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Detailed table of contents
About the authors xii Autosomal dominant inheritance 55

Preface xiii Autosomal recessive inheritance 56
Acknowledgements xv X-linked inheritance 56
Features of the text xvi Chromosomal abnormalities 57
Educator resources xviii Threshold and penetrance 61
Principles of multifactorial inheritance 64
PART 1 Congenital malformations 64
Cellular and tissue pathophysiology 1
5 NEOPLASIA 69
1 PATHOPHYSIOLOGICAL TERMINOLOGY, Introduction 69
CELLULAR ADAPTATION AND INJURY 2 Epidemiology of cancer 70
Carcinogenicity and cancer 75
Introduction 3
Characteristics of cancer cells 77
Important terminology 3
Tumour invasion and metastasis 82
Cellular responses to stimuli 3
Classification of tumours 82
Cellular adaptations 5
Clinical manifestations of cancer 84
Maladaptive cellular adaptation 7
Screening, diagnosis and management 87
Cellular injury 7
Agents of cell injury 12
PART 2
Body defences and immune system
2 DETERMINANTS OF HEALTH
AND ILLNESS 20 pathophysiology 99
Introduction 20 6 STRESS AND ITS ROLE IN DISEASE 100
Determinants of health and illness 21
Introduction 100
Disease burden and mortality 22
Stressors 101
Individual factors influencing health 23
Historical perspectives on the stress response 101
Sociocultural and socioeconomic determinants
of health 28 Current perspectives on the stress response 104
Environmental determinants of health 30 Ageing and the stress response 105
The Australian context 34 Sex differences in the stress response 105
7 IMMUNE DISORDERS 112

3 INFLAMMATION AND HEALING 39
Introduction 112
Introduction 40 An overview of immune function 113
Acute inflammation 40 Types of immune dysfunction 114
Chronic inflammation 44 Immune overactivity 120
Healing and repair 44
8 INFECTION 131
4 GENETIC DISORDERS 53 Introduction 131
Introduction 54 Infectious organisms 132
Principles of genetic inheritance 54 Types of colonisation by microorganisms 137
Clinical diagnosis 55 Chain of transmission 138
viii Detailed table of contents
Antimicrobial drugs 140 15 MENTAL HEALTH DISORDERS 291

Emerging infectious diseases 142 Introduction 291
Mental health and illness classified 292
PART 3 Factors influencing mental health and wellness 292
Nervous system pathophysiology 149 Brain regions involved in affect, cognition
and behaviour 292
9 BRAIN AND SPINAL CORD DYSFUNCTION 150 Affective disorders 292
Introduction 151 Anxiety disorders 298
Consciousness 151 Microbiome–gut–brain axis 301
Cerebrovascular accidents 155 Psychosis 305
CNS infections 161 Substance dependence and behavioural addictions 306
Guillain–Barré syndrome 165 Dual diagnosis 317
Hydrocephalus 166
Cerebral palsy 167
PART 4
Cerebellar disorders 169 Endocrine pathophysiology 325
Neural tube defects 169
16 CONCEPTS OF ENDOCRINE
10 NEURODEGENERATIVE DISORDERS 177 DYSFUNCTION 326
Introduction 177 Introduction 326
Common pathophysiological processes implicated The importance of endocrine feedback mechanisms 327
in neurodegeneration 178 Types of pathophysiological mechanisms 328
Parkinson’s disease 179 Methods used to assess endocrine function 332
Alzheimer’s disease 183 Principles of treatment 333
Huntington’s disease 187
Multiple sclerosis 189 17 HYPOTHALAMIC–PITUITARY DISORDERS 339
Motor neurone disease 191 Introduction 339
Growth hormone 340
11 NEUROTRAUMA 199 Prolactin hypersecretion 346
Introduction 200 Antidiuretic hormone 347
Traumatic brain injury (TBI) 200 Multi-hormone pituitary disruptions 350
Spinal cord injury 211
18 THYROID AND PARATHYROID DISORDERS 361
12 SEIZURES AND EPILEPSY 234 Introduction 362
Introduction 234 Thyroid disorders 363
Seizures 235 Parathyroid disorders 369
13 NOCICEPTION AND PAIN 249 19 ADRENAL GLAND DISORDERS 379
Epidemiology of pain 250 Disorders of the adrenal cortex 380
Nociception and pain 250 Disorders of the adrenal medulla 391
Pain assessment 256
Neuropathic pain 259 20 DIABETES MELLITUS 400
Clinical diagnosis and management of pain 262 Introduction 401
Type 1 diabetes mellitus 401
14 DISORDERS OF THE SPECIAL SENSES 269 Type 2 diabetes mellitus 402
Introduction 269 Gestational diabetes 404
Vision impairment 270 Clinical manifestations and complications of diabetes 407
Hearing impairment 278 Clinical diagnosis and management
Balance and vestibular disorders 285 of diabetes mellitus 410
Detailed table of contents ix
PART 5 PART 6
Cardiovascular pathophysiology 419 Pulmonary pathophysiology 543
21 BLOOD DISORDERS 420 26 PULMONARY DYSFUNCTION 544

Anaemias 421 Respiratory rate, rhythm and depth 545
Decreased production of erythrocytes 421 Alterations in oxygen and carbon dioxide levels 551
Increased destruction of erythrocytes: Pulmonary dysfunction 555
extracellular causes 428 Respiratory assessments and investigations 559
Increased destruction of erythrocytes: Respiratory failure 568
intracellular causes 430
Loss of erythrocytes from blood loss 432 27 OBSTRUCTIVE PULMONARY
Polycythaemias 433 DISORDERS 579
Haemophilias 435 Introduction 579
Thrombocytopenia 437 Asthma 580
Leukaemia and lymphoma 437 Status asthmaticus 586
Multiple myeloma 443 Bronchitis 587
Emphysema 590
22 VASCULAR DISORDERS AND Mechanisms of gas trapping 595
CIRCULATORY SHOCK 450 Cystic fibrosis 596
Introduction 451 Bronchiectasis 601
Hypertension 451
28 RESTRICTIVE RESPIRATORY
Common conditions affecting arteries 455
DISORDERS 609
Aneurysms 458
Introduction 609
Arteriovenous malformations 460
Parenchymal lung disorders 610
Common conditions affecting veins 463
Extraparenchymal lung disorders 620
Thrombophlebitis and phlebothrombosis 465
Circulatory shock 467 29 RESPIRATORY INFECTIONS,
CANCERS AND VASCULAR
23 CORONARY ARTERY DISEASE 478 CONDITIONS 631
Coronary artery disease 480 Respiratory infections 632
Acute coronary syndrome 488 Upper respiratory tract infections 632
Lower respiratory tract infections 634
24 CARDIAC MUSCLE AND VALVE Lung cancer 642
DISORDERS 498 Pulmonary vascular conditions 650
Introduction 499
Heart failure 499 PART 7
Other causes of heart failure 504 Fluid, electrolyte and renal
Heart failure: risk factors, clinical manifestations, pathophysiology 667
complications and diagnosis and management 512
30 FLUID IMBALANCES 668
25 DYSRHYTHMIAS 522 Introduction 668
Introduction 522 Distribution of body water and fluid
Aetiology and pathophysiology 523 balance 669
Clinical manifestations 528 Compartment osmolality 670
Clinical diagnosis and management 531 Alterations in body fluid levels 670
x Detailed table of contents
Fluid deficits 670 Chronic inflammatory bowel diseases 790

Fluid excesses 671 Intestinal obstruction 794
31 ELECTROLYTE IMBALANCES 683 38 DISORDERS OF THE LIVER, GALL

Introduction 683 BLADDER AND PANCREAS 805
Distribution of electrolytes 684 Introduction 805
Electrolyte imbalances 685 An overview of the pathophysiology of
hepatobiliary disease 806
32 COMMON INFLAMMATORY DISORDERS Major hepatobiliary diseases 809
OF THE KIDNEYS AND URINARY TRACT 704 Major pancreatic diseases 820
Introduction 704 Cystic fibrosis 823
The normal kidneys 705
Bacterial urinary tract infections 705 PART 9
Kidney disorders 708 Reproductive pathophysiology 831
Urinary incontinence 718
39 FEMALE REPRODUCTIVE DISORDERS 832
33 RENAL NEOPLASMS AND Introduction 833
OBSTRUCTIONS 725 Menstrual disorders 833
Introduction 725 Genitourinary prolapse 836
Polycystic kidney disease 726 Reproductive neoplasms 839
Renal system cancers 727 Female reproductive cancers 842
Renal obstructions 731 Inflammatory and infectious disorders 843
Breast disorders 846
34 ACUTE KIDNEY INJURY AND CHRONIC
Ectopic pregnancy 851
KIDNEY DISEASE 739
Female infertility 852
Introduction 740
Acute kidney injury 740 40 MALE REPRODUCTIVE DISORDERS 861
Chronic kidney disease 742 Introduction 861
Prostate disorders 862
PART 8 Urethral and penile disorders 867
Gastrointestinal pathophysiology 753 Testicular and scrotal disorders 874
Sexually transmitted infections 879
35 GASTRO-OESOPHAGEAL REFLUX
DISEASE AND PEPTIC ULCER DISEASE 754 PART 10
Introduction 755 Musculoskeletal pathophysiology 887
Gastro-oesophageal reflux disease 755
Peptic ulcer disease 758 41 MUSCULOSKELETAL TRAUMA AND
MUSCLE DISORDERS 888
36 MALABSORPTION SYNDROMES 766
Introduction 889
Introduction 767 Musculoskeletal trauma 889
Maldigestion 767 Fractures 894
Impaired mucosal function 768 Muscle disorders 901
Alterations in microbial flora 772 Inflammatory myopathies 904
37 INTESTINAL DISORDERS 780 Muscular dystrophy 907
Muscle atrophy 908
Introduction 781
Muscle contractures 909
Infectious conditions of the intestines 781
Muscle cramp 909
Acute inflammatory conditions of the
intestines 784 Delayed onset muscle soreness (DOMS) 910
Intestinal neoplasms 787 Rhabdomyolysis 911
Detailed table of contents xi
42 BONE AND JOINT DISORDERS 919 44 SKIN CANCERS, BURNS AND

