PERSPECTIVES ON DISEASE
Ed Friedlander, M.D., Pathologist
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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

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Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
Genes
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Autoimmunity
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Aging
Infections
Nutrition
Environmental Lung Disease
Violence, Accidents, Poisoning
Heart
Vessels
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White Cells
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Ear
Autopsy
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Lab Problem
Quackery
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

LEARNING OBJECTIVES
Course Introduction and First Hour

Outline the scope of the introductory course in pathology and clinical pathology. Describe the announced criteria for passing, and the factors that will be considered in any narrative performance summary. Give the title or nickname of the course text or the last name of its first author.

Describe the scope of pathology as a discipline. Distinguish general, systemic, anatomic, and clinical pathology. Mention at least three things a pathologist does when he or she is not teaching medical students! Tell how to contact your pathology instructors.

Identify Rudolf Virchow as the founder of modern pathology. Explain briefly the idea that pathology deals with human beings from the molecular to the social levels, and mention at least one health problem "caused by politicians".

Explain why we call our approach to pathology "scientific", and why we believe that we are telling you the truth. Distinguish various levels of scientific statements ("theory", "hypothesis", etc.) Answer common criticisms of pathology education made by non-physicians. Mention and justify at least one criterion for evaluating a media health claim.

Define iatrogenic disease, mention the extent of the problem, give at least two examples, and explain why some iatrogenic disease is acceptable. Comment on the application of Hippocrates' dictum, "First Do No Harm" to today's medical practice.

Mention how we screen for color-blindness, and tell what a color-blind student should do in lab.

KCUMB Students
"Big Robbins" -- Cell Injury
Lectures follow Textbook

INTRODUCTION

Where there is love of medicine, there is love of humankind.

Test all things; hold fast to what is good.

INEVITABLE, SERIOUS DISEASES: Everyone who lives long enough will probably get:

OUR VERY COMMON, SERIOUS DISEASES

OUR VERY COMMON, USUALLY LESS SERIOUS DISEASES (NON-DISEASES, ETC.):

WORLD HEALTH

WORDS FOR COMMON AND/OR TRANSMISSIBLE DISEASES: You need to know these terms.

HOW COMMON IS A DISEASE?

OUR FATAL DISEASES YESTERDAY

OUR FATAL DISEASES TODAY

What kills young people in the US?

The average American's chances of being killed by (Nature 367: 39, 1994):

LIFESTYLE-RELATED DISEASES:

Despite the claims of "alternative medicine", the following are probably not significant health problems. (Let us know if you have additional facts about these.)

INHERITED DISEASE AND BIRTH DEFECTS

DREAD DISEASES OF YOUNG ADULTS:

"NEW DISEASES" (unknown, rare, or seldom recognized a few years ago):

"NON-DISEASES" (i.e., named entities that produce no morbidity or are beneficial)

EASY-TO-MISS DISEASES

DISEASES WE SKIP

Other important medical problems are largely mechanical and you will learn about these on your rotations.

A few other important entities usually fall outside the domain of anatomic pathology:

RIGHT TREATMENT, WRONG REASON

MORE WORDS ABOUT DISEASES

THE GREATEST MISERY

MALE:FEMALE RATIOS

THE MOST INTERESTING DISEASES

CULT DIAGNOSES ("imaginary diseases")

TREATING DISEASE

UNCONVENTIONAL TREATMENTS

HOLISTIC MEDICINE

FINAL NOTE


Appendix I

A VERY SHORT HISTORY OF PATHOLOGY

Welcome to the introductory Pathology course. Most of you are undergraduate medical students. In this course you will learn the essential facts about human disease, so that you will be able to practice honest medicine.

Ideas about disease have changed during human history. People have thought about sickness as magical and mysterious, as abnormalities of whole persons, as abnormalities of individual organs, as abnormalities of cells, and as abnormalities of molecules.

Primitive people believe diseases are caused by gods and spirits. Diseases occur because people sin beyond the community standards, break taboos, or are bewitched. Primitive people treat diseases by praying, confessing their sins, and acting out magical ceremonies. In many cultures, the patient must show unquestioning faith, or the gods will be displeased and the patient will suffer. Most cultures also have some naturalistic ideas about disease. So primitive people also treat sick people by putting things into any and all body orifices, or even by creating new body orifices.

The ancient Egyptians made around 700,000,000 mummies. They took the organs out of the dead people and preserved them. Oddly, we have no record that Egyptian doctors ever examined their former patients' insides. They made some notes on practical therapeutics, but most of the surviving Egyptian medical literature is occult nonsense. One evil spirit is called "Mr. Pus-Friend, Cancer-Brother", etc.

The ancient Greek medical texts never mention supernatural causes of disease. The ancient Greeks had no concept of the real mechanics of disease, beyond observations of wounds, tumors, "swellings", etc. The best-known physician of ancient Greece was Dr. Hippocrates (460-377 BC). He and his students believed all diseases were processes that involved entire persons. Dr. Hippocrates sometimes tried to explain disease in terms of the traditional doctrine of four humors (blood, phlegm, yellow bile, black bile.) Disease is caused by imbalances of the four humors ("bad blendings," "dyscrasias") within the whole person. Disease was never localized to one part of the body. All this was wrong, but Dr. Hippocrates was no dogmatizer and the "four humors" myth probably did his patients no harm.

