural philosophy and the concept of disease in classical Chinese medicine
Chinese medicine is one of the classic forms of Naturalistic Medicine (with the Indian and the Hellenic ones). Its historical context takes place on the 3rd millennium before Christ, so it is considered the oldest classic civilization. The main feature of this kind of classic civilizations was the birth of the Natural Philosophy. According to it, the central idea is that there is a unicity in Nature. This one is caused by a unicity of the world (cosmos) and the individuals (microcosmos) living on it. This unicity in Nature suggests the existence of a natural harmony based on the polarity or duality, which consists on dialectic equilibrium of contrary forces. This concept is called Ying-Yang, representing each one of them one opposite force that together finally find the equilibrium. It also establishes the notion of element as the elemental unit. This aspect shows, even if it seems to be a very abstract way of thinking, the analytical mentality of these philosophers, and classifies natural philosophies as naturalistic systems. One example of that was the philosopher LaoTse, which followed Taoist Philosophy based on the analysis of Nature on its largest sense. It has as goal to determine the Natural Order of universe through the analysis of the dual functioning of the universal existing nature. As last idea, Natural Philosophy proposes the model of the eternal return of moments with the believing on circularity of time. Talking more specially about classical Chinese civilization, we can say that it had great technical development for the period: compass, silk, ink, navigation, porcelain, gunpowder, printing, trade It was established an Imperial political unity with a 13

complex administration of the Empire, which got together some legendary Emperors. Some examples of that in relationship with medicine were Fu-His that introduced the yin-yang vision; Shen Nung that was the responsible of the introduction of acupuncture as a kind of medical practice; Huang-Ti that created the Nei Ching or Medicine Canon. According to science, Chinese civilisation had a materialistic natural philosophy based on the mysticism and dialectics using always the number 5. They applied the Yin-Yang dialectics, and concerning for example the anatomy, they considered 5 principal organs, each one of them associated with a feeling: spleen/pancreas with worry, lung with sadness, heart with happiness, liver with anger, kidney with fear and stomach with confusion. So they pretend to explain problems on these organs through this association with feelings (feeling sad means that the patient has a problem in the lung, and so on). They also talked about the distribution of vital energy through hydraulic system by means of blood, which was considered the way of transport of this energy. As therapeutics, they used natural practices such as acupuncture technique or moxibustion, which consisted on burning the root of a kind of plant called artemisa to apply hot on specific points of the body. They also used the association of pain with certain areas of the foot plants and they pretended eliminating pain by treating the area of the foot plant associated with it. Everything was focused on the recovering of the natural equilibrium of dual forces, because its loss was the cause of the health problem.

11. THERAPEUTIC PROCEDURES IN CLASSICAL CHINESE MEDICINE:


Entre los textos antiguos de la medicina clsica china el ms importante es el Nei Ching o Canon de Medicina Interna. Las doctrinas chinas acerca de la salud y la enfermedad conceden gran relieve a la relacin entre dos principios opuestos: el yang (lo positivo, clido, seco) y el yin (lo negativo, frio y hmedo). Ambos principios se distribuyen por todo el cuerpo a travs de los canales especiales o chin y que las alteraciones de este flujo son las que conducen a las enfermedades. Durante este punto se desarrollarn las principales tcnicas teraputicas de la medicina clsica china para restablecer la correcta distribucin del yin y el yang mediante la interactuacin con los canales o chin: Para empezar, para el diagnstico se empleaban los cinco sentidos puestos en el paciente. Adems tena especial importancia la toma del pulso, que se realizaba en 11 puntos diferentes del cuerpo y con 3 grados diferentes de presin. Los chinos describieron con gran precisin enfermedades como la viruela, el beriberi, el escorbuto o la tisis. En cuanto a la teraputica y la farmacologa sus captulos ms importantes fueron: La acupuntura: se practica con agujas muy finas de distintos tamaos, cuya tcnica requera de gran habilidad y largos adiestramientos. Segn algunos tratados existen hasta 600 puntos especiales en el cuerpo humano donde se pueden pichar las agujas. Estos pinchazos estn dirigidos a eliminar las obstrucciones de los canales o chin para que el yin y el yang puedan circular correctamente y de esta forma restaurar el equilibrio y la salud. 14

La moxibustin: consiste en aplicar bolitas de hierbas aromticas o moxas sobre la piel y quemarlas con fines idnticos a los de la acupuntura. Medicamentos: existen una serie de tratados farmacolgicos con el nombre de Pn Tshao donde se recogen no menos de 2000 medicamentos. Estos pueden ser de origen vegetal, mineral o animal. Su accin se interpreta desde bases anatomofisiolgicas y se escogen tras la observacin de su efecto en los pacientes.

La ciruga no tiene cabida en las concepciones chinas de la teraputica, ya que la continuidad de la persona est integrada en un sistema de constante interaccin. Es lo que se denomina la interaccin del microcosmos con el macrocosmos (la circulacin del ying y el yang y la interrelacin de los 5 elementos: madera, fuego, agua, tierra y metal). Por tanto ningn tipo de tcnicas de este tipo pueden darse en la medicina clsica china. De este modo terapias como la acupuntura en la medicina clsica china son muy tiles para patologas como: dolores neuriticos, postraumticos, digestivos, combatir la ansiedad pero no servira frente a problemas internos como hernias, canceres o apendicitis.

12. AYURVEDIC MEDICINE:


Ayurveda is the traditional medicine in ancient India and is the word for knowledge of longevity (ayus= longevity and veda=knowledge), which showed how to live better and longer. In this culture, it was thought that there were five elements in nature, which were, earth, water, fire, air and sky, and in ayurvedic medicine they also included seven primary constituents of the human body, being chyle, blood, flesh, fat, bone, marrow and semen or female reproductive tissue. This type of medicine comes from two principal early texts, the Charaka (C. 4th-5th ) and the Sushruta (c. 3rd-4th) which divided Ayurveda in eight branches of medicine: internal medicine, Surgery, ophthalmology, ENT (otolaryngology - ear, nose and throat), paediatrics, spirit medicine and toxicology, science of rejuvenation and aphrodisiacs. Longevity was thought to be obtained by the balance of the three elemental energies, which were: wind, bile and phlegm. As long as these energies were balanced, the body was considered to be healthy and in harmony. But an unbalance of these energies made the body unhealthy in various ways. Surgery and instruments were employed from a very early period and hygiene is a central practice of Ayurvedic medicine, involving regular bathing, cleaning of teeth, skin care, and eye washing. Ayurveda also focuses on herbal treatment as well as on exercise, yoga and meditation. Diet was very important, it was thought that vitality was obtained by building a healthy metabolic system, attaining good digestion and proper excretion. Fasting (not eating certain foods) was important in religion, for example the religion didnt permit eating certain animals like pig, but it was also for health reasons, for example they didnt eat those animals because they transmitted some infectious diseases. 15

The concept of chakras was also a part of ayurvedic medicine. Chakra means wheel and it is a matter of energy and consciousness. There are seven chakras or energy centers associated to seven different parts of the body, the first being the highest level and the seventh being the lowest. The chakras from highest to lowest are the following: crown, third eye, throat, heart, solar plexus, sacral and base. The functioning of the chakras reflect decisions of responses in life, it creates a relationship between consciousness and our body, where the consciousness interacts with the nervous and endocrine systems. When the person feels stress in their consciousness, they will feel it in the chakra associated to that part of the consciousness, and therefore in that part of the physical body associated to that chakra. When this tension continues over a period of time, or to a particular level of intensity, the person creates a symptom on the physical level. In order to obtain longevity we need to open the chakras, and we do this by getting together with nature. The idea is to open first the lower level (the base chakra) and grow to the upper level.

13. Hippocratic medecine


The most important figure in ancient Greek medicine is the physician Hippocrates, known as the "Father of Medicine". He was a doctor from the Ancient Greece, who lived and practice during the called Pericles century. Hippocrates was the founder of the Hippocratic School, which revolutionized the medical practice in the Ancient Greece by separating medicine from other disciplines with which it was been always related as philosophy, religion or Tergia transforming that science into a real profession. Hippocrates and his students documented many conditions in the Hippocratic Corpus, and developed the Hippocratic oath for physicians, still in use today. The existence of the Hippocratic oath implies that this "Hippocratic" medicine was practiced by a group of professional physicians bound (at least among themselves) by a strict ethical code. Aspiring students normally paid a fee for training (a provision is made for exceptions) and entered into a virtual family relationship with his teacher. This training included some oral instruction and probably hands-on experience as the teacher's assistant, since the Oath assumes that the student will be interacting with patients. The Oath also places limits on what the physician may or may not do ("To please no one will I prescribe a deadly drug") and intriguingly hints at the existence of another class of professional specialists, perhaps akin to surgeons ("I will leave this operation to be performed by practitioners, specialists in this art"). Nowadays, Hippocratic medecine is considered as passive and naturist. According to this doctrine, the body possess in a natural way the intrinsic power to heal and stay healthy, vix curatrix naturae. So therapy was based on that power of the nature to heal and take care of the patient. So the physicians work was mainly to facilitate and improve as possible that process taking care of patient or giving him treatments. The doctor analyzes the polis to know about the weather, the places, water the natural environmental elements that could influence health. According to Hippocrates, rest and immobility of the patient was of primordial importance and determinant for the correct development of the process. In the practice it also stand out the relevance of keeping the patient always clean and sterile. Hippocratic doctors give much importance to

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dietetics and regime of life also. For the Greek, diet was not just about food, it implied the whole way of life. The different text that composes the Corpus Hippocraticum strongly associated with the Hippocrates and his teachings, however they really belong to different schools and authors that follows the Hippocratic ideal as the Hippocratic school of Cos (also Knido...etc.) Those texts, varied in content, age and style, and are largely of unknown authorship. They were compiled in the Alexandria library, and they share several elements as the influence of the environment in the diseases development so that both the disease and the pain could be influenced by external environmental factors and our way of life. Humorism was a theory utilised and followed by Hippocratic School that established that the body is composed by four humors. Those humors are Yellow bile, Black bile, blood and phlegm. According to them, an excess or deficiency of any of those four in a person directly influences their temperament and health. Other of the most important terms introduced in the practice was the establishment of the prognostic. The aim was to know if in a determined case the physician was able to act and treat the patient or only could accompany and help him in function of the cursus morbi, the evolution of the disease, taking into account several factors.

