Protein-energy malnutrition (PEM) or, as it is still sometimes called, protein-calorie malnutrition (PCM), is a term of convenience that refers to a range of syndromes among infants and children of preschool age in whom manifestations of growth failure occur because of protein and energy deficiencies. In most instances this condition besets those in the less developed world of Asia, Africa, and Latin America, where dietary factors are thought to be a crucial part of the etiology. PEM thereby tends to exclude what is conventionally known as “failure to thrive” in Europe and North America, in which the vast majority of cases result from organic disorders such as cystic fibrosis or congenital heart disease problems and are not so directly associated with diet as such.

PEM is best described in its two clinical versions of kwashiorkor and marasmus. In the former, edema is always present, whereas extreme wasting (commonly defined as below 60 percent that of normal weight for height) identifies the latter. Much of the research in the 1950s and 1960s focused on differentiating between the symptoms and etiologies of kwashiorkor and marasmus, but since then it has become evident that cases purely of one or the other are the exception rather than the rule. The majority display both edema and extreme wasting, plus a variable mix of other symptoms, that have earned them the rather inelegant designation of marasmic kwashiorkor. In addition, far more common than all of the three put together are numerous subclinical syndromes, usually referred to as mild-to-moderate PEM.

In 1628 William Harvey, physician to St. Bartholomew’s Hospital, London, used quantitative, experimental methods to show that the blood must move in a circle, rather than being continuously regenerated as earlier theories had proposed. In addition, Harvey showed that the heart supplies the power to send the blood on its circuit around the body. Harvey’s revolutionary ideas reflected ancient thought about the perfectibility of circular motion as much as they did new ideas about the value of experimental evidence. Nonetheless, in many ways and by most accounts, the year 1628 marks the beginning of current Western ways of looking at the heart and its diseases. However, although Harvey’s demonstration of cardiac physiology in animals seemed logically applicable to human beings, it failed to lead immediately to any dramatic changes in the diagnosis or treatment of human heart disease. Over the next few centuries many people tried to discover what was going on within the thoraxes of patients who showed the debilitating signs of cardiac disease. Their notions about heart disease were reflected in the diagnostic techniques they thought appropriate.

Diagnosing Heart Disease

Physical Diagnosis

During the mid-eighteenth century, Leopold Auenbrugger, working in Vienna, described a new diagnostic technique. By percussing the chest – that is, by striking the chest and both listening to and feeling the reverberation – he was able to tell, to some extent, what lay within. His method enabled him to ascertain the size of the heart and to determine the presence of fluid in the chest, a common manifestation of heart failure.

The dialectical method is pervasive in Hegel's mature philosophy. It governs all three parts of his system proper: the Logic, the Philosophy of Nature, and the Philosophy of Spirit. And it also governs the discipline that he developed as an introduction to this system, the Phenomenology of Spirit (expounded in the book of that name).

Few aspects of Hegel's thought have exerted as much influence or occasioned as much controversy as this method. Yet, paradoxically, it remains one of his least well understood philosophical contributions. The aim of this essay is to cast a little light where there remains much darkness.

It seems to me that three main shortcomings in the secondary literature have hindered a clear understanding of the method. First, most interpreters, if not actually denying that there is such a thing as the dialectical method, have at least characterized it in terms that remain too vague. Second, interpreters have generally made too little effort to explain the method's philosophical motivation. Third, many critics have been too hasty in dismissing the method as guilty of one or more of a variety of original sins that would render it useless in principle, such as violating the law of contradiction.

Japanese B encephalitis is a relatively uncommon disease, even in areas where the infection is endemic. The disease is one of several caused by arthropod-borne viruses (arboviruses); carried by mosquitoes of the genus Culex, this one is a member of the family Togaviridae and genus Flavivirus and thus is an RNA virus. The species of Culex that is the most common insect vector for Japanese B encephalitis is Culex tritaeniorhyncus. The disease was first recognized and described in 1871, and the virus was first isolated in 1935. The infection may appear in epidemic or in sporadic outbreaks, and is carried particularly in swine, but also has been isolated from a variety of birds and from equine animals. The virus is distributed principally in East and Southeast Asia.

Epidemic outbreaks of Japanese B encephalitis, like those of arboviruses in general, tend to occur in regions that are usually dry and arid and, therefore, relatively free of viral activity; such areas may accumulate a large number of individuals who, because of lack of previous exposure, are relatively susceptible. Then with rain and the appearance of conditions favorable to the proliferation of the insect vector, epidemic outbreaks may occur, particularly where there are relatively high population densities of the human host and of the amplifying hosts such as equine or porcine animal species. In addition, there is evidence that for some arboviruses a change occurs in the relative virulence of the infecting strain, which may also account for an epidemic outbreak.