Hippocrates
NIH photo


Dr. Hippocrates was really an empiricist. He taught his students to carefully observe patients and watch what happened to them as they were treated. Dr. Hippocrates proved that sick people can be examined, their diseases classified, a diagnosis made for each, a prognosis established, and the patient treated intelligently. Although the Greeks understood almost nothing about real disease processes, they did discover what treatments helped for different patients. But except for minor surgery, they had no specific remedies for specific diseases. The Greeks cured almost nobody. Dr. Hippocrates is most famous for institutionalizing the high ideals of medical ethics. The Hippocratic oath made medicine a sacred calling rather than just a way of making a living. Hippocrates emphasized that some diseases are not treatable and that it is a credit to the physician to be candid about this. Two Alexandrian physicians did autopsies. Dr. Herophilus (335-280 BC) to do the first descriptions of cadaver dissection, and Dr. Eristratos (310-250) to correlate organ changes with diseases (ascites with cirrhosis, etc.) Their work had no real impact on the understanding of disease. They tried to correlate their findings with the clinical pictures with some success, but they had no influence on prevailing dogmas.

Dr. Cornelius Celsus (first century AD) described medical practice in his time in De Medicina. This book includes descriptions of heart disease and mental illness, and the four classic signs of inflammation.

Dr. Claudius Galen (130-200 AD), another Roman, began his career as the government physician to the gladiators. A careful observer, Dr. Galen soon became a famous physician, writer and lecturer. He discovered and explained several anatomic structures, including the recurrent laryngeal nerve, which he named "Galen's nerve." He wrote up some amazing experiments he did on living animals, and he published long lists of the rich and famous people who attended his lectures.

Galen
NIH photo


Dr. Galen dissected Barbary monkeys instead of humans. His mistakes included the five-lobed human liver, the two common bile ducts, and the holes where the blood goes through the septum of the heart. Dr. Galen's work remained the absolute authority until time of Dr. Vesalius. At anatomy demonstrations in the middle ages, the learned anatomy professor read out loud from Galen while the lowly morgue attendant cut on the body. If the morgue attendant found something that was not in "Galen", the professor ignored it. So there was exactly no progress in anatomy or anatomic pathology.

Dr. Celsus and Dr. Galen knew how inflammation and cancer looked and acted, and they emphasized patterns of symptoms and signs. For lack of any better theory of pathology, both these Roman doctors subscribed to the "four humors" idea of Dr. Hippocrates. Dr. Galen was also an amateur pagan philosopher and some of these writings survive too. He respected his Jewish and Christian neighbors, and was opposed to the persecutions. Like Dr. Hippocrates, Dr. Celsus and Dr. Galen had no concept of organ pathology, and they probably cured nobody.

Neither Dr. Hippocrates nor Dr. Galen ever did an autopsy (at least lawfully). Ancient and medieval superstition prohibited opening a dead body. Pathologic anatomy was limited to observing war wounds, bone injuries, skin diseases and a few clinical signs. In the middle ages, the Muslim world produced the best physicians. They were excellent observers of the living, but did very few autopsies. It took special permission from the pope to allow Dr. Mondino de Luzzi to perform an autopsy in front of an audience; this took place in Bologna in 1316. The autopsy (necropsy, post-mortem exam, "post") became popular only after Dr. Vesalius's anatomic work (1543). People realized that they could learn about the world by observing it, instead of reading old books.

When autopsies became legal, early investigators made many discoveries that offered new understandings of old diseases, but nobody understood essential diseases processes. As Dr. Galen and humoralism lost popularity, new fad theories emerged to explain all disease. In countries where it was legal to teach the existence of atoms, methodist physicians attributed all disease to changes in distances between atoms. In countries where atomic theory was still banned for ideological reasons (too unspiritual), pneumatist (vitalist) physicians blamed disease on the spiritual forces that controlled physiologic processes.

All previous anatomic pathology was superseded in 1761 by Dr. John Morgagni, an Italian. He called his charming series of 700 autopsies The Seats and Causes of Disease, Investigated by Anatomy. Written at age 78, it summed up a lifetime's experience and is still a great read. On the evidence, Dr. Morgagni was a genuinely good human being and was among the most beloved people of his era. Thanks to his work, all disease was now recognized as disease of organs, and disease "sat" in different organs in different patients. Dr. Morgagni meticulously related his patients' symptoms to their diseased organs, making the first clinico-pathologic correlations. This was real progress, but Dr. Morgagni had no real idea of how disease in one organ caused malfunction in another organ, or even what disease is. Since every major organ has one vein, Dr. Morgagni's students developed the next fad theory. All disease was due to phlebitis, inflammation of the vein draining the organ.