14. Galenic medicine


Galen of Pergamon, 130-201 AD. Culmination of Hellenic medicine. His knowledge and practices remained for more or less fifteen centuries. He came form a well-positioned family, so his father made sure he received a good education. He studied medicine and philosophy in Smyrna, Corinth and Alexandria. Then he returned to Pergamon, where he was the doctor of the gladiators. Afterwards he went to Rome to be the chamber doctor of Emperor Marcus Aurelius. He wrote almost 400 treatises, of which we know more than 100 that contain the most used medical doctrine during the Middle Ages and the beginning of the Modern Ages. His pretension was to elevate medicine to the scientific knowledge category, differentiating it from the simpler empirical artisanal practices. He made contributions in the fields of physiology (calor innata: refrigeration and aliments were the fuel, situated at the heart), the humoral pathlogy, anatomy (descriptions of muscles, bones, arteries, nerves and viscera) and neuroanatomy (brain, ventricles and medulla), and also differentiated motor and sensitive nerves. The basis of his physiological doctrine and conception of disease was the Aristotelian philosophy and stoic tradition. He achieved the meeting point between the Greek philosophy (Aristotle, Plato) and the medical doctrine. His conception of disease was faithful to the Hippocratic tradition, so it had a humoral character. Disease = alteration of the humours. He defended active and methodical therapeutics, based on healing with remedies that contained the opposite qualities to those of the cause of the disease (contraria contraris curantur), and searching for the lost balance of the humours. He believed in the healing strength of Nature. 17

Contrary to what Hippocratic followers did (expectant attitude) he thought doctors should act with determination. Thats the reason for his bloodletting and purgative methods. The medieval Galenism gave way to the Modern Age.

15. Cultural and religious contexts of medieval medicine


During the middle ages we can appreciate plurality of political, cultural and religious contexts: a) Byzantine empire (eastern Christian): The Byzantine Empire was a Christian state heir of the Roman Empire which survived throughout the Middle Ages and early Renaissance and was located in the eastern Mediterranean. Its capital was in Constantinople. During its millennium of existence, the Empire was a bastion of Christianity, and prevented the spread of Islam to Western Europe. It was one of the main commercial centres of the world and had a determining influence on the laws, political systems and customs of much of Europe and the Middle East. b) Jewish communities. These were very dispersed communities. Jews have existed since very ancient times. By 1000 B.C.E. they founded a national state, Israel, and practiced a distinctive religion, Judaism. Throughout the Middle Ages the Jews became increasingly marginalized because of political and economic disadvantages. Throughout the Middle Ages Jews constituted their own communities. A strong sense of self-identification enabled Jewish survival c) Islamic communities: From the 7th century they started a political expansion following Mahomas orders. They were in contact with eastern traditions: numbers, compass, astrolabe, mapping, agriculture. They learn the system of Arabic numbers from India. From an old tradition without scientific knowledge, they developed. The points of contact between Europe and Islamic lands were multiple during the Middle Ages. d) Christian western communities: As Roman imperial authority effectively ended in the West during the 5th century, Western Europe entered the Middle Ages with great difficulties that affected the continent's intellectual production dramatically. Some of the older Roman elite families died out while others became more involved with Church. Many communities lived in poor, critical conditions. They were very fragmented and they suffered from epidemics, plagues. Talking about the Middle Ages is talking about the cohesion of all this cultures with the Christianism. They all share the fact of being adaptations of the Classic and Galenic adaptations and putting these ideas in different contexts.

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16. THE MEDIEVAL ISLAMIC MEDICINE


Evolucin de la cultura islmica Antes de la aparicin del Islam la tradicin rabe se caracterizaba fundamentalmente por una poesa y una literatura que se centraban en el comportamiento de los animales, la morfologa de las plantas, las flores, la anatoma, y la fisiologa animal. En el siglo VII, con la creacin del Islam, se produce una unificacin poltica, cultural y religiosa en todo el mundo rabe, basada en lo que dictaba el Corn (el texto sagrado), y se realiza una divisin poltica del territorio en regiones (califatos y emiratos). Tras la muerte del profeta Mahoma, comienza una gran expansin musulmana hacia el mundo oriental que permite el contacto de la cultura y tradicin islmicas con las tradiciones del este, y se van incorporando por mandato del profeta los elementos culturales ms importantes de cada territorio: la numeracin india, el uso del comps, el astrolabio, la cartografa (con usos especialmente marineros), la agricultura La evolucin de la cultura islmica se puede resumir en la siguiente cronologa: Siglo VII: se produce el contacto con la tradicin clsica en la ciudad de Gundishapur (Persia). Aqu se haban exiliado muchos filsofos, fsicos y mdicos que haban huido de la persecucin del Imperio Bizantino, entre ellos los nestorianos, quienes se dedicaron a traducir las principales obras clsicas del griego al rabe. Siglo VIII: se produce el esplendor de Baghdad, que se convierte en capital del Islam. Siglo X: esplendor de Crdoba (en ingls Cordova) Siglos X-XII: es un periodo en el que se construyen muchas mezquitas (en ingls mosques), libreras, colegios, hospitales, baos pblicos y asilos a lo largo de todo el territorio rabe.

La medicina islmica En la medicina islmica se mezclan elementos tanto del Islam como de otras culturas que se haban ido incorporando con la expansin poltica. As, la cosmogona del Islam (cosmogona = narracin mtica que pretende dar respuesta al origen del Universo y de la propia humanidad) estaba inspirada en la teologa cristiana, por lo que tenan la concepcin del alma como el aliento vital del creador que nos introduca a los hombres en el momento de nuestra creacin. Por otro lado, los conocimientos sobre los procesos de fertilizacin y la embriologa se haban incorporado de la tradicin griega, y las ideas que tenan sobre la filosofa natural provenan del Gnesis (tradicin cristiana). La aparicin de una medicina islmica como tal, que inclua estas ideas, se dio por primera vez con los nestorianos exiliados en Gundishapur, Syria y Baghdad, quienes durante los siglos VII y VIII tradujeron los textos griegos de medicina creando una cultura mdica propiamente rabe. Y ya en el siglo IX se traduce al rabe toda la obra de Galeno. Y para terminar, algunos de los personajes ms destacados de la medicina islmica y sus principales obras: 19

Rhazes: Liber de Medicina, Continens Ali Abbas: Liber regis Avicenna: Canon de medicina Joannitius: Isagoge Ibn an Nafis describi la circulacin pulmonar Averroism

17. Christian medieval medicine


Durante la Edad Media vemos una alianza entre la religin y la poltica, y el sincretismo, o intento de fusin, entre la teologa cristiana y la tradicin cientfica Helnica. Podemos decir por tanto que hay una amplia pluralidad de contextos polticos, culturales y religiosos durante la Edad Media donde podemos distinguir dentro de la comunidad cristiana el imperio bizantino (Eastern Christian) y las comunidades cristianas occidentales (Western Christian). Las comunidades cristianas de Occidente pertenecen a una sociedad feudal, cuya vida gira en torno a los castillos y monasterios. Es una poca de guerras donde el poder est a manos de los nobles, el estamento religioso y la monarqua. La religin era el centro de la vida cultural y los monasterios y conventos los centros culturales. Las lenguas clsicas, como el latn y el griego, eran las utilizadas para escribir y las ciencias ms importantes eran la astronoma, la farmacia o la medicina, as como el arte, la agricultura y la economa. Hasta mediados de la alta Edad media la medicina se ejerci principalmente en los monasterios. El primero un fundarse fue el Monasterio de Montecassino de la orden de los Benedictinos. Otro ejemplo es la Abada de San Galo (o St. Gallen) que fue una de las principales abadas en Europa durante muchos siglos. En la pennsula ibrica encontramos el Monasterio de Santes Creus, que es una abada de la Orden del Cster, al igual que el Monasterio de Poblet, que constitua el prototipo de abada cisterciense espaola. En Valencia el Monasterio de la Trinidad fue fundado en 1242 y cumpla funciones como cenobio y hospital. En estos monasterios se escriban y estudiaban los manuscritos iluminados, donde el texto es complementado con la adicin de decoracin. La mayora de ellos tienen un carcter religioso, aunque tambin se pueden encontrar manuscritos de ciencias como la medicina o la botnica. Las caractersticas ms importantes de la medicina en las comunidades cristianas fueron la supervivencia del galenismo, el concepto de regimina sanitatis (individual hygiene) y las medidas excepcionales de higiene pblica. En la Edad media se produjo claramente el divorcio entre medicina y ciruga. A esto contribuy, aparte de las creencias religiosas de la poca, el hecho de que Galeno abandonase esta prctica. El Rgimen Sanitatis es un tratado de carcter didctico escrito en latn que fue redactado en el entorno de la Escuela Mdica de Salerno y expona un conjunto de recomendaciones pautas para una vida saludable que se deban seguir para no contraer enfermedades como la peste. Estas pautas para una vida saludable fueron creadas por algunos doctores para ciertos reyes y tienen su origen en la tradicin hipocrtica. Se trata de un tipo de medicina preventiva vlido para las jerarquas dominantes como el clero alto y la aristocracia feudal. 20

Aparte de esto se establecieron muchas medidas de higiene pblica, que aparecieron en un principio en la Edad Media Islmica. El Mustassaf era una institucin que velaba por la higiene en la vida cotidiana, en mercados y en las calles de la ciudad. Se podan poner multas y juzgar a quienes no siguieran medidas higinicas. Esta institucin se creo durante a poca islmica en los reinos cristianos de la pennsula, como la Corona de Aragn. Tambin se crearon hospitales donde se realizaban prcticas religiosas, pues muchos de ellos eran iglesias y eran instituciones creadas para cuidar de los marginados. Por ultimo, la creacin de lazaretos medievales, que eran hospitales o instalaciones similares donde se trataban enfermedades infecciosas como la lepra o la tuberculosis, aunque algunos eran ms bien lugares de reclusin, sin ningn tipo de cuidados mdicos ni salubridad. Subrayados tenis todos los conceptos que corresponden al powerpoint de Barona sobre este tema.