Medical Literature

In 1392 Yi Songgye assumed the throne as King T’aejo and the Yi Dynasty (1392–1910) began. His supporters initiated a sweeping land reform program that began with a cadastral survey of landholding throughout the country and the destruction of previous registers of public and private landholdings. New developments in agriculture as well as in science, technology, and medicine followed, stimulating inventions and publications. For example, the agricultural manual called The Art of Farming, compiled in 1430, was based on the reasonable but novel premise that because Korean climate and soil differed from those of China, agricultural methods should be designed to meet the specific conditions found in the peninsula. Improvements in agricultural techniques produced increased yields, and the spread of cotton cultivation provided improved clothing for the common people.

Important developments in medical knowledge took place in the early years of the Yi dynasty, as the government encouraged its study and created two specialized institutions for medical care. One served the royal family and elite officials, and the other was to serve the general population. Candidates who scored well on the “Miscellaneous Examinations” could be employed in the Palace Medical Office, which trained regional medical officials.

The concept that indigenous conditions must be considered was increasingly incorporated into medical as well as agricultural writings. China’s influence on medical philosophy remained strong, but interest in the study and exploitation of Korea’s own traditional folk remedies stimulated the development of independent medical scholarship as may be seen in the Hyang-yak kugup pang (Emergency Remedies of Folk Medicine 1236).

Disease ecology refers to the intricate human and environmental relationships that form the context of one or a group of diseases. Diseases are not simply biomedical entities; rather, they have their physical, environmental, sociocultural, psychological, and even political parameters. Distinctive human and biophysical environmental webs form the context of distinctive groups of human diseases. Major changes in this web, whether brought about by human intervention, environmental catastrophes, or a combination thereof, can result in a new context and possibly a new group of diseases. In developing countries, human control of the environment is limited, basic needs of a healthful life are not met, and, therefore, infectious and communicable diseases are the major cause of death. Improvements in health conditions will no doubt reduce the incidence of mortality resulting from infectious diseases and, in turn, bring about the prominence of chronic diseases more closely related to life-styles and life stages than to environmental parameters. South Asia as a geographic region still remains a region of poverty within which there is a marked contrast between the rural and urban genre de vie. Morbidity and mortality patterns in the rural and urban areas are, therefore, likely to be somewhat different, although paucity and quality of data make generalizations hazardous.

Ecologically, South Asia is one of the most distinctive regions of the world. Physiographically well demarcated, and climatically distinguished by the monsoonal rainfall regime, South Asian life has a rhythm marked by seasonality. Although agriculture is still the dominant occupation, rapidly swelling cities create air pollution, overcrowding, social stress, and the immense problem of waste disposal.

Cirrhosis is a chronic hepatic disorder, anatomically characterized by diffuse liver fibrosis and nodule formation. These pathological changes produce the clinical features of portal hypertension and hepatocellular failure. Cirrhosis is the end product of progressive liver injury resulting from many diverse causes including toxins, drugs, viruses, and parasites. The clinical manifestations of cirrhosis vary according to the severity and duration of the underlying disease. In the West, cirrhosis is a major cause of disability and death among middle-aged alcoholic males. In the East and Africa, cirrhosis is predominantly an intermediate lesion in the evolution from chronic hepatitis B infection to primary hepatocellular carcinoma.

Classification

Cirrhosis is classified on the basis of morphology and etiology. The morphological classification recognizes three types based on the size of the nodules:

1. Macronodular cirrhosis. The liver is firm, large or small in size, with bulging irregular nodules greater than 3 millimeters in diameter.

2. Micronodular cirrhosis. The liver is usually enlarged, and very firm or hard in consistency. The nodules on cut sections appear small and uniform, less than 3 millimeters wide.

3. Mixed micro/macronodular cirrhosis. The liver shows groups of small nodules interspersed with fields of large nodules.

The terms “micronodular” and “macronodular” cirrhosis replace the older terminology, Laennec’s and postnecrotic cirrhosis.

Neither the gross nor the microscopic appearance of the liver can alone differentiate among the many causes (see Table VIII.28.1). In individual cases, the etiology is often unknown. Alcohol injury is most frequently associated with the pattern of micronodular cirrhosis, and other causes in this category include primary biliary cirrhosis, primary hemochromatosis, and chronic right heart failure.