Morgagni
NIH photo


Dr. Karl Rokitansky of Vienna was the next great autopsy pathologist. He wrote the Handbook of General Pathologic Anatomy (1846), and in his day was the world's most famous pathologist. Vienna law decreed that everybody who died got autopsied by him. He did over 30,000 autopsies personally. Dr. Rokitansky was a colleague of Dr. Joseph Skoda, the world's most famous clinical diagnostician. In the morning, Dr. Skoda taught all the Viennese medical students on the wards and tried to make diagnoses on the patients who were still alive. In the afternoon, everybody went downstairs to see Dr. Rokitansky's autopsies on the dead patients and find out whether Dr. Skoda had been right. Thus, Dr. Rokitansky performed the most important function of the medical pathologist, relating clinical signs and symptoms to pathologic anatomy, and correlating function and structure. The medical students handled all the fresh organs without gloves and then go deliver babies without washing their hands. This was unhealthy, but it continued until a young instructor named Dr. Ignatius Semmelweiss introduced mandatory hand-washing. But that's another story.

Semmelweiss
NIH photo


Dr. Rokitansky and Dr. Skoda agreed that the medical therapeutics of their era had little to offer. (They were right.) Dr. Skoda's motto was "Forget treatment, the diagnosis is everything". They called this approach therapeutic nihilism. Dr. Skoda the clinician and Dr. Rokitansky the pathologist were brilliant, but nobody really had any idea what caused most disease. They didn't even know about germs. Dr. Rokitansky came up with a theory to explain all disease as crasias and dyscrasias. These caused the non-cellular ground substance to produce new defective cells.

Rokitansky
NIH photo


Rokitansky
NIH photo


Skoda
NIH photo


Dr. Rudolf Virchow (1821-1902) is the greatest pathologist of all time. Dr. Virchow was a German, a tiny man but one of medicine's giants. Dr. Virchow started as a junior autopsy pathologist working for the German government at the University of Berlin. He liked to cut thin sections of diseased tissues with a razor, and look at them using the latest technology, the microscope. Dr. Virchow first achieved renown by discovering leukemia and myelin.

During the German revolution of 1848, there was a bad typhus epidemic. The government sent Dr. Virchow to find out what caused typhus. After investigating, he announced that typhus was caused by the conservative politicians, who had done nothing about poverty and overcrowding. The government fired him for saying this, and he continued his work elsewhere. Since Dr. Virchow's time, pathologists have remained interested in the social pathology that produces disease.

Dr. Virchow's book Cell Pathology (1858) is the basis for all modern pathology. Dr. Virchow worked out hypertrophy, hyperplasia, metaplasia, basic acute and chronic inflammation, granulomas, thrombosis, infarction, the nature of tumor growth and routes of tumor spread, and much more. If nobody tells you who discovered something, there is a good chance it was Dr. Virchow. Dr. Virchow established the principle that all cells come from pre-existing cells and he emphasized that all disease is disease of cells. Dr. Virchow's ideas were introduced within months of the two other great unifying principles of today's science, the periodic table of the elements and the common origin of living things. Although he described much of the anatomy of illness, and was not himself an experimentalist, Dr. Virchow realized the overriding importance of the new science of experimental physiology. He emphasized that morbid anatomy always reflects disordered pathophysiology.

Dr. Virchow became a member of the German senate, for his time an extreme liberal, even a pinko. Dr. Virchow liked to describe the body as a republic with every cell equal. Especially, Virchow despised notions of "race" as unscientific (Nature 427: 487, 2004). Chancellor Otto von Bismarck hated Dr. Virchow so much that in 1865 he challenged him to a duel. Dr. Virchow accepted, and chose as the weapons two sausages. He stipulated that his sausage was to be a clean cooked sausage, and Bismarck's sausage was to be loaded with trichinosis larvae, served raw, and eaten by Bismark.

Dr. Virchow became the world medical dictator and the arbiter of scientific controversy. He was usually right, but was skeptical about micro-organisms as causes of diseases. When Dr. Pasteur first demonstrated the streptococcus bacteria that cause human infections, Dr. Virchow was in the audience. Everybody looked to see what old Dr. Virchow would say about the new claim. Dr. Virchow nodded and walked out without saying anything, and Dr. Pasteur and his germs became official.

Virchow
NIH photo


Virchow
NIH photo


Virchow
NIH photo


Virchow
NIH photo


Virchow
Humor

Virchow
NIH photo


Dr. Louis Pasteur (late 1800's) was the first person to conquer diseases using the methods of laboratory science. He first solved the mystery of bad-tasting wine, then explained and prevented epidemic disease among silkworms, anthrax in sheep, and finally rabies in humans. Dr. Pasteur was a chemist and could not stand the sight of blood. He considered going to medical school but never went because he was terrified of having to watch an autopsy.

Pasteur
NIH photo


Cohnheim
NIH photo


Dr. Virchow's student Dr. Julius Cohnheim, inventor of the frozen section, worked out much of the pathology of acute inflammation and of tuberculosis. Dr. Cohnheim's pupil, the flamboyant Dr. Paul Ehrlich, devised many of the stains still in use by pathologists.

Ehrlich
NIH photo


In the mid-twentieth century, pathologists really started thinking about diseases of molecules -- the molecular basis of disease. Progress in biochemistry unravelled the defects in inborn errors of metabolism. Dr. Linus Pauling (1949) worked out the physical chemistry of red cell sickling in sickle cell anemia. Every effective therapy today is the result of the laboratory study of disease.