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FACTORS OF THE TRANSITION FROM MEDIEVAL TO

RENAISSANCE MEDICINE
Factors influencing the transition from Middle Ages to Modern Age: (16th -17th c.) To what extent were climate and disease key factors in producing economic and social changes? PERSIA!! POLITICAL ECONOMIC RELIGIOUS SOCIAL INTELLECTUAL ARTISTIC A) SOCIAL AND CULTURAL Rise of the first European Empires: Portugal, England, France, Roman Empire Rise of a bourgeoisie against the old feudal aristocracy and church elites: transition from feudalism to this new social class was the results of the creation of the big cities (they had the money and the new intellectuality) Working moral (Max Weber). To accumulate money gives power to the people and social capacity. (previously just the aristocrazy had it) Consolidation of an urban economy, trade and craft = possession of property and capital: start of pre-capitalist process: towns were centers for trade and shopping. Luxury goods such as silk, spieces, ivory and porcelain, guilds (gremios). Invention of accountability and accumulation of money Self-experience against tradition: experience is worthed in science and technology. Also when conquering new places, they learned from them (included medical stuff) Secularization of the idea of progress = technical progress and government of the world : the men is the center of the world (anthropocentrism). Progress means the ability to use knowdlege to control nature and improve its conditions. This is a scientific optimism. *secularization= loose of church power, it passes to civil society. Reaction against medieval scholasticism (Christianization of ancient philosophy and science): they wanted a separation of Church from art, philosophy, science Recovery of classical science progressive critique and crisis : a new interest in nature is rising, not just religion and faith.

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B) GEOGRAPHICAL: Discovery of New Worlds : discovery of America Start of European colonialism: America, Asia, Africa Transformation of the economic system: as a consequence of the previous things. New representations and narratives about the world : Recognition of the plural ethnicity, geography and culture: when travelling they saw how diverse are the people and its cultures.

C) TECHNICAL: - Print: dissemination of scientific knowledge : a higher number of people was able to know about science. Associated with the expansion of universities. Also books travelled among countries. - Technology innovations: navigation, extraction and separation of metals, air pump : inventions such as mechanical clock, eyeglasses, gunpowder Navigation becomes very important: allows the commercial relationship and the word control. - Secularization of life: not related to church. Education - Changes teaching: from glossing to "personal lecture : in the middle ages was just a talk, but after was more like nowadays, with interaction among professor and student.

19. La revolucin cientfica en Medicina / The scientific revolution in medicine


En el S. XVII se produjeron una serie de cambios que llevaron al paso de la edad Media a la edad Moderna. Entonces fue cuando se produjo una revolucin cientfica en el campo de la Medicina. (Factores sociales) Se trata de la poca de auge de los imperios europeos, y del crecimiento de la burguesa, a pesar de que segua gobernando la clase aristocrtica. La economa pasa a ser urbana/industrializada, y se produce un movimiento de secularizacin de las ideas (incluyendo la filosofa, en la que se observa un rechazo hacia el escolantismo cristianizacin de la filosofa griega). (Factores geogrficos)Adems, es la poca del gran colonialismo europeo, lo que lleva a unos cambios profundos en las sociedades (aceptacin de las diferentes etnias y culturas). (Factores tcnicos)En esta etapa se realizan grandes avances tcnicos como la imprenta (que fomenta la difusin del saber), se introduce el mtodo cientfico en las ciencias, con lo que se diferencia claramente entre el empirismo y las experiencias personales. Como consecuencia, se produjeron a grandes rasgos muchas innovaciones: se hizo una revisin de los conocimientos sobre la salud y la enfermedad, se afianz el fibrismo como unidad elemental morfolgica (de hecho se diferenciaron varios tipos de fibras: la crnica, responsable del movimiento voluntario, la cartilaginosa, que se ocupa del movimiento involuntario, y la mixta, se ocupa dela funcionalidad del aparato digestivo; esta doctrina se apoya en la res extensa Cartesiana), se produjo un cambio paradigmtico en el estudio de la fisiologa y se afianz la crisis galnica con la crisis de la patologa humoral. * Especial mencin a las Ciencias morfolgicas: Se produjo una revolucin con los conocimientos de Andrs Vesalio (1514-1564). Se rebela contra Galeno y enuncia que el cuerpo est formado por tres sistemas: unitivo, estructural e impulsador. 22

Se inician las exploraciones microscpicas y macroscpicas (anfiteatros anatmicos) de cadveres; se hacen famosos los microscopistas clsicos: Hooke (corcho; en 1665, libro: Micrographia), Van Leeuwenhoek (analiza el esperma en 1667), Malpighi (el de las cortezas para que os acordis estudi la corteza cerebral, corteza renal, descubre capilares y confirma las teoras que se postulan en cuanto a la circulacin), Redi (experimento demuestra la no existencia de la generacin espontnea, 1 libro parasitologa). * Se produce una profunda crisis de la patologa galnica (recordar que se basa en la medicina rabe con textos traducidos al latn, en las revisiones filolgicas de los clsicos llevadas a cabo por los humanistas y en la medicina hipocrtica y su observacin detallada del paciente), debida principalmente a la observacin clnica, pero tambin a la aparicin de nuevas enfermedades que no podan ser explicadas mediante los desequilibrios humorales, y que se observan mejor a raz de las autopsias anatomopatolgicas. Se generan as tres corrientes: Galenistas, antigalenistas intransigentes y anti-galenistas transigentes. A medida que avanza el siglo XVII, se afianzan dos maneras de pensar en el seno de la ciencia mdica: el mecanicismo biolgico y el vitalismo. MECANICISMO: concretaron en la doctrina de la fibra, que por influencia del atomismo se defini como una alineacin de tomos; en fisiologa, introdujeron el uso de la balanza (ETAPA MENSURATIVA), descubrimiento de quilferos y linfticos (Aselli y Pecquet) y capilares (Malpighi). VITALISMO: diferencian cualitativamente los fenmenos propios de la vida, debidos a una fuera especfica y exclusiva de la materia viva; estos fenmenos definen a la materia viva de la inerte, y en el vitalismo se piensa que los conocimientos cientficos derivados del estudio de una no pueden servir para explicar los fenmenos de la otra. Tambin aparece una tercera corriente de pensamiento, el YATROMECANICISMO, derivada de la unin entre la concepcin del cuerpo nicamente como algo mecnico (res extensa cartesiana) y el pensamiento galileano. Postulan que las funciones orgnicas pueden ser reducidas a simples procesos mecnicos (trituracin, cambios de presin y fenmenos de resistencia), y que todo el organismo se movera por las acciones cardacas y la actividad nerviosa. Esto produce un CAMBIO EN EL PARADIGMA VIGENTE EN FISIOLOGA. Se introducen nuevos conceptos como el empirismo fisiolgico (Santario) y la investigacin yatromecnica, y con ellos se producen grandes descubrimientos (circulacin menor por Servet, descubrimientos de W. Harvey). Esta Yatromecnica llev a la aparicin de la YATROQUMICA, basada en las ideas de Paracelso, y se desarroll una concepcin diferente de la enfermedad y la salud, integrando las diferentes tendencias innovadoras del momento en un sistema patolgico basado en el concepto de la fermentacin/ fermentatio (fue til, por ejemplo, en el caso de la explicacin de las fiebres). Se trat de un movimiento poco duradero, pero sirvi para romper con el conocimiento clsico y crear una necesidad de renovacin; estuvo marcado por Bacon y por la antropologa cartesiana, as como por Harvey y los descubrimientos de los mecanicistas

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20. The anatomical reform of the sixteenth century medicine


Galenic conception of anatomy was the predominant in the medicine teaching, until the XVI century. It started with an important change previous to XVI century; Italian and Spanish university were the first to introduce the human cadaver dissections in medicine lessons. The person who made the dissection was a professor helper. This was an improvement compared with the animal cadaver dissections form Galenic medicine, but the helper did not realise that during the cadaver dissection there were some details that did not fix to what was being read from classical text. Although there was an introduction of human cadavers dissections, there anatomical reform was yet to come. Its first change was that the dissection was now done by the professor, not by a helper. The most representative character of this movement is Vesalio, who as the dissection was done, he saw that there were some things that did not match with what was believed. This lead to the first anatomical descriptive book, which was based exactly on what he saw, called La Fbrica. This is how Vesalio starts the modern anatomy, with the description of the macroscopic anatomy, based on what you can see and describe with the naked eye. The anatomy classroom had an amphitheatre structure with the students on the seats and the cadaver in the centre. The dissections were public, so anyone interested could enter in the classroom and watch. From now on, each organ or structure will be described following architectonic criteria, as the human body was considered a building. The rooms of the building will be the different cavities and as in all buildings there will be some structures that will connect some cavities, being them the arteries, veins, nerves, ligaments, etc. At last, but not least, each organ will be described as a geometric figure which most adapts to it. Resumen: 1st change Introduction of human cadaver dissection in medicine classes. The Dissection was done by a helper professor. 2nd change Most important. Done by Vesalio. The dissection was done by the full professor 3rd change Lead by the second change. Discussion of things that were observed in cadaver and where not in classical texts Macroscopic Anatomy 4th change Architectonic criteria when describing human body.