Introduction 920 SCARRING 994
Bone and joint developmental disorders 920 Introduction 994
Arthritis 926 Skin cancers 994
Metabolic bone and joint diseases 937 Burns 998
Infective bone disorders 946 Scarring 1005
Osteogenic tumours 947
45 BITES AND STINGS 1012
PART 11 Introduction 1012
Integumentary system pathophysiology 957 Spider bites 1013
Snake bites 1015
43 INTEGUMENTARY SYSTEM DISORDERS 958 Tick bites 1017
Introduction 959 Wasp and bee stings 1018
Inflammatory skin conditions 959 Marine bites and stings 1019
Skin infections 967
Viral infections 972 Glossary 1024
Fungal infections 976 Index 1042
Parasitic infections 979
Dermal appendage disorders 980
About the authors
SHANE BULLOCK
Shane has been involved in the education of health professionals and science students for more than 30 years. He is an
academic at the Monash University School of Rural Health, where he is responsible for the delivery of the first year of the
university’s graduate-entry medical course. Shane is the co-author of two Australian textbooks, Fundamentals of Pharmacology,
now in its 8th edition, and Psychopharmacology for Health Professionals. He has also published a number of journal articles
on health professional education.
MAJELLA HALES
Majella has been nursing for over 25 years, much of this time in education roles both clinically and in academia. She is the
co-founder of Sciencopia, a business producing and manufacturing educational resources for nurses and other undergraduate
health care professionals. She maintains her clinical experience working occasional agency shifts in critical care units across
south-east Queensland and through clinical facilitation with undergraduate nursing students. Majella authoured several
chapters of Kozier & Erb’s Fundamentals of Nursing Vols 1–3 and LeMone and Burke’s Medical–Surgical Nursing. Along
with journal articles and conference presentations, she has also produced the original skills DVD for Tollefson’s Clinical
Psychomotor Skills text, and adapted the American case study resource The Neighbourhood. She is also co-author of the
Essential Aussie Drugs pocket-book series.
Preface
OUR GOALS
Principles of Pathophysiology is the first wholly local, comprehensive pathophysiology textbook written for students studying
nursing and allied health in Australia and New Zealand. Where possible we have embedded throughout this text epidemiological
data, lifespan issues, Indigenous issues, clinical practices, drug names, units of measurement and websites that are relevant to
the Australian and New Zealand region.
Most of the existing pathophysiology books are unwieldy in both a physical and a readable sense. There is a common
format—around half of the book comprises chapters on the normal anatomy and physiology of the body systems. In our view
these chapters are redundant, as student health professionals purchase anatomy and physiology textbooks during their first
year at university. The approach that we have taken is to maintain the focus on pathophysiology and to complement other
textbooks that the students have at hand that cover anatomy/physiology and pharmacology.
The book is designed to be very readable and accessible for students studying their chosen profession prior to
registration. We have endeavoured to strongly link and integrate the science with clinical practice. To this end, each chapter
is co-authored by a scientist and an expert clinician, given that few individuals possess both the scientific and clinical
expertise in any one field.
ORGANISATION OF THE TEXT

The book is organised into parts covering body system pathophysiology. The first part of the book contains chapters examining
major pathophysiological concepts, such as cellular adaptations, inflammation and neoplasia, as well as the determinants of
health and illness.
Chapters are structured with a consistent content framework for ease of accessing information about specific disorders
associated with a particular body system. This is best reflected in the sequencing of chapter subheadings for each disorder,
which are as follows: aetiology and pathophysiology, epidemiology, clinical manifestations, then clinical diagnosis and
management.
NEW FOR THIS EDITION

The content of this textbook has been reviewed with respect to the recent literature, as well as current clinical practices and
guidelines at the time of writing. In some sections the ordering of chapters has changed, and some chapters have been
amalgamated to increase the readability for students.
NEW CHAPTER: DETERMINANTS OF HEALTH AND ILLNESS

The social determinants of health play a significant role in the full assessment and management of a person’s illness by health
professionals. In this edition a new chapter on the sociocultural, economic, biomedical and behavioural factors that affect
health and the development of illness are discussed.
INDIGENOUS HEALTH FAST FACTS AND CULTURAL CONSIDERATIONS

The Indigenous health fast facts have been expanded to include a separate section called ‘Cultural considerations’. The focus
in this section is on social and cultural issues associated with the chapter content. This responds to reviewer feedback requesting
the inclusion of more of the qualitative influence of indigeneity on health and wellness.
xiv Preface
NEW IMAGES
A significant number of new images have been produced for this edition. These images provide clearer understanding or
representation of either new or reconceptualised content. Several new clinical snapshots have also been constructed to
accommodate new best practice, to clarify previously included material, or to expand on content not previously addressed.
LANGUAGE AND TERMINOLOGY

The use of correct scientific and clinical language is important in order to prepare student health professionals for the
workplace. However, preparatory textbooks need to be accessible and readable for students developing their knowledge base.
We believe that we have struck a good balance in writing style that does not compromise the integrity of the scientific and
clinical disciplines.
By their nature, pathophysiology textbooks contain jargon terms that pertain to the science and to the clinical practice. It is
important for students to have ready access to definitions of this terminology. In this book, key terms are printed in bold type.
All of these terms are defined in the glossary; many are described within the chapter text.
Shane Bullock and Majella Hales
Acknowledgements
We sincerely thank all those people who have contributed to the development of this textbook. We are grateful to the
contributors who have worked closely with us to create high-quality and very readable chapters. We also thank the reviewers
for their thoughtful and extremely valuable comments and suggestions on the text.
Shane would like to acknowledge that his family carries on living interesting and fulfilling lives around him while he labours
through the book writing and production period. You would think that they would prefer to suffer with him. Nevertheless, they
always provide a place of quietude to escape the hurly burly outside. Again it was a pleasure to write with Majella on this edition,
and her good humour, visually creative talent and love of sloths enlivened this project. Thanks also to his friend and colleague
Anna-Marie Babey, who is ever vigilant for important content that should be added or deleted from the text.
Majella would like to give many thanks to her dear friend, mentor and business partner Robin Fisher, who, despite her
unique capacity to become air-borne in a vehicle not designed for flight (resulting in quite serious injuries), managed to find
the effort and inclination to engage in rigorous intellectual debate to ensure the accuracy and quality of selected chapters.
Majella would also like to thank Eun Jeong Roh (friend and business partner) for her incredible illustration skills on several
new images. Thanks also to Bonnie Waite (her sister), who worked vigorously on cataloguing images for this edition. Although
her remittance seemed to inflate from ‘good coffee’ in the last edition to frequent Coffee Club visits this edition, her determined
efforts were well worth it. Finally, Majella would like to acknowledge the stoicism of her co-author. Shane’s display of
prodigious humour and the patience akin to a bonsai tree gardener ultimately ensured the completion of this edition.
It has been a pleasure to work with the team at Pearson Australia. They have shown us tremendous support, flexibility,
patience, encouragement, good humour and cajoling in equal measure. Our thanks to Mandy Sheppard, Anna Carter,
Bernadette Chang, Lisa Woodland and Katy Murenu. We are also grateful to Kate Stone (and her canine assistant) and Katie
Millar for their excellent copyediting and proofreading.
CONTRIBUTORS
The authors would like to thank the following contributors for their input to the first edition:
Judith Applegarth Melanie (‘Lainie’) Cameron Anita Westwood
Ralph Arwas Trisha Dunning Alison Williams
Anna-Marie Babey Elizabeth Manias
REVIEWERS
Dr Matthew Barton – Griffith University Dr David Simcock – James Cook University Reviewer of exercise science content in
Dr Lisa Chilton – James Cook University Ms Kate Smith – Curtin University Health professional connections
Dr David Good – Australian Catholic University Associate Professor Louise Ward – La Trobe Dr Peter Le Rossignol – Australian Catholic
Mrs Courtney Hayes – University of Canberra University University
Dr Snezana Kusljic – The University of Melbourne Mr Grant Williams-Pritchard – Griffith University Reviewer of physiotherapy content in
Mrs Anne Marks – Western Sydney University Reviewer of Indigenous cultural Health professional connections
Ms Gayle McKenzie – La Trobe University considerations content Mrs Allison Kloehs – Australian Catholic University
Dr Nicole Reinke – University of the Sunshine Machellee Kosiak – Australian Catholic University
Coast
is undertaken to identify signs of trauma. The GCS score
Initial rapid neurological assessment can be achieved by using should be assessed, as this will provide a more accurate account
EY TERMS L E Athe
R NAVPU
I N Gscale
O B(see
J E CClinical
T I V E SBox 9.1), whose name is an of changes in consciousness. When taken in the first hours of
abbreviation of the scale’s parameters. In a most basic form, injury, the GCS score can also accurately predict probable
etiology Afterassessment
completing by this chapter,
the AVPU scale you should
(Alert, Voice,bePain,
ableUnconscious)
to: outcomes.
poptosis is a rapid and simple method to determine the gross level of A full set of observations are taken, with attention to blood
1 Defi ne the terms
consciousness. pathophysiology,
If the aetiology,
person is not alert, pathogenesis,
assessment is made by clinical
pressuremanifestations
and temperatureand as possible causes. Widening pulse
trophy
Features of the text