Pauling
NIH photo


* In the twentieth century, two pathologists have distinguished themselves as spokespersons for human conscience, though you might not agree with one or both. Pathologist-turned-politician Salvador Allende took steps to turn Chile into his dream of a Marxist state. (Your lecturer considers this a misguided ideal, despite his admiration for Allende's social conscience.) McGill / Montral General Hospital's pathologist John McCrae wrote the brilliant World War I lyric, In Flanders Fields. (Read it. Is it a militaristic poem, an anti-war poem, or both? It's why we wear poppies on the day that commemorates those who died in war.) Dr. McCrae was also the second author of the popular medical student pathology textbook of the pre-WWI era. Martin J. Fettman is a Ph.D. physiologist-pathologist and astronaut.

It will be in your power every day to store up for yourselves treasures that will come back to you in the consciousness of duty well done, of kind acts performed, things that having given away freely you yet possess.
        -- Pathologist John McCrae, to his medical students

The end of the twentieth century brought a re-emphasis on disease as it involves whole persons. Today's most important diseases are lifestyle-related. Everyone recognizes the importance of habits in acquiring lung cancer, emphysema, heart disease, cirrhosis, and AIDS. Emotional factors influence other diseases, including high blood pressure, asthma, skin diseases, gastrointestinal diseases, and perhaps even cancer. Physicians are alert now to the ways in which illness affects a person's whole life, to the emotional needs of patients that cause them to seek medical attention, and to their spiritual needs, patient dignity, and their rights to make decisions about their own health care.

In Medical Pathology, you will think about all these things at once. Pathology deals with abnormal gross and microscopic anatomy, abnormal biochemistry, and abnormal physiology. Disease involves molecules, cells, organs, whole persons, and groups of people. We are sensitive to all aspects of disease. We'll put everything together in this course.

Appendix II: "SCIENTIFIC MEDICINE"

Why do we say that today's medicine is "scientific"? You will often hear people say, "That's only a theory", "That's not proven", "Medical schools do not teach the true causes of disease", or "Seventy percent of what you're taught in medical school is proven wrong within ten years." To give thoughtful answers, you need to know the following definitions of things that make up the business of science:

Fact: (1) A simple observation anybody can make (for example, grass is green, my shoe is untied, it is raining today). (2) A simple observation that anybody could confirm with instruments, assuming the correctness of current theories (for example, valine is substituted for glutamic acid at position 6 of the hemoglobin beta-chains in sickle cell disease).

Conjecture: A guess, educated or not (for example, all disease is ultimately caused by pressure on the spinal nerves).

Hypothesis: An educated guess that someone plans to test honestly (for example, let's actually TEST that conjecture about spinal nerves).

Experiment: Something somebody does to test or refute a hypothesis, using adequate controls to prevent self-deception, and planning to share the data with others (for example, let's do a prospective, randomized study of the effects on asthma of chiropractic treatment vs. simple kindness and human warmth).

Theory: An idea that explains a large number of observations, and which is not contradicted by any observation (for example, the round earth, atoms and molecules, the circulation of the blood, evolution, interleukin 1 as mediator of cell-cell communication).

A theory can never be "proved", it can only be "not falsified". (* For example, I will discard everything I believe about human origins if a person with real credentials as a paleontologist discovers a single, modern-type human skull in a rock stratum found to be more than 1 million years old by contemporary methods.) A falsified theory must be modified or discarded.

Knowledge: Facts and successful theories. A theory that works well ceases to be knowledge when a more comprehensive, elegant, and/or successful theory replaces it (for example, Ptolemy's astronomy was replaced by that of Copernicus; Newton's physics was modified by Einstein's; Darwin's evolution has been clarified by the discovery of the mechanisms of mutation and the idea that the rate of change has varied tremendously.) According to most of today's thinkers, theories are guides to action. Hence improving knowledge does not make the previous theory "wrong", only "less true". Math and logic are probably also forms of knowledge, and there may be others (ask a philosopher, or even an artist or theologian).

Proof: Ask a lawyer, mathematician, logician or theologian what this means. We don't use it much in real science.

Science: This might best be defined as the process of advancing knowledge by doing experiments and developing theories. It is the most cut-throat of all human endeavors, and scientists thrive on finding flaws in one another's work. There are still plenty of gaps in human knowledge. However, I know of no major theory since Ptolemy's astronomy that has been considered "successful" that has subsequently been discarded.

Pseudoscience: Using the language and authority of science without using its methods. Recognize pseudoscience by:

Junk science is one step above pseudoscience. It's a term, mostly used by lawyers, for poor natural-science (old studies, bad studies, discredited studies; also statistics and tables out of context as in pseudoscience) used in arguments directed at the public. Real work is cited accurately, but very selectively and misleadingly. Much of this is obviously intentional by agitprop writers. Today's grown-ups are well-aware of this, and generally dismiss "new information about health risks" and "warnings of impending environmental catastrophes" as junk science.

Pseudoscience and junk science appeal to basic human emotions (i.e., people are all-too-eager to believe lies that make them feel intellectually or morally superior). The disinformation campaigns often make its proponents wealthy and exert a massive influence on public policy. If you check your bookstores, you will discover that the public buys much more pseudoscience and junk science than real science. The United States public currently spends more money on health frauds than the total funds (government and private) used for medical research. The Supreme Court's "Daubert" decision made it the judge's responsibility to keep junk science and pseudoscience out of the courtroom (thanks Mr. Justice Scalia).