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21. The classical microscopists and medicine in the 16th and 17th c.
Tras el debilitamiento de la corriente humoralista, tuvo lugar el desarrollo de las ciencias morfolgicas, donde el concepto de fibra se impuso como unidad elemental de la materia viva. Se lleg a distinguir 3 tipos de fibras: la fibra crnica (movimiento voluntario), la fibra cartilaginosa (movimiento involuntario) y la fibra mixta (propia del aparato digestivo). La doctrina de la fibra encontr su principal apoyo en las primeras indagaciones microscpicas, todava imperfectas, y trataba de dar contenido a la idea de una unidad elemental de la res extensa cartesiana (significa a la cosa extensa descrita anteriormente por Descartes). Por otro lado, se fue consolidando la corriente del mecanicismo biolgico, que explica el comportamiento de los seres vivos mediante el estudio fsico-qumico de sus partes constituyentes. Esta apareca adems como rplica a la corriente intelectual basada en el vitalismo. El desarrollo de las investigaciones microscpicas, junto con la mentalidad mecanicista que comenzaba a cultivarse, favorecieron la aparicin de diversas disciplinas, como la Fisiologa Mecnica del msculo (Fabrizio), la Miologa Geomtrica (Stenon) y una incipiente Fisiologa Mecanicista (Borelli, Baglivi). Sin duda, la evolucin de las ciencias mdicas se desarrolla de manera acorde a los avances tcnicos, entre los cuales en esta poca cabe destacar el auge de la microscopa. Los principales microscopistas que impulsaron el desarrollo de las ciencias morfolgicas fueron: Robert Hooke (1635-1703): En su obra Micrographia, analiz laminillas de corcho e introdujo el concepto de clula o celdilla. Tambin se dedic a la descripcin de insectos, arcnidos y moluscos, as como a la observacin de la estructura de las plumas de pjaros. Antoni van Leeuwenhoek (1632-1723): fue el primero en realizar importantes observaciones con microscopios fabricados por s mismo y fue el precursor de la biologa experimental, la biologa celular y la microbiologa. Es conocido como el descubridor de los protozoos, las bacterias y los espermartozoides (1677). Se opuso a la teora de la generacin espontnea, para lo que llev a cabo estudios sobre los insectos y su reproduccin. Tambin se dedic a la descripcin de los capilares tanto en vertebrados como en invertebrados. Jan Swammerdam (1637-1680): fue el creador de la anatoma de los invertebrados. Trabajaba tambin con un microscopio fabricado por l mismo, y desarroll tcnicas de tincin con las que inyectaba el tinte en los rganos del insecto para su observacin. Marcello Malpighi (1628-1694): Es considerado el fundador de la Histologa. Su principal aporte fue la observacin de los capilares pulmonares de ranas, las comunicaciones arterio-venosas del pulmn y ramificaciones bronquiales, recogida en su obra De Pulmonibus (1691), lo que le permiti confirmar la doctrina de la circulacin. Realiz grandes contribuciones a la anatoma microscpica, como la descripcin de las neuronas piramidales de la corteza cerebral, el glomrulo renal, las papilas gustativas de la lengua o los cuerpos foliculares del bazo. Francesco Redi (1626-1697): refut la teora de la generacin espontnea (Experimentos acerca de la generacin de los insectos, 1668) mediante sus experimentos con carne en putrefaccin lleg a la conclusin de que no podan aparecer larvas a menos que se depositasen huevos. Esto supuso un refuerzo para

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las barreras que se conocan entre la materia viva y la inerte. Redi es tambin el fundador de la parasitologa, 22.The circulation of the blood and the physiological reform (16th-17th c.) Tras la aparicin de la revolucin cientfica, XVII, hay una ruptura con lo clsico, la fisiologa es un reflejo de ese cambio en la medicina. Principales cambios a la nueva teora moderna se reflej principalmente en un cambio del mtodo y los presupuestos. Mtodo y presupuestos Respecto al mtodo, se pasa de una idea esencialista basada en la especulacin e interpretacin de lo observado, a un mtodo notativo que utiliza experimentos para explicar fenmenos naturales. Los principios que guiaron el cambio o presupuestos fueron: Separacin de la forma y la funcin Visin dinmica del organismo: o El galenismo tradicional supone que el dinamismo del organismo se divide en movimientos sustanciales, cuantitativos, cualitativos y locales. Adems, las causas del movimiento se consideraban posibles como materiales, formales, eficientes o finales. o La ciencia moderna solo estudiar el movimiento local y las causas eficientes de estos. Funciones orgnicas como procesos energticos o materiales (ej fiebre, contraccin muscular) Experimentacin Respecto a la prctica de la experimentacin, nacida con la nueva mentalidad moderna, encontramos muchos ejemplos de experimentos que se llevaron a cabo en esta poca. Uno de ellos, probablemente el que supuso el gran cambio inicial con la fisiologa clsica, es el de William Harvey, cuando descubri la circulacin mayor sangunea. Expuso su teora en su libro Exercitatio anatmica de motu cordis et sanguinis in animalibus, publicado a principios del siglo XVII. Para contextualizarnos al respecto de la situacin en la poca, conocemos que el movimiento de la sangre segn Galeno segua una serie de pasos, a travs de los cuales sufre 4 transformaciones: Estmago, alimento pasa a quilo Hgado, transformacin a sangre venosa Aurcula izquierda, se une al pneuma, un principio vital que viene de los pulmones, y pasa a sangre pneumatizada Vasos, se distribuye por las partes orgnicas Aunque hubo otros experimentos previos al explicado, no fueron capaces de sobreponerse a la teora galnica. No fue hasta que Harvey propuso la teora de la circulacin mayor cuando se dej de lado la ideologa clsica. Otro hallazgo de Harvey fue intuir la circulacin menor o pulmonar. 2. DEL DESCUBRIMIENTO DE LA CIRCULACIN MAYOR A LA FISIOLOGA EXPERIMENTAL. William Harvey William Harvey, nacido en Inglaterra, fue un cientfico cuyo aprendizaje tuvo lugar en Padua (Italia), donde convivi con Fabrizzi dAcquapendente. Esto le permiti adquirir 26

unos conocimientos anatmicos, que fueron las vlvulas venosas, lo cual le daba ventaja en el estudio de la fisiologa sangunea. Los mtodos que utiliz mayoritariamente fueron, el clculo y la experimentacin. Mide, por observacin o experimentacin, datos como el volumen cardaco diario, las contracciones cardacas, etc. Gracias a eso llega a la conclusin de que el volumen de sangre que poseemos es mayor a la cantidad de alimento ingerido. Sus estudios eran sobretodo, mediante observacin, como abrir venas. Sin embargo realiz experimentos sencillos, como aplicar ligaduras para cortar la circulacin. As llega a la conclusin de que las arterias distribuyen la sangre por los miembros y las venas la recogen. Tras proponer su nueva teora, las autoridades clsicas son escpticas al principio. La razn es que todava no se saba el punto de conexin o paso de sangre arterial a venosa. El descubrimiento posterior de la circulacin capilar termin con esa duda. An con la polmica inicial, a finales del siglo XVII ya se haba extendido su ideologa. Revolucin cientfica en ciencias mdicas. Siglos XVI y XVII Durante el siglo XVI se continu con los patrones galnicos: - Arbico: tralaciones latinas de textos medievales - Humanista: revisiones fiolgicas de textos mdicos clsicos - Hipocrticas: especial atencin a la observacin del paciente Sin embargo, surge una crisis influenciados por: las observaciones clnicas y la aparicin de nuevas enfermedades: Dulcura inglesa, sfilis, varicela, pelagra. Tambin contribuy a la crisis las autopsias anatopatolgicas and provocaron numerosas disputas y controversias. Esta crisis llev a Sistemas Alternativos: el paracelismo La nica ruptura total con el sistema galnico que se formul en el Renacimiento fue el paracelsismo, que podemos considerar como un movimiento intermedio entre la medicina acadmica y la subcultura alqumica. Paracelso critic el galenismo desde los presupuestos de la alquimia. Desplaz a un segundo plano la teora de los cuatro elementos y de los cuatro humores, y convirti las tres sustancias alqumicas en el centro de su visin del organismo humano y sus enfermedades. Seal que todos los seres, vivos e inanimados, se integran por la combinacin en proporciones variables de mercurius, sulphur y sal. Eran stos al mismo tiempo, elementos y modos de comportarse la materia. Cuando se quema un cuerpo, el mercurius sera lo voltil, que se escapa en forma de humo; el sulphur, lo combustible, lo que produce la llama; y la sal, lo que resiste al fuego, que queda en las cenizas. Finales del siglo VXII: Polarizacin Ya se llega a un punto donde el Galenismo se opina desde distintos puntos de vista: - Intransigencia total hacia las ideas galnicas - Galenismo moderado - Novatores (anti-galeno) A partir de aqu, aparecen Cambios institucionales: - Foundation of institutions and academies of science and medicine: Jardin du Roi (Paris,1635), Accademia dei Lincei (Rome, 1602), 27

Royal Society (1660), Acadmie des Sciences (1666), Academia Naturae Curiosorum (Schweinfurt, 1652) - Great movement of institutionalization of scientific knowledge - Organization of a regulated system affecting science and artifacts - Spain: first botanical gardens (Aranjuez, El Escorial, Valencia) , Academy of Mathematics (Madrid), Casa de Contratacin (Seville)

23. Galenism in the 16th-17th c. Cambios en la medicina galnica


*La primer aparte no responde a la cuestin. Es una breve introduccin al Galenismo para comprender los cambios que se dieron posteriormente. La culminacin de la cultura mdica helenstica corresponde a la ltima etapa de su desarrollo y tiene como mximo exponente a la figura de Galeno de Pergamon (130200aC.) Su obra abarca ms de 100 tratados que contienen la doctrina mdica dominante durante toda la Edad Media y gran parte de la Moderna. Su perspectiva privilegiaba la parte doctrinal de la medicina y su conexin con los saberes tericos, que eran comparados en la escala de saberes como de nivel superior los puramente pragmticos. Entre algunos de sus logros, Galeno hizo aportaciones a los saberes anatmicos: descripciones de los msculos, huesos, vasos, nervios y vsceras. En los aspectos teraputicos, Galeno era ms activo y decidido que los hipocrticos. Defenda una terapia muy elemental pero metdica, basada en la curacin por el uso de remedios con las casualidades contrarias a la de los causantes de las enfermedades. Este punto de vista obedece el aforismo contraria contraris curantur y buscaba el restablecimiento del equilibrio perdido. Galeno era partidario de la accin decidida del mdico y no de la actitud expectante propia de los hipocrticos.

Los conocimientos mdicos atravesaron durante los siglos XV-XVI dos etapas diferenciadas: 1. La primera etapa coincide con el siglo XV y principios del siglo XVI y se caracteriz por el dominio de los textos clsicos ya reencontrados y traducidos por los rabes. A principios del siglo XVI, las obras de Galenos, Hipcrates, Aristtelesya haban sido traducidas y se tena una idea positiva sobre los conocimientos clsicos. Sin embargo, hubo un rechazo absoluto hacia los textos rabes medievales y desprecio absoluto hacia el escolasticismo.