epidemiology.
determining whether they respond to a voice; failing arousal to pressure may suggest increasing intracranial pressure (see
aseous necrosis someone speaking to them, response to pain/noxious stimuli Clinical Box 9.3). Hypothermia and hyperthermia can both
inical 2 Distinguish betweenbythe
should be assessed incidence
observing for aand the prevalence
reaction of a disease.
to a trapezius influence levels of consciousness. Changes in respirations (rate,
anifestations squeeze or supraorbital pressure. If there is no response to depth or rhythm) may imply injury and dysfunction to the
3 Describe the four
noxious stimuli, theytypes of cellular
are deemed adaptations,
unresponsive. and suggest
The AVPU situationscentre
scale respiratory whenineach may(apneustic
the pons occur. or pneumotaxic areas).
oagulative necrosis is not considered a comprehensive assessment, but it is beneficial Blood should be drawn for testing glucose, electrolyte and pH
ysplasia 4 Defi ne dysplasia, differentiate it from other cell adaptations, and outline its consequences.
in its simplicity and is used in many clinical situations, including imbalance, as well as drug panels for commonly overdosed
prehospital. Basic life support should be ongoing. A GCS should agents.
pidemiology 5 Differentiate between the characteristics of reversible and irreversible cell injury.
be undertaken as part of the secondary survey in a comprehensive Pupillary response and size should be assessed. Both a direct
at necrosis assessment. response (shining the light into the pupil and watching that
6 Compare and contrast necrosis and apoptosis.
angrene Methods to determine the cause of ALOC will be directed at pupil’s response) and a consensual response (e.g. shining the
omeostasis 7 Differentiate
the most obviousbetween the typesbased
considerations of necrotic cell death.
on the available history. light into the left pupil and watching the right pupil’s response
Failing this, investigations should be aimed at common causes and vice versa) should be assessed, as this will give an
yperplasia 8 Identify the major
first. Clinical Box 9.2 agents of cella mnemonic
provides injury. as a prompt for impression of the cranial nerve III function (oculomotor).
ypertrophy common causes of ALOC. Depending on levels of consciousness, motor and sensory limb
9 Describe the process of cell injury resulting from an ischaemic or hypoxicmay
assessments agent.
be carried out to determine motor cortex
ypoxia
function.
cidence Imaging investigations will generally include a computed
tomographic (CT) scan to determine the presence of any space-
What you should know before
chaemia
quefactive necrosis
CLINICAL BOX 9.1
W H A T Y O U S H O U L D K N O W B E F O R E Y O U S T A R T T H I S C H A P T Elesion,
occupying R such as a tumour, or an abscess. Other
pathology visible on a CT may include haemorrhage,
you start this chapter
AVPU scale
etaplasia Can you name the main structures of the cell and their functions?hydrocephalus, oedema or infarction.
Depending on the presentation, a lumbar puncture may be
These questions ensure that
ecrosis Can you describe how molecules are transported across the cell membrane?
A—Alert
V—Voice
performed if meningitis, encephalitis or subarachnoid students review the basic
xygen free radicals Can you describe the cell cycle? haemorrhage is suspected. However, there are many
athogenesis
P—Pain
Can you define cellular metabolism? contraindications to lumbar puncture, in which case other bioscience principles and concepts
U—Unconscious
methods may be employed instead. that provide the foundation for the
athophysiology Can you identify the major types of tissues and their functions?
revalence MANAGEMENT pathophysiological knowledge they
eactive oxygen An individual who is breathing spontaneously but has an ALOC
pecies (ROS) should be placed in the recovery position. Airway management15
C H A P T E R 1 PAT H O P H Y S I O L O G I C A L T E R M I N O L O G Y, C E L L U L A R A DA P TAT I O N A N D I N J U R Y will gain in the chapter.
equipment such as a Guedel’s airway (oropharyngeal airway—
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and/or its magnitude
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Encephalopathy impaired
P Pulmonary embolus/Psychosis
of normal cells that areissues.in close proximity.
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AND
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cytokines levels of referred to as ‘dysrhythmia’ in this book.
tissue mediators Calcium ion influx Raised O levels
2
disease
will havefor logistical,
Poor nutrition
Aboriginal andapproximately
Torres Strait
contributes topersonnel,
Islander peoples.
equipment
19% of the burden and outcome
of Indigenous health fast facts
and cytokines implications.
Estimations
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for Aboriginal this
and event,
costs mechanical
in rural
Torres Strait and remote
Islander ventilation
communities
peoples. must arebe
Inflammation
Membrane and
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Estimations be costs
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in rural and 30%remotehigher than in major
communities are and cultural considerations
Membrane and formation cities, which probably contributes to thethan veryinlow fruit and
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Inflammation cytoskeleton
damage
formation vegetable
cities, whichintake
probably described
contributes amongto theAboriginal
very low fruit andandTorres Strait Important health concerns for
Islander intake
vegetable groups. described among Aboriginal and Torres Strait
Protein Islander groups. results in the birth of low-birth-weight babies Aboriginal and Torres Strait Islander
denaturation
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M09_BULL7676_02_SE_C09.indd 154
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DNA damage Poor nutrition
almost twiceresults in the birth
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peoples, Māori and Pacific Islander
almost twice
Islander as frequently
women than in innon-Indigenous
Aboriginal and Torres
women.Strait
Islander women than in non-Indigenous women. people are highlighted in relation to
Cell injury
Food security is a greater issue for Aboriginal and Torres Strait
Cell injury
Food security is a greater issue for Aboriginal and Torres Strait
Islander peoples, with 22% of people reporting that at least one
Islander peoples, with 22% of people reporting that at least one
the issues presented in each
person went without food when the household ran out of food,
person went without food when the household ran out of food,
comparedto to 3.7% in non-Indigenous Australian households. chapter. A new feature expanding
Cell death compared 3.7% in non-Indigenous Australian households.
Cell death
Ma
Ma ˉoriororPacific
ˉori Pacific Islander
Islander babies
babies are less
are less likelylikely
than than European
European selected information is presented in
NewZealand
New Zealand children
children to breastfed.
to be be breastfed.
the separate section of Cultural
Figure 1.141.14
Figure Basedonona set
Based a set
of of predetermined
predetermined risk risk factors,
factors, MaˉoriMaˉori children
children
Re-perfusion injury
Re-perfusion injury
makeupup66%
make 66%of of children
children at risk
at risk of developing
of developing poor poor outcomes
outcomes considerations. This responds to the
later
laterininlife, compared
life, compared to 21%
to 21%of European New New
of European Zealand children,
Zealand children,
DNADNA 5 deoxyribonucleic
5 deoxyribonucleic acid;
acid; O2O255oxygen.
oxygen. 12%
12%ofofPacific
PacificIslander children
Islander and and
children only only
2.1%2.1%
of Asian New New
of Asian reviewer feedback requesting
Zealand
Zealandchildren.
children. inclusion of more of the qualitative
European
EuropeanNew NewZealand
Zealandbabies are,are,
babies on average, givengiven
on average, their first
their first
DNA, can enter a body cell and change its programming so that
solids at approximately 5½ months of age. Maˉori babies are
solids at approximately 5½ months of age. Maˉori babies are influence of indigeneity on health
DNA, can enter a body cell and change its programming so that more likely to be given solids before 4 months of age.
it becomes a factory for making new virus particles, or alter its
it becomes a factory for making new virus particles, or alter its
more likely to be given solids before 4 months of age. and wellness.
structure in such a way that it is irreversibly damaged. Sources: Australian Bureau of Statistics (2015); Australian Health Ministers’ Advisory Council
structureThe
in such
immunea way that itisisresponsible
system irreversiblyfor
damaged.
neutralising and Sources:
(2017); Australian
Australian BureauHealthInfoNet
Indigenous of Statistics (2015); Australian
(2017); National Health
Health andMinisters’ Advisory Council
Medical Research
(2017);(2013);
Council Australian Indigenous
New Zealand HealthInfoNet
Ministry (2017); National Health and Medical Research
of Health (2017).
The immune
removing system
these is responsible
microbial for neutralising
invaders. Infected body cells and
are
removing these microbial invaders. Infected body cells are
Council (2013); New Zealand Ministry of Health (2017).
Lifespan issues
Important health concerns or
C HIL DR EN AND ADO L ESCENT S
C H•IL DR EN AN D of
Assessment ADO L ESC EN
a child’s TS
quadriceps femoris for atrophy or hypertrophy is a good clinical indicator of age-related principles specific to
the need toof
• Assessment continue investigations
a child’s quadriceps for the presence
femoris of neuromuscular
for atrophy disease.
or hypertrophy is a good clinical indicator of individuals across the age
LIFESPAN •theHormonal
need to changes
continuefrom transition through
investigations for thegrowth stages
presence can influence a child’s
of neuromuscular tissue. Tonsils can
disease.
LIFESPAN
ISSUES hypertrophy during childhood and atrophy after puberty; many other tissues hypertrophy as a result
• Hormonal changes from transition through growth stages can influence a child’s tissue. Tonsils can
of puberty (e.g. secondary sex characteristics).
continuum—from neonates and
ISSUES hypertrophy during childhood and atrophy after puberty; many other tissues hypertrophy as a result children to older adults—are
Oof puberty
L DER (e.g.
ADU LT S secondary sex characteristics).
highlighted.
• As an individual ages, significant atrophy occurs in most major organs. These changes result in the
O L DER ADULT S
increased need to observe for drug toxicities, hydration status, malnutrition and changes to strength
• Asandan balance.
individual ages, significant atrophy occurs in most major organs. These changes result in the
•increased needmoderate
Exercise can to observe for drugmuscular
age-related toxicities,atrophy
hydration status,
to some malnutrition and changes to strength
degree.
and balance.
• Hyperplasia of the prostate gland occurs as a direct result of ageing, and can negatively affect an
• Exercise can moderate
older man’s age-related
urological and muscular atrophy to some degree.
sexual function.
• Hyperplasia of the prostate gland occurs as a direct result of ageing, and can negatively affect an
older man’s urological and sexual function.
M01_BULL7676_02_SE_C01.indd 15 28/07/18 6:11 PM
M01_BULL7676_02_SE_C01.indd 15 28/07/18 6:11 PM
Features of the text xvii
M21_BULL7676_02_SE_C21.indd 425
Clinical snapshots
Pernicious anaemia
These concept maps are designed
Genetic cause
to demonstrate the critical links
IF produced by from
Gastric parietal cells Intrinsic factor (IF)
Gastric mucosal atrophy
between pathophysiology, clinical Intestinal