Sub-science is my term for areas in which measurement is difficult and the subject matter is of great human importance. Ideology (i.e., emotionally-held, ill-founded beliefs that are contrary to common-sense) tends to dominate. Much of health-maintenance, psychology and education, and almost all of sociology, are obviously sub-science. Unfortunately, sub-science has an even greater influence on politics than does pseudoscience.

It is evidence of your own integrity that you have chosen scientific medicine. Your reward is that scientific knowledge gives you tremendous power to deal with the world as it really is. I know you'll all use this power to do good.


Appendix III: Principles of Biomedical Ethics

After Elkins, J. Med. Educ. 63: 294, 1988; see also Disease-A-Month Dec. 1993

Never let your sense of morals prevent you from doing what is right.

I. HONESTY (TRUTH-TELLING)

II. CONTRACT-KEEPING (PROMISE-KEEPING)

III. NON-MALEFICENCE (NOT DOING HARM)

IV. JUSTICE

V. AUTONOMY (SELF-DETERMINATION)

VI. BENEFICENCE (DOING GOOD)

VII. PREVENTING AND RELIEVING SUFFERING

VIII. DIGNITY

IX. TWO OVER-ARCHING PHILOSOPHIC THEORIES FOR ALL OF ETHICS

CONCLUSION:


Appendix IV
BLOOD GASES OVERSIMPLIFIED

INTRODUCTION

* NORMAL VALUES

CARBON DIOXIDE

OXYGEN

REMEMBER:

Dead space ventilation / total ventilation = (PCO2 (arterial) - PCO2 (expired air))/PCO2 (arterial)


Appendix V
ELECTROLYTES OVERSIMPLIFIED

INTRODUCTION

* NORMAL RANGES

SERUM OSMOLALITY

SERUM SODIUM (huge review for clinicians BMJ 334: 470, 2007)

SERUM POTASSIUM

METABOLIC ACIDOSIS

METABOLIC ALKALOSIS

QUESTION: What effect would very low serum albumin (as in cirrhosis or the nephrotic syndrome) have on calculated anion gap? What effect would a cationic M-protein have?

FUTURE FORENSIC PATHOLOGISTS: Think the death was due to an electrolyte / glucose / alcohol problem without obvious anatomic correlates? Check the chemistry of the vitreous humor, which for many, many hours closely mimics the blood chemistry over the few days prior to death.


Appendix VI
Reference Ranges for Common Lab Tests
and Physiological Parameters

NOTE: These are commonly-cited ranges. "Normal" depends on the technique, the lab, and the population.

SYSTEMIC BLOOD PRESSURE: Around 120/80 mmHg

PULMONARY BLOOD PRESSURE: Around 25/7 mmHg

PULMONARY VENOUS PRESSURE: ("wedge pressure"): 1-5 mmHg

CENTRAL VENOUS PRESSURE: 1 to 10 mmHg

PORTAL VENOUS PRESSURE: Around 10 mmHg

WHITE CELL COUNT... 4.8-10.8 x 103

RED CELL COUNT... Men 4.7-6.1 x 106; Women 4.2-5.4 x 106

HEMOGLOBIN

MEAN CORPUSCULAR VOLUME

RED CELL SIZE DISTRIBUTION WIDTH... 11.5-14.5

PLATELET COUNT ... 130-400 x 103

MEAN PLATELET VOLUME ... 7.4-10.4 fL

ABSOLUTE LYMPHOCYTE COUNT ... 1.2-3.4 x 103 (3.0-7.0 x 103 or so for kids)

ABSOLUTE MONOCYTE COUNT ... 0.11-0.59 x 103

ABSOLUTE GRANULOCYTE COUNT ... 1.8-6.5 x 103

Almost always, almost all of these are neutrophils. The large majority of these should be mature forms, not bands (immature neutrophils; the absolute count should be very low, but in the past they have been notoriously difficult to count accurately)

ABSOLUTE EOSINOPHIL COUNT... less than or equal to 400 (fewer in AM, more in PM)

SERUM SODIUM ... 135-153 mEq/L

SERUM POTASSIUM ... 3.5-5.3 MEq/L

SERUM CHLORIDE ... 95-105 mEq/L

SERUM BICARBONATE ... 24-31 mEq/L

SERUM GLUCOSE ... 70-110 mg/dL fasting

SERUM UREA NITROGEN (BUN) ... 5-25 mg/dL

SERUM CREATININE ... 0.5-1.4 mg/dL

SERUM CALCIUM ... 8.7-10.7 mg/dL

SERUM MAGNESIUM ... 1.6-2.4 mg/dL

SERUM PHOSPHORUS ... 2.6-4.9 mg/dL

SERUM URIC ACID ... 2.5-9.2 mg/dL

SERUM CHOLESTEROL... Decision Level 200 mg/dL

SERUM TRIGLYCERIDES ... 30-200 mg/dL fasting (a dubious "normal range")

TOTAL PROTEIN ... 6.1-8.0 gm/dL

ALBUMIN ... 3.5-4.9 gm/dL

TOTAL BILIRUBIN ... 0.0-1.2 mg/dL

ALKALINE PHOSPHATASE ... 37-107 U/L

CREATINE KINASE (CK, CPK) ... 61-224 U/L

CPK isoenzymes to remember...