Premedical Health Care

A concern with illness has been documented in China for three millennia; the earliest written evidence extant today on the theoretical and practical consequences of this concern dates from approximately the eleventh century B.C. At that time, and for centuries to come, it was assumed that the well-being of the living – be it related to success on the battlefield, to an abundant harvest, or to physical health – depended to a considerable extent on their interactions with the nonliving members of the community (i.e., with their ancestors). An adherence to specific norms was thought to guarantee social and individual health; transgressions were known to cause the wrath of the dead, who then had to be propitiated with sacrifices. The communication between the living and the nonliving that was necessary to establish the cause of an affliction and to identify an appropriate remedy was recorded on bones and turtle shells, many of which were found in the soil, especially in the province of Henan, earlier this century. Whether the belief in ancestral intervention was supplemented by a pragmatic application of drugs or other empirically valuable means of therapy was not documented in written form at this early time.

Political changes during the first millennium B.C., when the Chou dynasty fell into a period of turmoil with several centuries of civil war, may have been responsible for the rise of a new worldview. Even though a belief in the effect of ancestral curses or blessings on the health of the living has survived in Chinese culture well into the twentieth century, especially among some rural strata of the population, Chou sources indicate a change in emphasis.

Chagas’ disease (American; trypanosomiasis, trypanosomiasis cruzi) is an illness of the Americas which can take the form of either an acute, febrile, generalized infection or a chronic process. The cause is a protozoan, Trypanosoma cruzi, which is harbored by both domesticated and wild animals. When it is transmitted to humans by insects, this essentially untreatable disease is associated with fever, edemas, and enlargement of the lymph nodes and can cause dilation of parts of the digestive tract leading to megacolon and megaesophagus as well as cardiac enlargement and failure. In fact, Chagas’ disease is the leading cause of cardiac death of young adults in parts of South America.

Distribution and Incidence

The disease, which probably had its origins in Brazil, is limited to the Western Hemisphere, with heavy concentrations in Brazil, Argentina, Chile, and Venezuela. Cases are also reported in Peru, Mexico, and most other Central and South American countries along with the Caribbean islands and the United States.

Epidemiology and Etiology

T. cruzi, a member of the class Mastigophora, family Trypanisomidae, has over 100 vertebrate hosts including dogs, cats, armadillos, opossums, monkeys, and humans. Unlike other trypanosomes it does not multiply in the bloodstream, but rather lives within various tissues of the host and multiplies by binary fission. It is transmitted by reduvid bugs that ingest the trypanosome during a blood meal from a vertebrate host. The trypanosomes in turn develop in the intestines of the bug, and, while they neither enter its saliva nor are injected when the bug bites, they do pass out in its feces.

Ancylostomiasis, or hookworm disease, is caused by hookworm infection and is characterized by progressive anemia. In 1989, it was estimated that perhaps as many as one billion people, most of them living in tropical and subtropical regions, are afflicted to some extent with hookworm infection, although it is not known how many thus infected can be said to be victims of hookworm disease. It is difficult to define the difference between hookworm infection and hookworm disease because a host whose diet contains adequate amounts of iron may sustain a worm burden without debilitating consequences that would render a malnourished person anemic. A person exhibiting signs of the anemia associated with hookworm infestation, therefore, may be said to have hookworm disease regardless of the number of parasites present. Hookworm disease does not appear on the short list of major causes of death in developing countries, but it should be regarded as an important contributing factor in millions of deaths annually and as a source in its own right of widespread human suffering.

Two species of intestinal nematode, Ancylostoma duodenale and Necator americanus, are the parasites that cause ancylostomiasis. Although they apparently cause the same disease, there are important differences between the two species. A. duodenale is slightly larger, sickle-shaped, with hooks or teeth; N. americanus is smaller, “S” shaped, with shell-like semilunar cutting plates instead of teeth. Despite being named the “American killer,” N. americanus is less pathogenic than A. duodenale, as measured by comparative blood loss. A. duodenale has a higher reproductive rate and a shorter life-span. It is also able to infect the host in more ways than can N. americanus.

Few thinkers in the history of philosophy are more controversial than Hegel. Philosophers are either for or against him. Rarely do they regard him with cool detachment, weighing his merits and faults with strict impartiality. Hegel has been dismissed as a charlatan and obscurantist, but he has also been praised as one of the greatest thinkers of modern philosophy. As a result of these extreme views, Hegel has been either completely neglected or closely studied for decades.

Whether we love or hate Hegel, it is difficult to ignore him. We cannot neglect him if only because of his enormous historical significance. Most forms of modern philosophy have either been influenced by Hegel or reacted against him.