Intestinal V vitamin
itaminBB12 absorption
12Adsorption
manifestations and management.

Erythrocyte maturation
They are a key feature for integrating

the science and clinical practice Macrocytic normochromic anaemia
components of the text. Ideal for

Abdominal Glossitis Right-sided Hypoxia Pallor Fatigue Neurological dysfunction
visual learners, the boxes in the pain heart failure

from
Demyelination
manages
diagrams are colour-coded—pink manages
manages
Paraesthesias
(pathophysiology), blue (clinical
e.g.
Unsteady gait
Meat
Eggs IV cyanocobalamin Proprioception
B12-rich foods
manifestations) and yellow
manages
supplement
Cheese
if severe
if severe
Folate
Yoghurt
(management)—for quicker
of
CHAPTER 21 Blood disoRdERs

Diet Medication Oxygen Transfusion Manage cause
understanding and application.
Management
Key clinical issues

Figure 21.4
This is a summary of the significant Clinical snapshot: Pernicious anaemia
5 decreased; IF 5 intrinsic factor; IV 5 intravenous.
principles in each chapter that are
425
23/07/18 7:18 AM
central to providing safe, informed,

clinical practice. 48 PA R T 1 C E L L U L A R A N D T I S S U E PAT H O P H Y S I O L O G Y
K E Y C L I N I C AL I SSU ES areas within the site of chronic inflammation that are calcified and
hard are called granulomas. Cells within a granuloma tend to undergo
liquefactive necrosis, leaving a hollowed-out structure.
• Following trauma or surgery, excessive inflammation can result in limb-
• Healing and repair processes restore the lost parenchyma and re-
threatening neurovascular compromise. Undertake frequent
establish the continuity of the tissue framework through scar formation.
Chapter review and Review neurovascular assessment distal to the site of injury. Observe for
changes in colour, warmth, movement and sensation.
• Appropriate positioning to promote venous return and lymphatic
Healing and repair processes comprise debridement, epithelialisation,
regeneration of parenchyma, formation of granulation tissue and wound
contraction.
drainage will assist in reducing oedema.
questions
• First intention healing involves minimal loss of functional cells. Healing
• Oedema can result in challenges to skin integrity. Ensure that pressure is relatively quick and uncomplicated. Second intention healing
area care is undertaken frequently in individuals with excessive involves a significant loss of tissue framework and is characterised by
inflammation. significant scarring and little parenchymal regeneration. Second
• Use of non-steroidal anti-inflammatory drugs (NSAIDs) in the control of intention healing is more prolonged, and is often associated with
A summary of the key content inflammation can be beneficial; however, NSAID therapy can also
induce gastric ulcers, photosensitivity and kidney failure, depending on
the dose and the duration of treatment. Use of NSAIDs in certain
complications such as contractures.
• A number of factors can greatly influence the degree and rate of
healing. These include blood supply to the affected area, the
groups can be dangerous. Individuals with asthma have an increased
essential to understanding the

oxygen-carrying capacity of the blood, nutrition (especially glucose,
risk of serious adverse reactions, and the use of aspirin in children is vitamin C and protein availability), infection, drug therapy and
associated with Reye’s syndrome. movement.
pathophysiological knowledge in C H A PT ER R EVI EW R EVI EW Q U EST I O N S

• The purpose of inflammation is to neutralise an agent of injury and
each chapter is provided. Questions

1 Briefly outline the pathophysiological processes underlying each of the
stop further damage. It also prepares the site of injury for healing. following cardinal signs of inflammation:
• The cardinal signs of inflammation are swelling, redness, warmth, pain a swelling
and loss of function. The suffix representing an inflammatory condition
b pain
enable the student to assess, is -itis.

• A range of chemicals released into the site of tissue injury mediate the
induction and magnitude of the process of inflammation. The key pro- 2
c increased warmth
Determine the body tissue affected in the following inflammatory
conditions (Note: You may have to do some research):
review and consolidate what they

inflammatory chemical mediators are prostaglandins, histamine,
leukotrienes, kinins, cytokines, platelet-activating factor, thromboxanes, a laryngitis
nitric oxide and neuropeptides. b cellulitis
• The vascular phase of acute inflammation comprises tissue blepharitis
have learnt in the chapter.

c
vasodilation and increased capillary permeability. Three important CHAPTER 3 INFLAMMATION AND HEALING 49
d rhinitis
cascading reactions contribute to the inflammatory response: the
complement system, coagulation and the kinin–kallikrein system. 3 What are the roles for each of the following pro-inflammatory chemical
H E A LT H P R O F E S S I O N A L C O N N E C T I O N S
mediators?
• The cellular phase involves the movement of immune cells to the site
of the inflammation in order to neutralise the agent of injury and a histamine
prepare the site for healing. The phagocytic cells, monocytes/ b cytokines
macrophages and neutrophils play a key role in this phase.
Health professional connections

c nitric oxide
• The fluid that accumulates in the site of inflammation is called an
exudate. The four main types of exudate are: serous, fibrinous, purulent
Midwives
d leukotrienesIntrauterine inflammation can occur as a result of microbial invasion of the amniotic cavity (MIAC). As a result, the risk of preterm
4 In what ways does the complement system contribute to inflammation?
and haemorrhagic. labour is increased, and therefore issues relating to lung immaturity are also amplified. Premature rupture of membranes increases the risk of
5 Which type of exudate is particularly associated with the following?
• Chronic inflammation is defined as the persistence of the response for
MIAC,a and therefore preterm labour. These women are more likely to develop chorioamnionitis. The presence of microbes (or colonisation)
This feature enables students to more than two weeks. Chronic inflammation can be distinctly different
from the acute response. When this occurs, neutrophils die out and
lymphocytes can infiltrate the site along with monocyte/macrophages—
abscesses
aloneb will not necessarily result in poorer clinical outcomes; however, a fetal inflammatory response may occur, which will influence gestation
blisters
adhesions
CHAPTER 3 INFLAMMATION AND HEALING 49
time cand premature delivery. Microbial contamination can occur by ascending through the cervix or, less commonly, as a haematogenous
understand the roles and
these become the dominant cell types in the site. By this stage, there is
little evidence of the vascular phase of the acute inflammatory
response.
dissemination, H EALT H PR O F ESSI O N AL C O N N EC T I O N S
6 In what ways is it possible to differentiate between acute and chronic
inflammation? or from instrumentation from invasive procedures such as amniocentesis. Midwives should be familiar with the signs of MIAC,
and
7 ensure
Arrange thethat they
following seek
in the assistance
correct from
sequence for the other
healing and repair Midwives
members of the healthinflcare
Intrauterine team
ammation can to ensure
occur a ofpositive
as a result outcome.
microbial invasion of the amniotic cavity (MIAC). As a result, the risk of preterm
• The definition of acute and chronic inflammation can be simplistic and
importance of the various health