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2. La segunda etapa coincide con la mitad del siglo XVI y se caracteriz por la correccin de errores del saber antiguo al ser contrarrestado con la experiencia sensible.

Estas dos etapas, con los cambios que introdujeron, supuso una renovacin que condujo a dos orientaciones fudnamentales que se desarrollaran por completo en el siglo XVII. El experimento risolutivo, formulado por Galileo y basado en la comprobacin prctica de una idea a priori, que dara a la formulacin de leyes matemticas que surgiran de la matematizacin de la naturaleza. La experiencia simptica (Erfahrung) descrito por Paracelso. Era entendida como un descubrimiento espiritual de lo que la realidad es en s misma.

Por otra aprte, hubo grandes avances tcnicos que permietieron mejorar la calidad de los estudios y de la observacin del cuerpo humano: mejora en la calidad de los microscopios, diseccin anatmica Las consecuencias que todo ello gener fueron: Reconomicmientos mdicos sobre la salud y la enfermedad: Cambios en la patologa Los saberes patolgicos procedentes del Galenismo fueron asimilados e interpretados de acuerdo con las diferentes corrientes intelectuales de la poca. Sin embargo, la teora de que la enfermedad se debe al desequilibrio de los humores perdi la fuerza, siendo sustituida por la teora de la enfermedad de Paracelso (reconocimiento de que la enfermedad tena su realidad propia). Nueva estequiologa: fibrilarismo La estequiologa es el estudio sobre cul era el elemento mminimo del que el cuerpo estaba formado. Segn esta nueva visin del cuerpo, el cuerpo tena tres tipos de fibras: las musculares, las cartilaginosas y las mixtas. Esta teora tena una base mecanicista enunciada por Descartes (la mejor manera de comprender las cosas era desmembrandolas hasta su pieza ms simple. Esta descripcin por lo tanto no es nueva, pues ya los antiguos cientificos helnicos y griegos y las culturas India y China describieron la teora del elemento. Cambio en el paradigma de la physiologa: Las aportaciones de esta nueva fisiologa renacentista fue el redescubrimiento de la circulacin menor o pulmonar (redescubrimiento porque fue descrita por Miguel Servet primero). Revision del conocimiento anatmico: (punto ms importante) La anatoma comenz a enriquecerse con nuevos detalles descriptivos, iniciando entonces una fase de recogida de nuevos datos empricos Revolucion vesaliana. Andres Vesalio era anti-galnico y su principal motivacin era desbancar las teoras 29

galnicas sobre la anatoma humana. Bas sus estudios anatmicos en la observacin directa, rechazando algunos errores anatmicos presentes en la obra de Galeno. Por lo tanto es el fundador de la anatoma moderna. Su sistema descriptivo se bas en la descripcin de 3 sistemas: El sistema constructivo El sistema unitivo El sistema animador La estequiologa de Vesalio era la misma que la de Galeno: humor, elemento y parte similar.

24- The institutional dimension of the scientific revolution: universities and academies
During the 17th and th 18th centuries, big progresses were made in the scientific and the literary environments, hence, the creation of academies where this knowledge could be shared and discussed was necessary. Therefore, this necessity lead to the formation of new institutions and academies of science and medicine where the scientific knowledge was shared, disseminated and learnt. This movement wasnt limited to few areas, but the scientific revolution involved many countries. For instance, an important institution was the Accademia dei Lincei, in Rome (1602), a project made by Federico Cesi, which was almost the first academy of sciences in Italy which perdured in the sinus of the Scientific Revolution. The name Linzei is a simbol of the linx and its ability of huge observation, the clue of the progress in science. Other institution was the building of the Jardin du Roi, in Paris (1635) was made thanks to the influence of Guy de la Brosse in Luis XVIII (duet oi the fact that the frst one was the doctor of the second). Then, the creation of a botanich garden of medical plants was created. Another one was the Acadmie des Sciences, founded in 1666, during the kingship of Luis XIV, which counted withs scientifics as Descartes, Pascal or Fermat. Its one of the five French academies which form the current Institute of France. As a curiosity, it was the first which addopted the methric decimal system as the universal one. On the other hand, the Royal Society of London was made in th 1660, and its the oldest scientific society of the United Kingdom. Its foundation dates in 1660, but years before, many scientifics met with periodicity. Moreover, there was a great movement of institutionalization of scientific knowledge and an organization of a regulated system affecting science and artifacts. For exemple, in the Spanish territory we can speak about the first botanical gardens such as the ones of Aranjuez or El Escorial. Furthermore, ion our city we have the Botanical Garden of Valencia, which was created from its origin for cultivating medicinal plants. We also should spaek about the Academy of Maths in Madrid, which was founded by Felipe II in 1582, for integrating the most important geographers, astronoms, engineers and military specialists related to the maths. And for finishing we must mention the Casa de contratacin de Sevilla, founded in 1503, very important in relation with the discovering of new geographical places, due to the fact that every people travelling to the New World had to give notice to the Casa de Contratacion and it was also the pace where the travellers to the India were preparred

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25. The influence of physics in 18th c. medicine


Influence of Newtonian Physics: Vitalism (Stahl, Montpellier School)

Vital force: forces in Nature: gravity, heat, electricity, light, magnetism Physiological properties (Albrecht Von Haller) Sensibility, irritability, contractility New ideas: Animal Magnetism Hemodynamic (Hales) Electrophysiology (Galvani)

The basic idea of what was life was still a question but they decided that it was stupid and that understanding how it worked was what really mattered. They were influenced by Newtonian physics. Newton translated into a mathematical expression the existence of the gravity and established a law trying to explain the attraction of bodies. This translation to mathematical expressions was the scientific ideal in that moment and scientists and doctors considered that everything had to be translated (light, magnetism) because those forces were the ones that controlled nature. Vitalism was used to explain things like digestion, intelligence because every change was considered to be caused by vital forces. This perspective provoked several discussions about the nature of the different forces; even the concept of vital force was ambiguous, so those forces needed to be studied and the founder of experimental physiology was Albrecht Von Haller. He said that living beings were different from the non-living ones because they had properties, facultas: sensibility (capacity to receive stimuli), irritability and contractility (reactions provoked by the stimuli). In this period body was not seen as something separated from mind, so vitalism caused a big discussion because some people thought that natural laws were different between living and non-living beings. Birth of experimental Physiology Benefits from advances in physics and chemistry: research on heat, electricity, combustion, oxidation, gas analysis New instruments (thermometer, calorimeter) Stephen Hales (1677-1761): Vegetable Statistics (1727) and Haemostatics (1733), physical behavior of the blood in mammals: pressure differences between arteries and veins

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Albrecht von Haller (1708-1777): first synthesis of physiological knowledge. Elementa physiologicae (1756-1766): functional properties of living matter: irritability, contractility and sensitivity. Respiration a chemical approach by J. Priestley and A. Lavoisier: end of phlogiston theory (17th c. GE Stahl) Electrophysiology experienced a significant boost due to the work of Volta and Galvani on animal electricity and nervous stimuli.

In the 18th century experimental physiology started to include new sciences, mainly chemistry and physics. There were new instruments (thermometers, calorimeters) because measuring was the most important concept. In medicine they measured some parameters such as blood pressure and established the idea of normality. Respiration (breathing) is just an example of this evolution of knowledge, because it totally changed with the discovery of oxygen. The phlogiston theory was abandoned because a new theory appeared. Another example of controversy is electrophysiology: Galvani said that nervous stimuli were electric (he produced contractions in frogs legs using electricity) but Volta was against this.

26. Public health and the political ideology of the Enlightenment


The Age of Enlightenment was a cultural movement of intellectuals in the 17th and 18th centuries, which began first in Europe and later in the American colonies. Its purpose was to reform society using reason, challenge ideas grounded in tradition and faith, and advance knowledge through the scientific method. This was due to the influence of newtonian physics (the vitalism), because of the birth of the experimental physiology and the improvement of technologies. This advances promoted scientific thought, skepticism and intellectual interchange and opposed superstition, intolerance and some abuses of power by the church and the state. Public health started in a thought, an idea, that arose in Europe at the end of the 18th century, nourished by the main social and sanitary determinant: the Industrial Revolution- city crowding led to increased incidence of disease and those suffering from a disease were not good workers, and partly inspired by Enlightenment. This cultural movement changed contemporary perspectives- political, social, and also medical, and, during the French Revolution, marked a direction for the changes that would define the new France and differentiate it from the Ancient Regime: the Declaration des Droits de lHomme was adopted as a first step towards writing a constitution for France, based on Enlightenment principles and defining a set of individual and collective rights for everybody, and this led to the consideration of health as a human right. In 1790 the Comite de Salubrite was created, and this committee received conclusive reports from Villerm, who studied the epidemiological situation of people in prisons, hospitals, city outskirts, etc., statistically, indicating how a greater proportion of people living in places with poor hygienic conditions suffered disease that those living in cleaner sites.