LACTATE DEHYDROGENASE (LD, LDH) 94-172 U/L

LDH isoenzymes to remember...

GLUTAMATE OXALOACETIC TRANSAMINASE (GOT, SGOT, AST) ... 12-45 U/L

GLUTAMATE PYRUVATE TRANSAMINASE (GPT, SGPT, ALT) ... 7-40 U/L

RETICULOCYTE COUNT... 0.5-1.5%

DIRECT COOMBS TEST... NEGATIVE

FLUORESCENT ANA... less than or equal to 1:20

ERYTHROCYTE SEDIMENTATION RATE (Westergren)... Up to half of a man's age, or half of a woman's age plus five. Infamously unreliable test.


Appendix VII
CLASSICAL ROOTS

annulus... little ring anser... goose acanth... spine, prickle
aceto... vinegar acou... hear acro... extremity, tip, sharp
actin... ray, beam acu... sharp, abrupt, sudden adeno... gland
adipo... fat aero... air (a)esth... perception
agogue... leader agon... contest, struggle ala... wing
alb... white algo... pain alien... stranger, strange
allelo... one another, mutual amauros... blind am(o)eb... constantly changing
ambi/amph... both sides ambly... dim, faint amnio... amnion, "bowl"
amylo... starch andro... male angio... vessel (blood, bile)
ankyl... bent, crooked; a joint locked in one position anthem... flower anthrac... black
anthro... man / human aort... aorta aphro... froth, sexual love
aqu... water arachn... spider, spiderweb archo... ancient, beginning
argy... silver, shiny artero... artery (as opposed to vein) arthro... joint
artic... little joint asthm... panting, short breaths athero... gruel
atri... entry chamber axilla... armpit axo... center, axis
aud... hear aur... hear aus... hear
auto... self aux... make grow azo... nitrogen
bac(t)... rod ball... throw balano... acorn, glans
blast... sprout blenno... snot bleph... eyelid
bol... throw brachi... arm brady... slow
branch... gill bronch... bronchus bucc... cheek (inside)
burs... bursa, purse caes... cut deep c(h)ord... notochord
c(o)ele... rupture carpo... wrist calci... limestone
calco... heel, spur calyc... cup campy... bend
canc... crab capo... head, expanded part centr... center
carbo... charcoal, carbon carcin... crab carcinoma... cancer from epithelium
card... heart, heart-shape carot... great neck arteries carpo... wrist
caus... burn centesis... puncture centr... center
cep(h)... head, expanded part cephal... head cept... seize, take
cereb(r)... brain cervic... neck ch(e)ir... hand
chemo... chemistry chlor... light green chol(e)... bile
chondr... cartilage; grain chorea... dance chori... chorionic membrane
chrom... color chron... time, long time chyle... digested food juice
cide... killing, "falling" cise... cut deep cili... eyelash
cion... uvula clast... break claustr... barrier
cleido... collarbone, key clino... bed clivus... slope
coagul... coagulate, clot coccus... berry coccyx... cuckoo, cuckoo bill
collic... hill collo... glue collus... neck
conios... dust cond... hard knob core... dolly, pupil (of eye)
cori... leather corn... horn cox(a)... hip
corp... physical body cre(s)c... grow cribi / cribri... sieve
crine... secretion ("separation") cubit... elbow cubo... lay down
cule... little culpo... vagina cuneo... wedge
cutis... skin cyan... dark blue cycl... circle, wheel
cysto... urinary bladder cyto... cell dacr... tear (from the eye)
dacty... finger demos... people dens... tooth
dent... tooth derm... skin desm... harden, bind together
desis... binding desmo... hard dextro... right-sided
diadocho... succeed, take over didym... twin digi(t)... finger, toe
diphth... leathery membrane docho... cup, container drepan... sickle
dromo... running a race; course duc,...duct lead, guide dynia... pain
echin... spiny echo... echo ectasia... dilatation
edem(a)... excess tissue fluid embol... bottle stopper embryo... embryo, fetus
em(ia)... blood enceph... brain enchyme... filling, installation
entero... intestine ergo... work erythro... red
esthesia... perception f(a)eco... feces, refuse fac... make, build, do, perform
facie... face, countenance, looks fasc... bundle, fascia fec... make, build, do, perform
fer... carrying, bearing fibr... fibrous fic... make, build, do, perform
fis,...fid split, cleave, divide flagel... whip flav... yellow
flat... blow flect... bend flex... bend
fora/foro... make a hole fornic... arch fract... break into pieces
frag... break into pieces fring... break into pieces fuge... flee
fun... melt, pour fus... melt, pour gala(k)... milk
gam(y)... marry gangl... knot gangr... gangrene, gnawing sore
galact... milk gastr... stomach, belly gemin... twin
gen... become, beget, produce genesis... origin genu... knee
ger... old age gest... bring forth, produce glans... acorn
gleno... shoulder gli(o)... glial cells, literally "glue" glob... sphere, ball, round body
glomer... tuft gloss... tongue glute... buttocks
gnatho... jaw gnosis... know gogue... lead
gono... offspring, product, seed, semen gonio... angle gracile... slender
gram... record gran... grain graph... writing, scratching
gryph... claw gynec... female (h)(a)em... blood
habeo... to hold, habit, general state of halluc... big toe helic... spiral
helm... worm hermaphro... male and female in one body hepat... liver
hernia... rupture, hernia hidr... sweat hippo... horse
histo... tissue, web, cloth hy(a)l... glass, primitive material hydatid... water drop
hydro... water hypno... sleep hystero... uterus
iatric... healing iatro... physician ichth... fish
idio... self, personal, private inguin... part of body from groin to hip insul... island
irid... rainbow, bright-color circle ischi... hip joint islet... island
ject... throw, hurl jejun... hungry junc... join together
jug... join together jux... join together kera... horny
kerato... skin surface, cornea, horn kine... set in motion kyn... dog
lachry... tear (from the eye) labio... lip lacto... milk
lal... babble, talk latero... side lecith... egg yolk
leiomyo... smooth muscle lein... spleen lens... lentil