processes: labour is increased, and therefore issues relating to lung immaturity are also amplified. Premature rupture of membranes increases the risk of
arbitrary. In inflammation, a complex interplay between states occurs,
scar formation debridement MIAC, and therefore preterm labour. These women are more likely to develop chorioamnionitis. The presence of microbes (or colonisation)
which means that aspects of acute inflammation can be present during
chronic states, and significant cell damage is not limited to only the
Physiotherapists/Exercise
wound contraction regeneration
scientists Exercisealone canwillreduce C-reactive
not necessarily protein
result in poorer clinicaland inflammatory
outcomes; however, a fetalcytokines. It is well
inflammatory response established
may occur, which will inflthat
uence gestation
time and premature delivery. Microbial contamination can occur by ascending through the cervix or, less commonly, as a haematogenous
chronic form. exercise can have anti-inflammatory effects; however, some important considerations—such as the type, duration and intensity of the exercise—
professionals with whom they will
epithelialisation
dissemination, or from instrumentation from invasive procedures such as amniocentesis. Midwives should be familiar with the signs of MIAC,
• Chronic inflammatory processes may damage parenchymal cells, which
are replaced by fibrous connective tissue produced by local fibroblasts.
can
8 infl uence
Compare and this effect.
contrast first andStrenuous exercise
second intention healing. can induce
andpro-infl ammatory
ensure that mediators
they seek assistance from otherasmembers
well asof the
anti-infl ammatory
health care cytokines.
team to ensure It is important to
a positive outcome.
9 How can movement and poor blood flow affect healing?
This fibrosis can lead to significant scarring and deformity. Walled-off understand the influence of short-term strenuous exercise and also prolongedscientists exercise Exercise
on thecanimmune system andandthe inflammatory
cytokines. response.
work in an inter-professional team.

Physiotherapists/Exercise reduce C-reactive protein inflammatory It is well established that
Exercise professionals assisting clients with inflammatory disorders
exercise can have anti-inflmust
ammatory ensure that some
effects; however, the important
individual effects of asthe
considerations—such disease
the type, duration process
and intensity are
of the exercise—
can influence this effect. Strenuous exercise can induce pro-inflammatory mediators as well as anti-inflammatory cytokines. It is important to
considered when developing an exercise or rehabilitation program.
understand the influence of short-term strenuous exercise and also prolonged exercise on the immune system and the inflammatory response.
This information is presented in the M03_BULL7676_02_SE_C03.indd 48

All allied professionals Inflammation can be a06/07/18 sign1:33ofPMwhen
considered infection.
Exercise professionals assisting clients with inflammatory disorders must ensure that the individual effects of the disease process are
developingItanisexercise
important that program.
or rehabilitation when working with a client, all observations of
inflammation are reported to other members of the health care team so that furthercaninvestigation andItmanagement canworking
be instituted. Early
context of the management of the
All allied professionals Inflammation be a sign of infection. is important that when with a client, all observations of
inflammation are reported to other members of the health care team so that further investigation and management can be instituted. Early
treatment will often result in a less serious clinical outcome, reducing morbidity and mortality risks. Open communication with all members of
treatment will often result in a less serious clinical outcome, reducing morbidity and mortality risks. Open communication with all members of
the health care team will result in the provision of a better service.
the health care team will result in the provision of a better service.
specific disorders discussed in each

chapter. C ASE ST U DY
C A S E S T U DY Mrs Linda Carter is a 35-year-old woman (UR number 654238). She has been admitted for management of cellulitis on her right calf. She suspects the
original insult was a spider bite, although she never saw the spider. However, she did see two small puncture marks when she first noticed the wound. Over
the next few days, the site became red and inflamed, a red line began tracking up the inside of her right thigh, and she developed bilateral inguinal
lymphadenopathy. Her observations were as follows:
Case studies Mrs Linda Carter is a 35-year-old woman (UR number 654238). She has been admitted for management of cellulitis on her right calf. She suspects the
original insult was a spider bite, although she never saw the spider. However, she
Temperature did
Heart see twoRespiration
rate small puncture
rate marks when she first SpO
Blood pressure noticed
2
the wound. Over
the next few days, the site became red and inflamed, a red line began
38°C tracking up80the inside of her20right thigh, and
116
she
⁄76 developed
98%bilateral
(RA*) inguinal
Clinically accurate and realistic lymphadenopathy. Her observations were as follows:

*RA 5 room air.
Mrs Carter was commenced on intravenous antibiotics, paracetamol q6h PRN and daily dressings as necessary. Although no pus was observed, a swab was
scenarios allow students to apply, Temperature

38°C
Heart rate
80
Respiration
20
rate Blood pressure SpO2
taken of the lesion. Her admission pathology results have returned as shown overleaf.
116
⁄76 98% (RA*)
synthesise and evaluate their
*RA 5 room air.
knowledge, and in some instances Mrs Carter was commenced on intravenous antibiotics, paracetamol q6h PRN and daily dressings as necessary. Although no pus was observed, a swab was
taken of the lesion. Her admission pathology results have returned as shown overleaf.
predict clinical outcomes.
M03_BULL7676_02_SE_C03.indd 49 06/07/18 1:33 PM
M03_BULL7676_02_SE_C03.indd 49 06/07/18 1:33 PM
Educator resources
A suite of learning resources is provided to assist with delivery of the content, as well as to support teaching and learning.
TEST BANK
The Test Bank provides a wealth of accuracy-verified testing material. Updated for the new edition, each chapter offers a wide
variety of question types, arranged by learning objective and tagged by NMBA standards. Questions can be integrated into
Blackboard, Canvas or Moodle Learning Management Systems.
DIGITAL IMAGE POWERPOINT SLIDES

All the diagrams and tables from the course content are available for lecturer use.
SOLUTIONS MANUAL
The Solutions Manual provides educators with detailed, accuracy-verified solutions to in-chapter and end-of-chapter problems
in the book.
PART 1
Cellular and tissue

pathophysiology
1 Pathophysiological terminology,
cellular adaptation and injury
KEY TERMS LEARNING OBJECTIVES

Aetiology After completing this chapter, you should be able to:
Apoptosis
1 Define the terms pathophysiology, aetiology, pathogenesis, clinical manifestations and
Atrophy
epidemiology.
Caseous necrosis
Clinical 2 Distinguish between the incidence and the prevalence of a disease.
manifestations
3 Describe the four types of cellular adaptations, and suggest situations when each may occur.
Coagulative necrosis
Dysplasia 4 Define dysplasia, differentiate it from other cell adaptations, and outline its consequences.
Epidemiology 5 Differentiate between the characteristics of reversible and irreversible cell injury.
Fat necrosis
6 Compare and contrast necrosis and apoptosis.
Gangrene
Homeostasis 7 Differentiate between the types of necrotic cell death.
Hyperplasia 8 Identify the major agents of cell injury.
Hypertrophy
9 Describe the process of cell injury resulting from an ischaemic or hypoxic agent.
Hypoxia
Incidence
Ischaemia
Liquefactive necrosis
WHAT YOU SHOULD KNOW BEFORE YOU START THIS CHAPTER
Metaplasia Can you name the main structures of the cell and their functions?
Necrosis Can you describe how molecules are transported across the cell membrane?
Oxygen free radicals Can you describe the cell cycle?
Pathogenesis Can you define cellular metabolism?
Pathophysiology Can you identify the major types of tissues and their functions?
Prevalence
Reactive oxygen
species (ROS)
C H A P T E R 1 PAT H O P H Y S I O L O G I C A L T E R M I N O L O G Y, C E L L U L A R A DA P TAT I O N A N D I N J U R Y 3
INTRODUCTION CLINICAL MANIFESTATIONS