The history of diseases in Korea, especially the diseases of the early historic period, constitutes a still largely unexplored area, save for the efforts of a few pioneering scholars whose findings are not yet available in English translations (Miki 1962; Kim 1966). However, this field should be of considerable interest to students of Asian history as well as those concerned with the history of medicine.

Geography, History, and Background

Much of Korea’s epidemiological past has been shaped by its geography. The country occupies a peninsula south of Manchuria that is separated from the Chinese mainland to the west by the Yellow Sea, and from nearby Japan to the east by the Korean and the Tsushima Straits. Forming a land bridge between northern Asia and the islands of Japan, Korea has time and again been subjected to invasions by armies from the Asian mainland intending to attack Japan, or by Japanese armies establishing a base from which to attack the Asian mainland. Undoubtedly, these contacts must have brought infectious diseases to Korea.

To discuss diseases of antiquity in Korea means to discuss those illnesses that occurred during the Old Choson Period (traditionally dated 2333 B.C. to A.D. 562), and the Three Kingdoms Era encompassing the Kingdoms of Koguryo (37 B.C. to A.D. 688), Paekche (18 B.C. to A.D. 660), and Silla (57 B.C. to A.D. 935), as well as the Koryo Era (918–1392). By the ninth century B.C., rice-cultivating Bronze Age cultures had been established on the Korean peninsula. During the Three Kingdoms Era, the Chinese writing system was adopted by the courts in order to ensure the writing down of state chronicles.

The infant mortality rate (which is commonly calculated as the number of deaths among infants under 1 year of age in a calendar year per 1,000 live births in that year) measures the probability that a newborn baby will survive the hazards of infancy and live to celebrate his or her first birthday. Whether a given infant survives this crucial first year of life is influenced in part by certain biological characteristics (e.g., genetic makeup, nature of the birth outcome, susceptibility to particular diseases). But a voluminous body of research over the past century has clearly identified the major determinants of the overall infant mortality rate to be, first, the nature of the physical environment, especially the state of sanitation, and, second, the nature and availability of health care facilities. Although the health of persons of all ages is affected by these conditions, the newborn infant is most susceptible and most likely to be adversely affected by the absence of appropriate sanitary and health care facilities.

It has also been solidly established that within any society infant mortality rates are strongly related to family income, which in turn is an indicator of both the nature of the environment in which an infant is born and raised and the family’s ability to provide the infant with optimal health care. The basic aim of this essay is to review briefly some of the relevant research and to present empirical justification for designating the infant mortality rate as the most sensitive indicator of the overall health status of any population group.

Lead poisoning (plumbism) is defined simply as the undesirable health effects induced by that metal. Many of these, however, are “nonspecific”; that is, they are similar to or identical with symptoms and signs produced by causes other than lead, and some of the toxic effects are so subtle they require laboratory identification. This historical and geographic discussion concerns itself primarily with those overt effects obviously apparent upon even casual observation by nonmedical observers, which therefore are most likely to appear in the historical record. Principal among these are abdominal colic, muscle paralysis due to lead-damaged nerves, and convulsions.

Physiology

Lead gains access to the human body principally through the air we breathe and the substances we ingest. Residents of industrialized nations acquire about half of their “body burden” of lead from polluted respired air. Healthy adults only absorb about 10 percent of ingested lead, but children may absorb as much as half of the lead they eat or drink. Lead absorption is enhanced by a low level of calcium in the diet. Lead may also be absorbed through the skin. Prolonged applications of lead-containing substances such as poultices or cosmetics may result in health-threatening absorption of lead.

Absorbed lead is distributed throughout the body by the blood. The human body’s ability to excrete absorbed lead is so limited, however, that normal life activities in Western countries will produce lead absorption in excess of the body’s excretory capacity. About 5 percent of unexcretable lead is deposited in the liver, brain, and other viscera, where its residence time is only a matter of a few weeks.

Meningitis is an acute inflammation of the meninges, the membranes covering the brain and spinal cord. The disease is usually the result of bacterial infection, but a number of viruses, fungi, and other microbial agents can also cause it. Meningitis can develop as well from noninfectious conditions such as tumors, lead poisoning, and reactions to vaccines. Meningococcal meningitis, caused by a bacterium, Neisseria meningitidis, is the only form that occurs in major epidemics. Also called cerebrospinal meningitis (CSM), it has been known in the past as “spotted fever,” cerebrospinal fever, typhus cerebralis, and meningitis epidemica. Aseptic meningitis refers to inflammations of the meninges without detectable bacterial involvement. The most common causes are any of a number of viruses.