lepros... rough and rotting off lepto... thin, fine, slender leuco... white
levo... left-sided liga(t)... bind together, bandage ling... tongue
lith... stone lumbo... lower back, loin lumbri... earthworm
lumen... the tube down a hollow organ lymph... "clear fresh water" lysis... breaking down
malar... cheek (outside) mal(i)... abnormal, bad malacia... soft
malako... soft medi... middle portion medulla... soft inner part
meli... sweet malleo... hammer mere... part
manu... hand mara... wither mast(i)... whip, flog, beat
mast(o)... breast mea... passage meatus... external opening
meios... lessening melano... black melia... limb
mening... meninges men(i)s... moon, month ment... mind, chin
meter... measure metro... uterus mito... thread
mnem... memory mnes... memory mob... move
morb... sick morph... shapes, dreams mot... move
mur(al)... wall musc... mouse, muscle myc(o)... fungus
myelo... soft, pith myi... fly (insect) myo... muscle
myxo/muco... slime narco... sleep naso... nose
necro... dead nephelo... cloud nephr... kidney
nerv... nerve neuro... nerve nos,...nox nasty, sickening
nous... mind, spirit nyct... night occiput... back of the head
ocul... eye (h)odo... way, path, road odon... tooth
odyn... pain olfact... smell oma... tumor/lump
omen(t)... omentum omphalo... belly button on(e/t)... to be
onco... tumor, mass onycho... nail (finger/toe) oo... egg (umlaut over second "o" is optional)
oophor... ovary (umlaut over second "o" is optional) op... eye, see, etc. ophth... eye
opio... poppy juice opsi... late opson... relish, meat seasoning
orbi... wheel orch... testis org... work
oro... mouth ortho... straight os... bone, mouth
osm... smell ost(eo)... bone ot(o)... ear
ovin... sheep oxy... oxygen, acid p(a)ed... child
palpebr... eyelid pap... nipple par(i)t... have a baby
parietal... wall partheno... virgin partum... birth
patho... disease, misery pect... chest pelvis... basin
pes/ped... foot phage... eat phakos... lentil, lens of the eye
pharmako... sorcery, poison, drug phase... phase pheo... ugly, dusky
phero... carry, bear philo... like, love phlebo... vein
phleg... flame phoco... seal (the animal) phoro... carry, bear
phos/phot... light phragm... divide into two, wall off phren... mind, breath
phth... waste away, wither phyllo... leaf-like physio... nature
phyte... a plant pineo... pine cone pinna... feather
pino... drink pisi... pea pituit... snot
placent... cake, placenta plak... cake plantar... sole of the foot
plasm... molded plast... molded platy... flat
plegia... stroke, paralysis pleur... pleura ("side of ribs") plex... braid, wind together
plexy... stroke plic... braid, wind together pn(e)... breath
pod(o)... foot poie(sis)... making polio... gray; gray matter of the nervous system
pollic... thumb pomp... precede, parade porph... purple
porta... door posthe... foreskin prac... done
prag... done prax... done pre/pro... before
procto... rectum pron(o)... prone, face down proto... first
pseud... false psyche... spirit, mind psychr... cold, frigid
pter... wing pto... droop pty(alo)... spit
pulmo... lung punct... prick, little spot pupa... doll, miniature figure
purp... purple pyelo... vat, basin, pelvis pykno... shrivelled
pyo... pus p(u/y)ri... pear pyr(o)... fever (cognate to "fire")
radi... rod r(h)ach... backbone re(i)n... kidney
ret(ic)... net rhabdo... striated muscle rhaph... sew together
rheo... flow rheum... runny stuff rhino... nose
riso... smile rrha(g)... discharge from a burst vessel rub(r)... red
sacc... sack sacch(ar)... sugar salpinx... trumpet, oviduct
sang(ui)... blood sapro... dead sarc(o)... flesh
sarcoma... cancer from connective tissue or muscle scato... feces, filth scapho... boat
schi(s/z)... split sclero... hard scope... examine carefully
sebo... hard fat, skin grease, suet sec/seg... cut sella... saddle
seps/sept... make rotten septo... fence, partition sero... whey, wet protein
sial... saliva sinus... hollow or pocket skel... dried up, skeleton
soma/somy... body spasmo... a drawing tight spondylo... spine
sphinct... bind tight, squeeze shut sphygno... heartbeat spir... breathing
splanchn... innards staphyl... bunch of grapes stasis... standing up, being stable
stat... stop statio... standing up, being stable staxis... drip, drop
stem... standing up, being stable steato... fat sterco... feces
sthen... strength stigm... spot stole... to pull, to draw
stom(a)... mouth stomy... mouth strepto... wavy
stylo... stylus sudo... sweat sulco... plowed furrow
syring... pipe, tube, reed tachy... fast, swift tact... touch
tainia... band, tapeworm talo... ankle tasis... stretch
tarso... flat plate taxo... arrangement, put in order telo... the tip, the end
temporal... temple ten(d)o... stretch, tendon terato... monster
theca... box (sheath, covering) thel... breast, covering layer thenar... palm, sole
thym... mind, spirit, mood thym... warty mass, thymus gland thyro... oblong shield
toco... have a baby tom(e)... cut tono... stretch
topo... place tort... twist tox(o)... bow, arrow, poisoned arrow
trema... hole tricho... hair trophy... grow/food
tryps... break into many pieces, crush tuber... bump, potato(e) typho... smoky, delirious fever
typhl... cecum unguis... nail (finger, toe) uro... urine
uvo... grape vacc... cow vago... wanderer
valgus... turned outward varus... turned inward vaso... blood vessel
velo... veil, curtain, cover vener... sexual acts, lusty veno... vein (as opposed to artery)
vert... turn vesico... bladder viscero... innards
volv... turn around, twist around xantho... yellow xeno... stranger
xero... dry z(a)o... to live zoo;... animals (umlaut over second "o" is optional)
zema... boiled zygo... yoke zyme... ferment
Late additions (sorry) karyo... nucleus kern... kernel, deep brain
pannus... cloth, rag