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This was but the start of the reformist ideology and was followed by multiple similar initiatives; for instance, in the UK Edwin Chadwick led the Sanitary Movement. At this time medical statistics gain importance thanks to epidemiologists as William Farr or Mc Culloch who developed A statistical account of the British Empire. In Germany Johann Peter Franck published the Medizinische Polizei that was a 9-volume treatise that dealt with all aspects of hygiene and economic policies of public health. Hyeginist litterature was very useful to increase the knowledge about hygiene in Europe. Rudoplf Virchow lead the Medizinische Reform in 1848, he tried to improve the medical situation of Berlin in his years as a politician. He is considered the father of social medicine. Von Pettenkoffer published Uber die Wert der Gesundheit fur eine Stadt (1873) highlighting how the costs of improvements in hygiene would be paid off by the decrease in morbidity and mortality . This introduced the thought that health is wealth and encouraged a series of initiatives to stop impoverishment of the country due to disease and ensure wealth and progress, such as the creation of the Krankenkassen in Germany to give public medical assistance to the poor, the Poor Laws in the UK for abandoned children, widows, unemployed, and the like. In Spain the hygienist ideology of the Enlightement also develops but in the XIX century thanks to specialist like Mateo Seoane that carries out the Consideraciones generales de Estadstica mdica in 1837. Epidemiology becomes important and as a result they created the Boletn de Estadstica demogrfica-Sanitaria de la Pennsula e Islas Asyacentes (1879). The thought of Health is Wealth encouraged International Sanitary Conferences during the second half of the 19th century. As trade evolved and merchants bought and sold over empires, a need for an international regulation arose, and measures, including the introduction of new concepts such as quarantines, to protect public health were introduced. These conferences encouraged the creation of a public health administration and public health experts together with humanitarian health care organisms that ensured that any person could receive medical assistance when they needed it (Rockefeller Foundation, Red Cross...) and international offices such as the League of Nations. This International Sanitary Movement, motored by the principle that public health is wealth, lead also to the organisation of health care in hygiene centres, dispensaries, campaigns, etc. In addition, professions such as doctors, vets and pharmacists (but also engineers) started the politics of health, encouraging the creation and introduction of a new concept: the Providential State. This arose as consequence of the necessity of attending excluding people, like widows or retired people; in Southern Europe close family nuclei attempted to supply the absence of protection and in them the Providential State started later, but was ultimately introduced too to guarantee health, well-established as a human right, and compulsory working insurance, retirement pay, or social insurance, appeared, thus making up the precursor of our current Welfare State.

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27. Health care and the providential state. Historical context


La construccin del Estado del Bienestar en Espaa comenz durante el periodo de la Restauracin con el establecimiento de la Comisin de Reformas Sociales en diciembre de 1883, como parte del reformismo liberal. En un principio naci como Estado de Providencia, para ms adelante ser llamado Estado del Bienestar. La Comisin surgi con el objetivo de estudiar todas las cuestiones que afectasen directamente a la mejora o el bienestar de la clase obrera y las cuestiones que afectan a las relaciones del capital y del trabajo, por iniciativa de don Segismundo Moret. Fue la primera institucin en este pas que se preocup de la realidad social de los obreros en Espaa. La tarea esencial asignada a la Comisin consisti en la obtencin de informacin acerca de la situacin de la clase trabajadora. Para alcanzar sus objetivos polticosociales, la Comisin abri una gran encuesta (1884) en todo el Estado en la que podan participar los individuos y sociedades que desearan contestar el formulario remitido. Una parte sustancial del cuestionario tena que ver directamente con las condiciones de vida y trabajo de la clase obrera. La informacin obtenida fue importante, ya que en ella se desvelaron la amplitud de los problemas sociales que afectaban a la clase obrera y las condiciones de explotacin que sufra. El Estado Providencia como tal, tuvo sus orgenes con el surgimiento de una serie de instituciones. En 1903 fue creado el Instituto de Reformas Sociales (IRS), bajo un gobierno conservador (Antonio Maura). El IRS vino a sustituir a la Comisin y signific la institucionalizacin de la reforma social. Ahora ya contaba con rganos estables, funciones definidas e incluso una plantilla administrativa y un presupuesto. Entre sus tareas se encontraban las de preparar la legislacin del trabajo, cuidar de su ejecucin y favorecer la accin social gubernativa en beneficio del bienestar de las clases trabajadoras. A continuacin, el Instituto Nacional de Previsin (INP) fue establecido en 1908 con el fin de preparar, administrar y desarrollar un moderno sistema de seguros sociales, especialmente programas de pensiones de vejez. Estaba basado en el principio de libertad subsidiada, lo que significaba que los seguros eran voluntarios y estaban subsidiados por el gobierno. El trabajador industrial poda pagar una cuota de la cuanta que deseara, siendo la entrega mnima de media peseta mensual. El estado contribua con la misma cantidad que el trabajador sin que aqulla excediera una peseta al mes. Ms tarde, surgi el Ministerio de Trabajo y Previsin Social, en 1920. Este es el que actualmente conocemos como Ministerio de Empleo y Seguridad Social. En 1917, se celebr una nueva Conferencia sobre Seguros Sociales en Madrid. En ella se acord que exista la necesidad de establecer un sistema de seguros sociales obligatorios por etapas. En 1919 se cre el Retiro Obrero Obligatorio para todos los trabajadores industriales entre 16 y 65 aos y cuyo salario no sobrepasara las 4.000 pesetas anuales. Este programa sera financiado por el estado y los empresarios en una primera fase, mientras que los trabajadores deberan pagar una cuota obligatoria en una segunda fase. 34

Durante 1920-1935 se establecieron finalmente una serie de medidas que beneficiaran a los trabajadores: seguridad social obligatoria, jubilacin, seguros de trabajo, accidentes, Cabe aclarar que el Estado Providencia fue el paso que precedi al surgimiento del Estado del Bienestar, es decir, fue sus orgenes y antecedentes. Esta es la diapositiva del powerpoint que corresponde a esta pregunta (nmero 69):

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28. Historical context of the cell theory.


Due to the invention of the microscope in 1590 and its application to the study of live structures, the concept of elemental unit of the live mattery adopted a new dimension. It was in this moment when the concept of cell appeared by the scientist Robert Hooke. But despite of that, appeared the first stoichiology* around the concept of fiber and the morphologic sciences not only took into account the macroscopic study. Nevertheless, many scientists refused using the microscope because depending on the lens they used different things were seen, and with that, the weak doctrine of the fiber was doubted and was a return to the macroscopic observation. This period of time corresponds to the second half of the 18th century, when the concept of tissue appeared thanks to the anatomist Xavier Bichat that defended the sensualism and vitalism. Later, from 1830, optic microscopes began to develop and many cellular theories began to appear thanks to some authors like Schleiden (due to observations on plant cells) or Schwann (observation on animal cells) that introduced the idea that the cell is the basic unit of tissues founded on: Importance of the nucleous. In 1831 Robert Brown observed it. The cell as a morphofunctional unit.

This was a change from the previous century, when the elemental unit was considered to be the tissue, we can say that the whole concept of cell changed from the point of view of Hooke to that moment. However, scientists disagreed on how did cells appeared or reproduce. Schleiden thought about gemmation and Schwann on blastema or citoblastema. At the second half of the 19th century Rudolf Virchow, a German pathologist, exposed the idea that every cell came from a preexistent cell. For Virchow all pathologies had a cellular basis. In that moment, appeared a new explanation about how does the body is constituted and what happens with the cells during illnesses. Furthermore, Jakob Henle described the cell mitosis in embryonary tissues and Jan Purkinje the active role of the protoplasm. From 1850 there was a huge change in the biological science because of: Publication of On the Origin of the Species. Microscope. Discovery of the cells. Mendel laws.

It was a period of great changes that we have to take into account. It was an authentic Scientific Revolution. *the branch of biology concerned with the study of the cellular components of animal tissues.

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29. The neuron theory.


The 19th century saw the rapid development of experimental medicine in many areas, including, perhaps most notably, physiology and microbiology. The most important paradigms in which actual medical knowledge is based, such as the germ theory, the cell theory, or psychoanalysis, were proposed and accepted. However, none of them saw immediate approbation and had to overcome considerable debate until their final establishment. This was also the case for the neurone theory. As the optical microscope was reinstated at the start of the century, new concepts such as tissue (Bichat) and nucleus (Brown) were introduced, and Schleidens and Schwanns observations of plant and animal cells, respectively, brought the full incorporation of the concept of the cell as morphofunctional unit responsible for the specialised functions of living tissues. This was a very ambitious proposal that required all tissues to be made up of cells; cells were gradually described in all tissues, except in the nervous tissue. Most histologists thought that the nervous system was an exception to the cell theory and that it was actually a reticular system, a continuous net across which nervous impulses would flow. The most important figure defending this reticular theory was perhaps Camillo Golgi, who developed the black reaction, based in silver impregnation, as a histologic technique for the observation of nervous tissue. With this technique, Golgi showed that dendrites did not fuse into a net, as Walther Gerlach thought, and that the axon was ramified; though he still advocated for reticularism, only in a different way to Gerlach. His reticularist ideas were endorsed by some evidence, such as investigations by Marie-Jean Flourens, a neurobiologist who said that the functions of the cerebral cortex, for instance memory and cognition, were the result of global cortical activity. Lo que est en gris es extra, lo he puesto porque no me pareca que tena mucho sentido si no explicaba algo de Golgi pero en el power slo dice que era un reticularist y no mencion mucho ms en clase. Santiago Ramn y Cajal, however, did not agree. He was a neuroanatomist and thought that the nervous tissue was, too, made up of cells. He affirmed that these cells, called by Heinrich Waldeyer neurones, showed a dynamic polarisation, which explained the unidirectional travel of the nervous impulse from the dendrites to the axon, and proposed laws for the transmission of the impulse from one neurone to the other. Cajal also developed a new staining technique, the double chrome silver impregnation (as opposed to Golgis single argentic technique), and showed the existence of individual cells in brain, then in the retina, olfactory bulb and spinal cord. He finally published El sistema nervioso del hombre y los vertebrados in the first decade of the 1900s. German speaking countries were the first to accept this work, because they were in favour of research but also because they were in favour of the cell theory and neuronism could become its ultimate proof. Others, however, criticised the yet unproven existence of a cytoskeleton in the hypothetical neurones, which the rest of cells did have. Luis Simarro, who taught Cajal staining techniques during their stay in Madrid, then developed an improved silver-based stain: the technique of the silver nitrate, which he used to perform studies of neuronal degeneration. This stain, unlike 37

Golgis and Cajals stain, allowed the observation of structures in the neural cytoplasm, and Cajal, with whom Simarro kept correspondence, used Simarros technique to show the neurofibrillar arrangement in nerve cells, thus refuting these criticisms. With neurones included into the cell theory, this paradigm experienced a new phase of experimental biology based on improving the technical capacity for observation and consequent unravelling of how the cell behaves, how it regenerates or not, how it develops, how it works (genetics)... This determined, between the end of the 19th century and until the outbreak of World War I, a core crystallisation of contemporary studies on cell physiology, molecular biology, biochemistry, genetics...

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30. EXPERIMENTAL RESEARCH OF ORGANIC FUNCTIONS IN NTHE 19TH.