The clinical manifestations are the demonstrable changes
LEARNING OBJECTIVE 1 representing the changes in function brought about by a disease
process. The clinical manifestations are the changes observed
Define the terms pathophysiology, aetiology, pathogenesis,
by the affected person, their families or other people, as well as
clinical manifestations and epidemiology.
the changes felt by the affected person. They are also known,
respectively, as the signs and symptoms of a disease. In a book
Pathophysiology is defined as an understanding of the mechanisms
such as this, common signs and symptoms are stated, but in
by which disease and illness alter body functioning. These
reality a person with a particular disease may not show all of
changes represent a breakdown of homeostasis, the dynamic
the clinical manifestations at any time during the progress of
state of equilibrium characterised by constant adjustment to
the condition.
changing circumstances to maintain normal function. Health
professionals require a sound knowledge of pathophysiology
for competent clinical practice. This knowledge is important in EPIDEMIOLOGY
that it provides the rationales for care, and informs the clinical
assessment and management of patients. LEARNING OBJECTIVE 2
In this chapter, you are introduced to the key principles and Distinguish between the incidence and the prevalence
concepts of pathophysiology that underpin your understanding of a disease.
of the specific diseases encountered in later chapters. These
concepts include cellular responses to stimuli, cellular Another important term associated with pathophysiology is
adaptations, types of cell injury and agents of injury. First, epidemiology. This is the study of the patterns of disease within
important terms that provide the framework for describing the populations. The factors that are frequently used to describe
pathophysiology of specific diseases in subsequent chapters are patterns of disease at the population level include age, sex,
defined. ethnicity, location, socioeconomic status and lifestyle. Risk
factors and the aetiology can emerge from epidemiological
IMPORTANT TERMINOLOGY studies.
Such studies also reveal the incidence and the prevalence of
It is important to familiarise yourself with the four key principles diseases within our communities. The incidence rate represents
of pathophysiology that form the framework in this textbook for the number of new cases of a disease diagnosed within a
the descriptions of specific diseases. The four important terms particular period, usually over a calendar year. The prevalence
are aetiology, pathogenesis, clinical manifestations and rate is the total number of cases of a disease, both newly and
epidemiology. previously diagnosed, at a particular time. Prevalence can be
affected by other factors, such as disease recovery, mortality,
AETIOLOGY recurrence and emigration. Health measures, such as
Aetiology is the study of the cause, or causes, of a disease. immunisation, can lead to reductions in incidence and
Identifiable reasons for the development of a disease can include prevalence. Figure 1.1 illustrates the relationships between
a person’s diet, environment, inheritance and other genetic incidence, prevalence and these other factors.
factors, occupation, health and age. Disease can arise within the Where possible, we have drawn on the population statistics
body as a result of cell injury caused by immunological, available for our region—Australia and New Zealand—and we
metabolic, nutritional, inheritable, psychological or cancerous have highlighted Indigenous health issues. This information is
agents. It can also arise external to the body, due to the action of drawn from government documents, the Australian Institute of
infectious organisms or traumatic physical agents, such as Health and Welfare, the World Health Organization and recent
extreme temperature or force (see the ‘Agents of cell injury’ published epidemiological research. Where these statistics are
section later in this chapter for more detail). not readily available, we will draw on those from other Western
If the cause is unknown, then an illness will be classified as industrialised nations.
an idiopathic disease. Alternatively, if an illness is a direct
consequence of medical treatment, it is called an iatrogenic
condition.
CELLULAR RESPONSES TO STIMULI
LEARNING OBJECTIVE 3
PATHOGENESIS Describe the four types of cellular adaptations, and suggest
The pathogenesis represents the development of a disease. It situations when each may occur.
usually covers the mechanisms by which a disease becomes
established and progresses. Pathogenesis can be described in In order to maintain homeostasis, the body must make
both chronological and spatial terms. In this aspect, the way in adjustments to functioning in response to changes in its
which homeostatic mechanisms attempt to adapt and then internal and external environment. These environmental
collapse are detailed. In detailing the pathogenesis of a disease, changes are called stimuli. Examples of stimuli include
acute and chronic phases can be identified and differentiated. changes in temperature, oxygen supply or demand, pH, energy
4
Vaccination
and screening
Cases prevented
by primary health
Incidence and preventative
New cases medicine
entering population initiatives
Recovery
Cases leaving as a
result of a cure
PA R T 1 C E L L U L A R A N D T I S S U E PAT H O P H Y S I O L O G Y
Prevalence R ecurrence
Cases added from
Number of cases
re-emergence of
with the condition
the condition
Emigration Mortality
Cases lost through Cases lost
leaving population through death
Figure 1.1
Epidemiological relationships
A conceptual representation of incidence and prevalence, and the effects of other factors and health measures on these rates.
Source: E.J. Roh & M. Hales © Sciencopia.