Etiology and Epidemiology

Many species of bacteria can cause meningitis, but over 80 percent of all cases in developed countries in recent years have been due to only three: N. meningitidis, Hemophilus influenzae, and Streptococcus (Diplococcus) pneumoniae. Other common members of the human bacterial flora such as Escherichia coli and various streptococci and staphylococci can also produce meningitis under special circumstances, as can members of the genera Listeria, Pseudomonas, and Proteus. Meningitis sometimes develops as a complication of tuberculosis.

Aseptic meningitis is usually the result of viral infection. Among the many types of viruses that can be involved are mumps, echovirus, poliovirus, coxsackievirus, herpes simplex, herpes zoster, hepatitis, measles, rubella, and several mosquito-borne agents of encephalitis. Fungi, most commonly Cryptococcus, are other possible agents.

This essay addresses some of the themes that modern scholarship has identified as central to an understanding of Hegel's thoughts on religion. For a variety of pedagogic reasons, which will become evident over the course of this essay, I have chosen to approach these themes historically and contextually rather than philosophically and abstractly. To that end, my discussion of Hegel's thoughts on religion focuses primarily on the religious, philosophical, and political circumstances that conditioned, and were conditioned by, his writings during his so-called Berlin period (1818-1831).

During these years - from his appointment to the prestigious chair in philosophy at the University of Berlin in 1818 until his death in 1831 - Hegel's philosophy came to public prominence. Indeed, it was in Berlin that Hegel's philosophy became an ideological factor in public debate. As we shall see, that was especially true in the realm of religion, for from about 1821 on Hegel's views on Christianity in general and on Protestantism in particular were not only publicly debated but fiercely contested as well. Thus, Hegel's Berlin period provides an important context both for measuring the ideological impact his views on religion had on public consciousness and for determining the ways in which the public opposition to his views shaped his private as well as public pronouncements on religion.

During the Middle Ages (roughly A.D. 500-1500), Europe changed from an agrarian society composed of relatively small and isolated communities to an increasingly commercial and urban world, though still predominantly agricultural. After centuries of static or declining growth in late antiquity, the population of Europe increased approximately threefold between 800 and 1300. Generally, the history of medieval diseases reflects these demographic and economic facts. While the ancient diseases of pneumonia, tuberculosis, and smallpox, and others including typhoid, diphtheria, cholera, malaria, typhus, anthrax, scarlet fever, measles, epilepsy, trachoma, gonorrehea, and amebiasis persisted throughout our period, many diseases of Europeans during the early Middle Ages were related to deficient diet.

Improved nutrition in the later Middle Ages led to a relatively larger population. As Fernand Braudel (1979) has emphasized, an increase in population alters all aspects of life, bringing advantages but at the same time threatening the existing standard of living and hope of improving that standard. In addition, it can bring disease. Ironically, the improved nutrition that made possible the growth of population, towns, and trade in the Middle Ages in turn created fertile opportunities for the contagious diseases that ultimately changed the face of Europe.

Nutrition and Disease

A revolution in agricultural techniques in northern Europe has been credited with this remarkable population growth (e.g., White, Jr. 1962). Agrarian methods inherited from the Roman Empire were suitable for the warm, dry lands of the Mediterranean and Near East, but proved inadequate on the broad, fertile plains of northern Europe.

Epidemic typhus fever is an acute rickettsial disease transmitted among victims by the human body louse, Pediculus humanus corporis. Its characteristic symptoms include high fever, prostration, headache and body aches, and a widespread rash that covers the trunk and limbs of the body. Mortality rates in untreated cases vary widely. Broad-spectrum antibiotics provide an effective therapy for the disease.

Because of its association with conditions of human misery, typhus has been known by many names. Jail distemper and its variations – morbus carcerum, gaol fever, and jayl fever – indicate the prevalence of typhus in detention facilities. Ship fever, camp fever, and famine fever reflect the poor hygiene characteristic of travel, of military expeditions, and of refugee populations. The characteristic rash of typhus has elicited other descriptive names, including spotted fever in English, Fleckfieber and typhus exanthematicus in German, typhus exanthématique in French, tifo exantemático and tabardillo in Spanish (the latter meaning “red cloak”), and typhus-esantematico in Italian. Although Hippocrates applied the word typhus, from the Greek word meaning smoky or hazy, to confused or stuporous states of mind frequently associated with high fevers, the word was not associated with the disease as it is currently known until the eighteenth century. After murine typhus was identified, the appellation typhus historique was sometimes applied to the classic, epidemic disease.

Etiology and Epidemiology

Occurring as a natural infection only in humans, epidemic typhus is caused by Rickettsia prowazekii. It is spread from host to host by the human body louse, P. humanus corporis, and less often by the human head louse, Pediculus humanus capitis.