The 19th century (from the French revolution to the Second World War) is the period in which most of the scientific knowledge in medicine and in biology is renewed. The new paradigms and the new theories are proposed, like the cell theory. From the theoretical perspective (not practical) of the health of the human body the most important theories were proposed and accepted in the 19th century. But from a technological perspective, in medicine, the capacity of intervention in the human body, the real revolution, took place after the IIWW. A new paradigm appeared in the XIX century and it also had a great influence in physiology. The physiological thinking experienced a Copernican change in the 2nd half of the 19th century. Before this, mainly in Germany (Lamarck), we could find the romantic philosophies, naturalistic philosophies that had an idealistic conceptions of nature in which this one was always moving and all animals evolved according to an idea introduced by the Creator. This philosophy was led by the idea of polarity that defended that the smaller and less evolved animals tended to go up in the evolutionary ladder, becoming more and more complex, until arriving to the humans. This tendency to evolve is very close to the first transformation theories, before Lamarck and Darwin, since the end of the 18th century. But, this speculative physiology, based on philosophical ideas, was substituted, in the second half of the 19th century, by an experimental movement against speculation. Conclusions should be made only on the facts we see, no new ideas should be added if not tested. This radical empirism tried to counter balance the previous speculative ways. And the empirism together with the positivist movement, led Claude Bernard to introducing the experimental medicine. He also tried to justify and rationalize how, in biology and physiology, the dynamic of the living beings is based on a deterministic approach cause-effect, and how this is not a contradiction or a materialistic approach at all. He created the concept of internal medium, which was the previous concept to homeostasis (capacity to regulate the conditions in which the internal dynamics take place independently from the external medium). When decades passed, the main topic in physiology, at the beginning of the 20th century, became the regulation of animal processes: how do animals regulate the internal processes? Two ideas appeared: one was the discovery of internal secretion glands, endocrinology (chemical regulation through hormones); the second one was the nervous regulation. They also studied how both of them, in collaboration, affected the development of physiological functions. This led to the idea of organic integration. The concept of organic integration refers to the fact that we are not organs that are put together however we have a biological identity.

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31. EXPERIMENTAL PHYSIOLOGY AND THE CONCEPT OF ORGANIC REGULATION


The development of the experimental medicine took place during the 19th century. The change from the clinical medicine to the experimental one was possible in that moment due to the appearance of the new specialties such as microbiology, physiology or genetics and the creation of new technologies for diagnosis and therapy. The classical space of production of the medical knowledge was the hospital, but in that moment it moves to the laboratory creating the concept of laboratory medicine, based on the experimental investigation. This change of mentality allowed the development of the experimental physiology thanks to the laboratory investigation in the organic functions. However, in order to arrive to this point, it was necessary to overcome three main obstacles: The belief of a great difference between the three levels of life complexity: vegetal, animal and human being. Overcome the belief that the phenomena that occur in the healthy organism are different to the ones that occur in sick organisms. It was needed a scientific differentiation between chemical and physical phenomena that occur in inert and living matter.

This experimental physiology focused on the explanation of the origin and development of diseases and this interest lead to the appearance of a great number of new devices such as the electrocardiograph, the electroencephalograph or different measuring tools. So, it is clear that the main objective was the objectification of the symptoms (the measure of them). In addition, in order to reach this aim, different metabolic tests were also created. But this change could not be possible without the help of Claude Bernard, considered as the principal creator of both the modern physiology and the experimental medicine. His main contributions were the concept of homeostasis and his studies about the nervous system, which include the discovery of the sympathetic system and its functions. Medicine according to Claude Bernard is based on the experimental practice. The observation of the patients should give ideas about the problem and these ideas have to be justified by the experimentation. In this field, we should mention also Karl Wunderlich, famous for his studies about human body temperature. To end up, we should take into account two physiologist of the early 20th century that focused on organic regulation: Walter Cannon and Charles Scott Sherrington. Walter Cannon expanded Claude Bernards concept of homeostasis, defending the constancy of the internal medium and the existence of a regulatory system that determines this homeostasis due to different cooperating mechanisms acting simultaneously, such as hormones.

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Charles Scott Sherrington gained the Nobel Prize thanks to his neurophysiological studies related to the integrated functions of the nervous system.

32. Physiology, physiological chemistry, biochemistry and molecular biology


The cell theory meant the start of a new phase in experimental biology, which represented a point of departure between cell physiology and molecular biology (which focuses on subcellular structures such as proteins, nucleotides and nucleic acids), taking place from the end of the 19th century and until the end of World War II. This new paradigm also had a great influence in physiology. Thus, the physiological thinking experienced a Copernican change in the second half of the 19th century. Before this period, we could find the romantic philosophies, naturalistic philosophies, mainly in Germany (Lamarck), that had an idealistic conception of nature: nature was always moving and all animals evolved according to an idea introduced by the Creator. This philosophy was led by the idea of polarity, which defended that smaller and less evolved animals tended to go up in the evolutionary ladder, becoming more and more complex, until arriving to the humans. This tendency towards evolution is very close to the first transformation theories, before Lamarck and Darwin, by the end of the 18th century. However, this speculative physiology based on philosophical ideas was substituted in the second half of the 19th century by an experimental movement against speculation. This radical empiricism stated that conclusions should be based only on the facts we see, and that no new ideas should be added if not tested. The empiricism together with the positivist movement led Claude Bernard to introducing the new experimental medicine. He tried to justify and rationalize how, in biology and physiology, the dynamic of the living beings is based on a deterministic cause-effect approach, and how this is not a contradiction or a materialistic approach at all. He created the concept of internal medium, which was the previous concept to homeostasis (capacity to regulate the conditions in which the internal dynamics take place independently from the external medium). At the beginning of the 20th century, the regulation of animal processes became the main topic in physiology. Two ideas appeared: one was the discovery of internal secretion glands, endocrinology (chemical regulation through hormones); the second one was the nervous regulation. They also studied how both of them, in collaboration, affected the development of physiological functions. This led to the idea of organic integration: we are not organs that are put together, but we have a biological identity; and as a consequence, it opened another line of investigation which was immunology and the recognition of what is ours and what is alien. The three main lines of research after the discoveries of the new experimental physiology were physiological chemistry (the study of nutrients and their effects, differentiating the normal and pathological composition of the body by analyzing organic products and checking the pureness and composition of urine, blood), the 41

capacity of synthesizing organic matter and biochemistry (the study of metabolism, biological cycles etc.). They tried to analyze from a chemical perspective the animal physiology, as well as apply knew knowledge to clinical practice (for instance, in the case of blood analysis). Currently, the cell paradigm is being substituted by the molecular paradigm in the sense that molecular biology is reorganizing knowledge in the medical territory, including medical physiology, medical pathology, etc. Therefore, new molecular diagnoses and prognoses applied from a genetic perspective are bound to steer nowadays medicine towards a clinical practice in which each individual is considered to be unique and different from any other one, and because of that, personalized assistance will take more and more important positions in the future of medicine.

33. Anatomopathological Medicine: concept, historical context and signs of lesion


El movimiento anatomoclinico se desarroll con las nuevas escuelas mdicas del siglo XIX. La institucin hospitalaria jug un papel decisivo en este desarrollo junto con el apogeo de la bsqueda experimental que se traslad a los laboratorios. A pesar de la existencia, obviamente, de hospitales en pocas anteriores esto cobr gran importancia a medida que avanzaba la industrializacin y aumentaban las agrupaciones urbanas. As lo exiga el aumento de enfermedades infecciosas consecuencia de las malas condiciones sanitarias de las ciudades y la masiva emigracin desde zonas rurales. El cambio epidemiolgico demandaba nuevas instalaciones hospitalarias y proporcionaban material abundante para la observacin clnica y para la prctica de necropsias post-mortem. Esta nueva forma de medicina se inici en Francia como consecuencia del movimiento revolucionario y alcanz su mxima expresin en los hospitales de Pars, una vez que el triunfo de la Revolucin haba acabado con las viejas instituciones y academias del Ancien Rgime. La inauguracin en 1794 de la cole de Sant marc un hito en la docencia mdica. A partir de entonces iniciaron un proceso de cambio influido intelectualmente por el movimiento de los idologues. El mximo representante de los idelogos en el campo de la medicina fue Cabanis quien tuvo una enorme influencia en el desarrollo de la Escuela Clnica de Pars. Profundamente influido por la filosofa sensualista de Condillac, Cabanis supona que el origen del conocimiento est en las impresiones captadas por los sentidos, y de este punto de vista proviene la importancia que otorgaba a la observacin clnica hasta el punto de que la medicina de la poca aspiraba a construirse exclusivamente desde fundamentos clnicos. El clnico ms destacado fue Pinel, conocido como psiquiatra y reformador de los asilos para locos. Cabe sealar su influencia sobre el joven Bichat, cuya actividad frentica lo llev a diferenciar 21 tejidos en el organismo. Adems de esto enunci algunas concepciones fisiolgicas de carcter vitalista con ciertos matices nuevos como la definicin de fuerzas vitales especficas asentadas en cada uno de los tejidos. Este cambio tan importante en el vitalismo alcanz una fuerte implantacin a causa de su aceptacin y difusin por parte de la Escuela de Montpellier, ncleo fundamental del vitalismo del momento. Lo ms significativo de su obra es la orientacin localicista 42

y solidista en la concepcin de la enfermedad y por tanto su inters por la anatoma patolgica. Otro conocido autor, Broussais, fund una llamada medicina fisiolgica que deriv en un sistema cerrado y sin salida. En general, los supuestos de la Escuela de Pars se basaban en la exploracin fsica y la diseccin como fundamento inmediato de la clnica. Estos dos aspectos estn perfectamente ejemplificados en Corvisart, mdico de cmara de Napolen y uno de los primeros defensores de la leccin clnica junto a la cama del enfermo. Sus discpulos Bayle y Lannec desarrolaron las tcnicas de auscultacin perfeccionadas por la invencin de este ltimo del estetoscopio. Estas nuevas ideas que asociaban la enfermedad al concepto de lesin se extendieron por toda Europa encontrando como ejemplos Dublin, Guys Hospital Por tanto, el movimiento anatomoclnico dio lugar a la formacin de una nueva semiologa basada en el concepto de lesin y desde su inters por la lesin promovi tambin directamete el progreso de la estadstica clnica y la ciruga. El desarrollo de la perspectiva emanada de la Escuela Clnica parisina dio lugar tambin al nacimiento de la anatoma patolgica y la teraputica as como a la aparicin de las primeras especialidades mdicas: Dermatologa, pediatra, psiquiatra o toxicologa.