C H A P T E R 1 PAT H O P H Y S I O L O G I C A L T E R M I N O L O G Y, C E L L U L A R A DA P TAT I O N A N D I N J U R Y 5
Homeostatic
stimuli
Particular
cell stimuli
Injurious
stimuli CELLULAR ADAPTATIONS
Reversible Body cells are able to adapt to new conditions by increasing or
cell injury
decreasing their size, number or shape. The terms associated
Normal cell
structure and
Cellular Cell with these adaptations are atrophy, hypertrophy, hyperplasia and
adaptation injury
function metaplasia.
Irreversible
cell injury
ATROPHY
Inflammatory processes
Cell atrophy occurs when the demands on a population of cells
decrease below normal or cannot be maintained at normal levels.
The cells respond by decreasing in size (see Figure 1.3). An
Figure 1.2 example of atrophy is during disuse when a person is bedridden
for an extended period of time. The workload on the skeletal
Continuum of cellular responses to stimuli muscles of the legs decreases. Muscle fibres will decrease in size
This is a representation of the interplay between normal as an adaptation to the changed conditions. Functional changes
cell structure and function, cellular adaptation and cell accompany this structural adaptation so that muscle weakness can
injury in response to stimuli. Inflammation plays an be a consequence. Muscle atrophy can also occur when a person
important role when cells are injured. has fractured a limb that is immobilised in plaster for months, or
when astronauts are in space for a long period. Appropriate
exercise/activity programs can assist in minimising the degree of
atrophy experienced, or assist in the return of normal muscle
function if and when the condition can be reversed.
demand and body water levels. Homeostatic imbalances can Cell atrophy may also be induced when regulatory
arise if the adjustments to the changed conditions prove to be communication with another structure becomes compromised.
inadequate. Examples of this are in cases of spinal injury, when the neural
The focus of this section of the chapter is on cellular stimulation of muscles is blocked, or when the hormones
responses to such stimuli. In response to persistent or intense responsible for the maintenance of normal tissue function are not
stimuli, cells can adapt to the new conditions and maintain available. An example of the latter would be testicular atrophy as
homeostasis. A number of adaptations are possible, and these a result of the inhibition of luteinising hormone secretion, which
are described below. may occur during the misuse of androgenic anabolic steroids.
Cellular adaptation and injury need to be considered across
a continuum. If cells cannot adapt to current environmental HYPERTROPHY
conditions, then they may become injured. Cellular injuries If the demands on cells are greater than normal, they may
can be reversible, where the affected cells recover after the respond by increasing in size; this is called hypertrophy (see
stimulus is removed, or they can be irreversible and result in Figure 1.4). Again, skeletal muscle is a good example of a
cell death. Inflammation is initiated in response to cell injury. population of cells that readily undergo hypertrophy. When the
Inflammatory processes can neutralise the agent of injury and workload of muscles increases, they undergo hypertrophy.
promote healing. In some circumstances, the intensity or Indeed, this is the basis of ‘pumping iron’ (muscle conditioning
duration of inflammation can itself injure cells (see Chapter 2). by lifting weights) in order to increase muscle mass.
The continuum of adaptation and injury is represented in This effect can also occur in the heart. As the heart has more
Figure 1.2. load placed on it, the cardiac myocytes will increase in size,
Figure 1.3
Cellular atrophy
The cells on the left are
normal cells. Those on
the right have
undergone atrophy—a
decrease in the size of
the cells.
6 PA R T 1 C E L L U L A R A N D T I S S U E PAT H O P H Y S I O L O G Y
Figure 1.4
Cellular hypertrophy
The cells on the left are normal
cells. Those on the right have
undergone hypertrophy—an
increase in the size of the cells.
which will cause cardiac hypertrophy. If the heart is diseased, within the tissue that proliferate in the right circumstances.
such as in heart failure (see Chapter 24), a normal workload is Other cell populations, such as epithelial cells, can undertake
considered an increased load and results in hypertrophy. The hyperplasia more efficiently.
increase in muscle mass creates an upsurge in demand on In reality, observed increases in the size of organs or other
oxygen supply that cannot be met under these circumstances, body structures are usually brought about through a combination
worsening the cardiac impairment. of hyperplasia and hypertrophy. This can be demonstrated in
examples where an increased exercise/workload can induce an
HYPERPLASIA enlargement of the heart, or the change in hormone levels during
Hyperplasia is another form of cellular adaptation in response to pregnancy leads to an enlargement of the uterus. In these cases,
increased demand. In hyperplasia, cells increase in number (see the change in organ size is largely due to hypertrophy.
Figure 1.5); they do this by increasing their rate of mitosis. The
capacity of cell populations for this is highly variable, with METAPLASIA
mature muscle cells and neurons lacking the capacity for this In metaplasia, cells change from one cell type to another (see
response. If hyperplasia occurs in these cell populations, it is Figure 1.6). These cells are fully differentiated, and if the stimulus
usually due to a proportion of relatively undifferentiated cells is removed the cells may revert back to their original type.
Figure 1.5
Cellular hyperplasia
undergone hyperplasia—an
increase in the number of cells.
Figure 1.6
Cellular metaplasia
undergone metaplasia—a
transition from one cell type to
another.
Another random document with
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the place to me. Do you know what I did? I went away before
daylight in order not to see them. What are, in fact, three cohorts?
And if there had been more, what should I have done with them?”[173]
This was speaking like a prudent man and one who knows himself
well. As for Atticus we ask whether he were really sincere in the
ardour that he showed for his cause when we see him obstinately
refuse to serve it. Those grand passions that confine themselves so
prudently in the breast, and never show themselves outwardly, are
with good reason suspected. Perhaps he only wished to enliven a
little that part of spectator that he had reserved for himself by taking
part, up to a certain point, in the excitement of the struggle. The wise
man of Epicurus always remains on the serene heights whence he
tranquilly enjoys the view of shipwrecks and the spectacle of human
conflicts; but he enjoys them from too far off, and the pleasure that
he feels is diminished by the distance. Atticus is more skilful and
understands his pleasure better; he goes into the midst of the fight
itself, he sees it close, and takes part in it, while always sure that he
will retire in time.
The only difficulty he found was to make everybody accept his
neutrality. This difficulty was so much the greater for him as his
conduct especially offended those whose esteem he was the most
anxious to preserve. The republican party, which he preferred, and in
which he reckoned most friends, was much less inclined to pardon
him than that of Caesar. In antiquity itself, and still more in our days,
great praise has been bestowed on that saying of Caesar at the
beginning of the civil war: “He who is not against me is for me,” and
the contrary saying of Pompey has been much blamed: “He who is
not for me is against me.” However, looking at things fairly, this
praise and this blame appear equally unreasonable. Each of the two
rivals, when he expressed himself thus, speaks in character, and their
words were suggested by their position. Caesar, however we may
judge him, came to overturn the established order, and he naturally
was grateful to those who gave him a free hand. What more could he
reasonably ask of them? In reality, those who did not hinder him
served him. But lawful order, established order, considers it has the
right to call upon every one to defend it, and to regard as enemies all
who do not respond to its appeal, for it is a generally recognized
principle that he who does not bring help to the law when openly
attacked before him, makes himself the accomplice of those who
violate it. It was, then, natural that Caesar, on arriving at Rome,
should welcome Atticus and those who had not gone to Pharsalia, as
it was also that those in Pompey’s camp should be very much
irritated against them. Atticus was not much moved by this anger: he
let them talk, those thoughtless and fiery young men who could not
console themselves for having left Rome, and who threatened to
avenge themselves on those who had remained. What did these
menaces matter to him? He was sure that he had preserved the
esteem of the two most important and most respected men of the
party, and he could oppose their testimony to all the indignation of
the rest. Cicero and Brutus, notwithstanding the strength of their
convictions, never blamed him for his conduct, and they appear to
have approved of his not taking part in public affairs. “I know the
honourable and noble character of your sentiments, said Cicero to
him one day when Atticus thought it necessary to defend himself;
there is only one difference between us, and that is, that we have
arranged our lives differently. I know not what ambition made me
desire public office, while motives in no way blameworthy have made
you seek an honourable leisure!”[174] Again, Brutus wrote to him
towards the end of his life: “I am far from blaming you, Atticus; your
age, your character, your family, everything makes you love
repose.”[175]
This good-will on the part of Brutus and Cicero is so much the
more surprising, as they knew very well the mischief such an
example might do to the cause that they defended. The republic did
not perish by the audacity of its enemies alone, but also by the
apathy of its partisans. The sad spectacle it offered for fifty years, the
public sale of dignities, the scandalous violence that took place on
the Forum every time a new law was discussed, the battles that at
each new election stained the Campus Martius with blood, those
armies of gladiators needed for self-defence, all those shameful
disorders, all those base intrigues in which the last strength of Rome
was used up, had completely discouraged honest men. They held
aloof from public life; they had no more relish for power since they
were forced to dispute it with men ready for every violence. It
required Cato’s courage to return to the Forum after having been
received with showers of stones, and having come out with torn robe
and bleeding head. Thus, the more the audacious attempted, the
more the timid let them alone, and from the time of the first
triumvirate and the consulship of Bibulus, it was evident that the
apathy of honest men would deliver the republic over to the
ambitious nobles who desired to dominate it. Cicero saw this clearly,
and in his letters never ceases his bitter railleries against those
indolent rich men, doting on their fish-ponds, who consoled
themselves for the ruin that they foresaw by thinking that they would
save at least their lampreys. In the introduction to the De Republica
he attacks with admirable energy those who, being discouraged
themselves, try to discourage others, who maintain that a man has
the right to withhold his services from his country, and to consult his
own welfare while neglecting that of his country. “Let us not listen,”
says he in finishing, “to that signal for retreat that sounds in our ears,
and would recall those who have already gone to the front.”[176]
Brutus also knew the evil of which the republic was dying, and
complained more than once of the weakness and discouragement of
the Romans. “Believe me,” he wrote, “we are too much afraid of exile,
death, and poverty.”[177] It was Atticus to whom he wrote these noble
words, and yet he does not dream of applying them to him! What
strange charm then did this man possess, what influence did his
friendship exercise, that these two great patriots have thus belied
themselves in his favour, and have so freely pardoned in him what
they condemned in others?
The more we think of it, the less can we imagine the reasons he
could give them to justify his conduct. If he had been one of those
scholars who, wedded to their researches in history or philosophy,
only dwell in the past or the future, and are not really the
contemporaries of the people with whom they live, we might have
understood his not taking part in their struggles since he held
himself aloof from their passions; but we know that, on the contrary,
he had the most lively relish for all the small agitations and obscure
intrigues of the politics of his time. He was anxious to know them, he
excelled in unravelling them, this was the regular food of his
inquisitive mind, and Cicero applied to him by choice when he
wished to know about such matters. He was not one of those gentle
and timid souls, made for reflection and solitude, who have not the
energy necessary for active life. This man of business, of clear and
decided judgment, would, on the contrary, have made an excellent
statesman. To be useful to his country he would only have needed to
employ in its service a little of that activity and intelligence he had
used to enrich himself, and Cicero was right in thinking that he had
the political temperament. And, finally, he had not even left himself
the poor resource of pretending that he sided with no party because
all parties were indifferent to him, and that, having no settled
opinions, he did not know which side to take. He had said the
contrary a hundred times in his letters to Cicero and Brutus; he had
charmed them a hundred times by the ardour of his republican zeal,
and yet he remained quiet when the opportunity came of serving this
government to which he said he was so much attached. Instead of
making a single effort to retard its fall, he was only careful not to be
crushed under its ruins. But if he did not try to defend it, did he, at
least, pay it that last respect of appearing to regret it? Did he show in
any way that, although he had not appeared in the combat, he felt
that he shared in the defeat? Did he know, while he grew old under a
power to which he was forced to submit, how to retire in a dignified
sadness which forces respect even from a conqueror? No, and it is
assuredly this that is most repugnant to us in his life; he showed an
unpleasant eagerness to accommodate himself to the new order of
things. The day after he had himself been proscribed, we see him
become the friend of the proscribers. He lavishes all the charms of
his mind on them, assiduously frequents their houses, attends all
their fêtes. However habituated we may be to see him welcome all
triumphant governments, we cannot get used to the notion that the
friend of Brutus and the confidant of Cicero should become so
quickly the familiar of Antony and Octavius. Those most disposed to
indulgence will certainly think that those illustrious friendships
created duties which he did not fulfil, and that it was a treason to the
memory of these men who had honoured him with their friendship,
to choose just their executioners as their successors.
If we are not disposed to show ourselves as indulgent towards him
as Cicero and Brutus, with still more reason shall we not partake in
the naïve enthusiasm that he inspires in Cornelius Nepos. This
indulgent biographer is only struck, in the whole life of his hero, with
the happy chance by which he escaped such great dangers. He cannot
get over his surprise when he sees him, from the time of Sulla to that
of Augustus, withdraw himself from so many civil wars, survive so
many proscriptions, and preserve himself so skilfully where so many
others perished. “If we overwhelm with praises,” says he, “the pilot
who saves his vessel from the rocks and tempests, ought we not to
consider admirable the prudence of a man who in the midst of those
violent political storms succeeded in saving himself?”[178] Admiration
is here too strong a word. We keep that for those courageous men
who made their actions agree with their principles, and who knew
how to die to defend their opinions. Their ill success does not injure
them in our esteem, and, whatever the friend of Atticus may say,
there are fortunate voyages from which less honour is drawn than
from some shipwrecks. The sole praise that he thoroughly deserves is
that which his biographer gives him with so much complacency,
namely, that he was the most adroit man of that time; but we know
that there are other forms of praise which are of more value than
this.
CAELIUS
THE ROMAN YOUTH IN THE TIME OF CAESAR

There is perhaps no more curious figure than that of Caelius in the
history we are studying. His life has a special interest for us. He was
not, like Brutus, a brilliant exception among his contemporaries; on
the contrary, he quite belongs to his time; he lived as others lived
around him. All the young men of that time, the Curios, the
Dolabellas, resemble him. They are all, like him, corrupted early,
little concerned about their dignity, prodigal of their wealth, friends
of facile pleasures; they all throw themselves into public life as soon
as they can, with a restless ambition and great needs to satisfy, and
with few scruples and no beliefs. His history, then, is that of all the
rest, and the advantage we find in studying it is that we know at once
the whole generation of which he formed part. Now, thanks to
Cicero, this study is easy for us. Notwithstanding so many differences
in conduct and principles, Cicero always felt a singular inclination for
Caelius; he liked the conversation of this clever man who laughed at
everything, and was more at ease with him than with people like Cato
or Brutus, whose severity somewhat alarmed him. He defended him
in the law courts when a woman whom he had loved tried to ruin
him, and this speech of his is certainly one of the most interesting
that remain to us. Later, when he was obliged to go to Cilicia, he
chose him for his political correspondent. By a happy chance Caelius’
letters have come down to us with those of Cicero, and there are
none in all this collection that are more witty and more racy. Let us
collect all the details scattered through them; let us try, in collecting
them, to reproduce an account of Caelius, and by it to gain an idea of
what the Roman youth of that time was. It is not without interest to
know them, for they played an important part, and Caesar made use
of them more especially for the revolution that he wished to
accomplish.
I.
Caelius did not come of an illustrious family. He was the son of a