PREFIXES

a(d)-... towards a(n)-... without ab-... from
ab(s)-... away from ad-... towards allo-... other, another
ambi-... both amphi-... on both sides, around ana-... up to, back, again, movement from
aniso-... different, unequal ante-... before, forwards anti-... against, opposite
ap-, apo-... from, back, again bi(s)-... twice, double bio-... life
brachy-... short cata-... down circum-... around
con-... together contra-... against cyte-... cell
de-... from, away from, down from deca-... ten di(s)-... two
dia-... through, complete di(a)s... separation diplo-... double
dolicho-... long dur-... hard, firm dys-... bad, abnormal
e-, ec-... out, from out of ecto-... outside, external ek-... out
em-... in en-... into endo-... into
ent-... within epi-... on, up, against, high eso-... I will carry
eu-... well, abundant, prosperous eury-... broad, wide ex-, exo-... out, from out of
extra-... outside, beyond, in addition haplo-... single hapto-... bind to
hemi-... half hept-... seven hetero-... different
hex-... six homo-... same hyper-... above, excessive
hypo-... below, deficient im-, in-... not in-... into, to
infra-... below, underneath inter-... among, between intra-... within, inside, during
intro-... inward, during iso-... equal,same juxta-... adjacent to
kata-... down, down from macro-... large magno-... large
8b>medi-... middle mega-... large megalo-... very large
meso-... middle meta-... beyond, between micro-... small
neo-... new non-... not ob-... before, against
octa-... eight octo-... eight oligo-... few
pachy-... thick pan-... all para-... beside, to the side of, wrong
pent-... five per-... by, through, throughout peri-... around, round-about
pleo-... more than usual poly... many post-... behind, after
pre-... before, in front, very pros-... besides prox-... besides
pseudo-... false, fake quar(t)-... four re, red-... back, again
retro-... backwards, behind semi-... half sex-... six
sept-... seven sub-... under, beneath super-... above, in addition, over
supra-... above, on the upper side syn-... together, with sys-... together, with
tetra-... four thio-... sulfur trans-... across, beyond
tri-... three uni-... one ultra-... beyond, besides, over

SUFFIXES

-ase... fermenter -ate... do -cide... killer
-c(o)ele... cavity, hollow -ectomy... removal of, cut out -form... shaped like
-ia... got -iasis... full of -ile... little version
-illa... little version -illus... little version -in... stuff
-ism... theory, characteristic of -itis... inflammation -ity... makes a noun of quality
-ium... thing -ize... do -logy... study of, reasoning about
-megaly... large -noid... mind, spirit -oid... resembling, image of
-ogen... precursor -ol(e)... alcohol -ole... little version
-oma... tumor (usually) -osis... full of -ostomy... "mouth-cut"
-pathy... disease of, suffering -penia... lack -pexy... fix in place
-plasty... re-shaping -philia... affection for -rhage... burst out
-rhea... discharge, flowing out -rhexis... shredding -pagus... Siamese twins
-sis... idea (makes a noun, typically abstract) -thrix... hair -tomy... cut
-ule... little version -um... thing (makes a noun, typically concrete).....

Appendix VIII

Curriculum Position Paper -- Pathology


BIBLIOGRAPHY / FURTHER READING

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