34. Physiopathological Medicine: concept, historical context and signs of dysfunction


Appears in Germany in the central decades of the 19th. Consists in the explanation of the disease in a more dynamic way, in other words, it is the study of organic dysfunctions in a mesurative and experimental way taking the disease as a process with functional proofs. To understand in a scientific way the functional dysfunctions of the organism they take them as energetic or material processes being able to analyse them with physic resources or chemistry resources, respectively.

Fever was the first functional alteration who was studied in a scientific way as a energetic process Carl R. August Wunderlich (1815-1877) wanted to discover by experimentation that changes temperature in the diseases where funded over a principle (in this period it was already known that animal temperature was mainly created by organic oxidation and the thermodynamic law was also discovered). With this, Wunderlich published in 1868 The Behaviour of Body Temperature in Diseases where he exposed the physics principles of fever and made a recompilation of the different temperatures in different diseases with the thermometer becoming this apparatus the first objective sign of a functional dysfunction. The scientific study of the organic dysfunctions as material processes was started by Friedrich T. Von Frerich (1819-1885). Professor of medical clinics in various German universities with his main publication Clinics of the Disease and the Liver where his major contribution was to show that the acute yellow atrophy of the liver, one of the functional consequences in cell destruction was caused by an alteration in the metabolism of proteins.

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New Semiology: The physiopathology started to enrich with a series of dysfunctional signs of physical or chemical types. This was possible by making graphic tracing of the different dysfunctions thanks to recording apparatus used in: Sphygmography (1854, Karl Vierodt and 1860, Jules Marey), tracing of the arterial pulse using a shpygmograph. Electrocardiography, (1910, Willem Einthoven). Electroencephalography (1929, Hans Berger). Functional proofs: They were done in order to make the dysfunction appear and observed it controlling the variables. Test of the Alimentary Glycosuria (functional capability of diabetics) Eduard Klz (1845-1895) Renal, Cardiac, Hepatic funcional proofs... Conversion of the spontaneous signs into physiopathological signs: Kussmaul breathing (1874) in severe Diabetic ketoacidosis or Kussmauls sign(1873) paradoxical pulse in Constructive pericarditis. Physipathological nosology and nosography: Dysfunctions that are constant and particular of each disease characterise both the dysfunction and the injury. Disease patterns are not just the signs and symptoms but recurring injuries, dysfunctions and causes of disease. Nowadays, the dysfunctions and the physiopathological dysfunction semiology has more hegemony in the endocrine, metabolism and nutrition diseases. It also appears a new discipline: The Experimental Pathology started by Ludvig Traube(1818-1876), R. Virchow and B. Reinhardt and Julius F Conheim (1839-1884), and it was based in the study of dysfunctional processes in animals.

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35. Etiopathology and causes of disease: concept, historical context and dimensions
In the Galenic Medicine, the concept of the causes of the diseases was directly influenced by the Aristotelic natural philosophy and it was not until the Modern Ages that the occidental medicine explained infection by microscopic or macroscopic organisms. However, the spontaneous generation of life still did not have any scientific explanation and it was still the object of polemics. In this historical context, a new scientific doctrine, etiopathology, was born. This doctrine was created in the last part of the XIXth century and the first decades of the XXth and gave an experimental approach to the causes of diseases. These causes of diseases were divided in two: 1.External causes of diseases: Correspond to infectious causes. In a first stage, diseases were believed to be physical or chemical however little by little, new disciplines such as toxicology or miasmatic ideas were born which gave a new conception of contagion. These miasmatic ideas were a general doctrine that explained the contagion of diseases by miasmas. Miasmas were generated by water or food or places of the environment in bad sanitary conditions. This therefore, was the beginning of the ideas of infection and the mechanism of transmission. A further study of diseases was done thanks to the introduction of the microscope as an observational element and to the creation of the microscopic parasitology by Francisco Redi which helped scientists to understand contagion by living beings. The discovery that surgeons hands were a route of spread of puerperal infection created the concept of antisepsis or the use of chemical solutions for disinfection (J. Lister) and asepsis or absence of infectious organisms (Semmelweiss). However, it was not until the second half of the XIX th, that the idea of infection was truly conceived. This was due to the creation of bacteriology by Louis Pasteur and Robert Koch. In the XXth century, bacteriology was further developed and new contributions were given by doctors and scientists. Some examples of this were the creation of immunology and serology by Paul Ehrlich and the progressive consolidation of a new symptomatology given by immunologic proofs. 2.Internal causes of diseases Corresponded to hereditary causes. In the Galenic medicine, pathology had a direct relation with the function of the body by the four humors. These four humors had specific and opposite qualities and according to the higher or lower predominance of one of them, a temperamental predisposition to a disease was given. At the end of the XIXth century, Kretschmer defined 4 biotypes (leptosomic, athletic) each one related with a particular idiosyncrasy or with particular traits that made them have a higher or lower predisposition to some diseases. Both the Galenic medicine and the Kretschmer biotypes originated the constitutionalist tradition. Nevertheless, the scientific explanation to pathologic heritage, that is to say, the transmission of certain diseases (formation of monsters and teratology (study of abnormalities of physiological development)) due to hereditary causes was not created until the last century. Another great contribution of the XXth was genetics (chromosomic theory and DNA). Its creation helped in the understanding of some diseases, the technical dominance of heritage and the possibilities of technical action in medicine. 45

Con los sucesivos avances tecnolgicos y el nacimiento de los sistemas nacionales de salud auspiciados por el estado de bienestar en los pases industrializados, el hospital se convirti en el principal emblema de la nueva medicina. La institucin hospitalaria era el nico escenario capaz de integrar el creciente grado de tecnificacin de la asistencia de la salud. La creciente tecnificacin de la asistencia sanitaria creci paralela a un proceso de transformacin muy importante de la institucin hospitalaria y su funcin social. La revolucin tecnolgica que ha tenido lugar a lo largo del siglo XX no solo ha incrementado el nmero de hospitales y camas sino que los ha llenado de instrumentos cada vez ms sofisticados y complejos. El inicio de este de ese imparable proceso de transformacin hospitalaria puede situarse en el descubrimiento y la inmediata aplicacin clnica de los rayos X. Su empleo sanitario no solo modific los hbitos y costumbres en cuanto a la exploracin clnica, sino que tambin favoreci la confianza del mdico en la tecnologa. Mas tarde, apareci el ECG, que represent el ideal de la medicina anatomo-clnica al permitir la visualizacin en el interior del cuerpo de las lesiones provocadas por las enfermedades. Ms descubrimientos fueron hechos como el laser, los ultrasonidos y la medicina nuclear, que solo fueron el principio de esta revolucin. Poco a poco estos descubrimientos ya no se basaban solo en mejorar la medicina sino que adems generaban grandes beneficios y se iban concentrando en unas pocas industrias de grandes dimensiones. Sin embargo, tambin supuso un incremento enorme del gasto hospitalario, lo que desencaden la preocupacin de los economistas de la salud y de los polticos. El elevado coste que significaba la discrecionalidad del uso de los recursos sanitarios puso en marcha en muchos pases 46

los informes justificativos de su empleo. Al mismo tiempo, es el momento en el que empieza a revisarse el modelo sanitario y se establecen jerarquas en los hospitales principalmente en funcin de sus recursos tecnolgicos. La enorme dimensin de este fenmeno ha provocado la subordinacin del paciente como sujeto de la enfermedad a la tecnologa sanitaria y ha provocado la medicalizacin o desnaturalizacin no solo de la enfermedad sino tambin de fenmenos naturales como el embarazo, el parto o el envejecimiento. La tecnologa sanitaria como instrumento del poder profesional de los mdicos y de control social de la poblacin ha encendido las luces de alarma de colectivos defensores de los derechos humanos y ha reforzado la aparicin de normas de proteccin de los derechos de los pacientes frente al poder de la tecnologa asistencial y de los profesionales sanitarios.

37. La relacin mdico-paciente:


La relacin mdico-paciente, ha ido evolucionando a lo largo de la historia de la humanidad. En primer lugar, podemos observar la existencia de una relacin patrialcal en la que el mdico era el encargado de curar a sus pacientes mientras que el enfermo tena un rol de persona disminuida de sus funciones, incapaz A pesar de este hecho, la relacin se basaba en una relacin humana donde el mdico tena una relacin directa con el paciente, la cual se mantuvo hasta la revolucin cientfica (s. XVI y XVII). Sin embargo, con el aumento de la tecnologa, ha hecho que, en la actualidad se basa en una relacin con el sistema de salud pblica siendo una relacin con la tecnologa, la administracin, de forma que se ha perdido gran parte de ese componente humano caracterstico de la relacin mdico-paciente. Asimismo, tambin, el rol del paciente ha ido cambiando pues ha ido adquiriendo una serie de derechos que antes no posea. A pesar de que se han aumentado sus derechos, la relacin no se supone igualitaria debido a que se produce entre un especialista frente a una persona, paciente que sufre de una determina enfermedad. En consecuencia, este tipo de relacin ha originado una relacin desigual de forma que existen diferencias en: Diferencias del papel y el estatus de los participantes: ya que el mdico es concebido como la persona que posee el conocimiento mientras que para el paciente la enfermedad puede suponer un punto de ruptura donde se pasa del concepto de persona sana al de persona enferma. Diferencia entre las expectativas: el paciente es una persona que pide ayuda para recuperar la salud mientras que el mdico es un profesional que busca su reconocimiento por el papel que tiene en la sociedad mediante su papel como profesional as como por sus investigaciones. Diferencias en la dimensin humana: las relaciones se deben de basar en la confianza, confidencia (confidence) y moverse entre los lmites personales y profesionales lo que puede generar una mayor o menor implicacin con el paciente.

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