Roman knight of Puteoli, who had been in trade and acquired great
wealth in Africa. His father, who had all his life no other concern
than that of enriching himself, showed, as often happens, more
ambition for his son than for himself: he wished him to become a
politician, and as he saw that dignities were reached only through
eloquence, he took him betimes to Cicero, that he might make him a
great orator, if it were possible.
It was not yet the custom to confine young men to the schools of
the rhetoricians, and to be contented with exercising them in
imaginary cases. As soon as they had assumed the toga virilis, that
is, when they were about sixteen years old, no time was lost in taking
them to some statesman of reputation, whom they did not leave.
Admitted to his most intimate society, they listened to his
conversations with his friends, his disputations with his adversaries;
they saw him prepare himself in silence for the great battles of
eloquence, they followed him into the basilicas and the Forum, they
heard him pleading causes or speaking to the assembled people, and
when they had become capable of speaking themselves, they made
their first appearance at his side and under his patronage. Tacitus
much regrets this manly education, which, placing a young man
under the conditions of reality instead of retaining him among the
fictions of rhetoric, gave him a taste for real and natural eloquence
which strengthened him, by throwing him from the first into the
midst of real contests, and, according to his expression, taught him
war on the field of battle, pugnare in praelio discebant.[179] This
education, however, had its dangers. It taught him things that it is
better to be ignorant of for a long time, it familiarized him with the
scandalous and corrupt sights that public life usually offers, it gave
him a too rapid maturity and inflamed him with precocious
ambition. Must not a young man of sixteen, who thus lived in
intimacy with old and unscrupulous statesmen, and to whom were
laid bare without precaution the basest manœuvres of parties, must
he not have lost something of the generosity and sensitiveness of his
age? Was it not to be feared that this corrupting intercourse might
end by giving him a taste for intrigue, for the worship of success, an
unbridled love of power, the desire to attain a high position quickly
and by any means, and as, generally, the worst means are also the
quickest, the temptation to employ them by preference? This is what
happened to Caelius. For three entire years, three honest and
laborious years, he did not leave Cicero; but he perceived at length,
that a young man like himself, who had his political fortune to make,
would gain more with those who wished to destroy the government
than with him who wished to preserve it, and he abandoned Cicero to
attach himself to Catiline. The change was sudden, but Caelius never
took the trouble to delay about these transitions. Henceforth, we can
easily understand, his life took another turn; he became a seditious
and turbulent man, whose biting speech in the Forum and violence
in the Campus Martius were dreaded. At the election of a pontif he
struck a senator. When he was appointed quaestor, every one
accused him of having bought his votes. Not content with disturbing
the comitia at Rome, we see him stirring up a popular tumult at
Naples, we do not know why. At the same time, he did not neglect his
pleasures. The debaucheries of those noisy young men of whom he
was one, continually disturbed the public peace. It is said that the
streets of Rome were unsafe when they returned at night from their
suppers, and that, after the manner of those giddy fellows that
Plautus and Terence depict, they molested honest women whom they
met on their road. All these follies did not go on without great
expense, and the father of Caelius, although he was rich, was not of a
temper to be always paying. No doubt at this time the honest
merchant of Puteoli must have regretted his ambition for his son,
and thought it cost him dear to have wished to make him a politician.
Caelius, on his side, was not of a temper to put up with reprimands
easily; he left the paternal house, and, under pretext of being nearer
the Forum and business, rented a lodging on the Palatine, in the
house of the famous tribune Appius Clodius, for ten thousand
sesterces (£80). This was an important event in his life, for it was
there that he became acquainted with Clodia.
If we relied on the evidence of Cicero we should have a very bad
opinion of Clodia; but Cicero is a too partial witness to be altogether
just, and the furious hatred he bore the brother renders him very
much suspected when he speaks of the sister. Moreover, he partly
contradicts himself when he tells us she had kept up relations with
very honourable people, which would be very surprising if it were
true that she had committed all the crimes that he lays to her charge.
It is very difficult to believe that persons of consideration in the
republic, and persons who were careful of their reputation, would
have continued to see her if they had thought that she had poisoned
her husband, and was the mistress of her brothers. Cicero, however,
did not invent this; it was public rumour that he complacently
repeated. Many people in Rome believed it, Clodia’s enemies liked to
repeat it, and mischievous verses were made about it which were
written upon every wall. Clodia’s reputation was, then, very bad, and
it must be admitted that, notwithstanding some exaggerations, she
partly deserved it. There is nothing to show that she killed her
husband, as she was accused of doing; these accusations of poisoning
were then widespread, and were accepted with incredible levity, but
she had made him very unhappy during his life, and did not appear
very much grieved at his death. It is doubtful, also, whatever Cicero
may assert, that her brothers were her lovers, but it is unfortunately
too certain that she had a good many others. The sole excuse that can
be pleaded for her is that this way of living was then very general.
Scandals of this kind had never been more common among the great
ladies of Rome. Roman society was passing through a crisis whose
causes, which go back a long way, deserve to be considered. We must
say a few words about them, in order to account for the grave injury
that public morals had received.
In a country where the family was respected as it was at Rome,
women could not fail to have much importance. It was impossible
that their influence, which was already so great within the house,
should not attempt to show itself outside, and the honourable place
they held in private life must one day tempt them to invade public
life also. The ancient Romans, so jealous of their authority, had the
consciousness of this danger, and neglected nothing in order to
defend themselves against it. We know how they affected to treat
women; there was no sort of unkind remarks they did not make
about them; they got them attacked on the stage and mocked them
even in their political speeches:[180] but we must not mistake the
sense of these railleries and pity the objects of them too much. They
are only attacked thus because they are feared, and all these
pleasantries are not so much insults as precautions. These rough
soldiers, these rude peasants, have learnt, in living with them, how
subtle and enterprising their minds are, and in how many ways they
are more capable than themselves; consequently they take a good
deal of trouble to confine them to their households, and even that
does not suffice to reassure them; in the household itself they must
be subjugated and bridled. They affect to think and to say that they
are weak and untamed beings (indomita animalia), incapable of
governing themselves alone, and they hasten to provide for their
management. They are kept, under this pretext, in a continual state
of tutelage; they are always “under the hand” of their father, brother,
or husband; they cannot sell, buy, trade, or do anything without a
council to assist them: in acting thus the men pretend they are
protecting them, in reality it is themselves they are protecting against
them. Cato, their great enemy, ingenuously admits it in a moment of
frankness. “Remember,” Livy makes him say à propos of the lex
Oppia, “all those regulations our ancestors made to subject wives to
their husbands. Shackled as they are, you have trouble to manage
them. What will happen if you give them their liberty, if you allow
them to enjoy the same rights as yourselves? Do you think you will
then be their masters? The day they become your equals they will be
your superiors.”[181] This day arrived just about the time of which we
are treating. In the midst of the weakening of ancient usages, the
laws against women were not more respected than others. Cicero
says that the gallant lawyers furnished them with ingenious means to
free themselves from these laws without appearing to violate them.
[182]
At the same time, men were accustomed to see them take a more
important place in society, and to recognize their influence in the
government of the republic. Almost all the politicians of that time are
governed by their wives or by their mistresses, thus the innumerable
gallantries of Caesar must have passed in the eyes of many people, as
later those of Augustus did, for profound policy, as it might be
supposed that he only sought to please the women in order to lead
their husbands.
Thus, by the abolition of the old laws, and by the alteration of
ancient maxims, women had become free. Now, it is to be remarked
that, in general, the first use made of regained liberty is to abuse it.
We cannot enjoy quietly the rights of which we have been long
deprived, and the first moments of liberty bring a sort of intoxication
that it is difficult to check. This is what happened to the Roman
society of that time, and all these irregularities that we notice in the
conduct of women then are partly explained by the allurements and
intoxication of their new liberty. Those who love money, like
Terentia, Cicero’s wife, hasten to take advantage of the right of
disposing of their fortune, that has been restored to them, they
associate themselves with freedmen and agents for doubtful gains,
rob their husbands without scruple, and throw themselves into
speculations and trade, to which they bring, together with an almost
incredible rapacity, that taste for small savings and economies which
is natural to them. Those who prefer pleasure to wealth give
themselves up to all pleasures with a passionate eagerness. The less
bold take advantage of the facilities of divorce to pass from one
amour to another under cover of the law. Others do not even take
this trouble, and impudently flaunt their scandalous behaviour.
Clodia was one of the latter; but among all her vices, which she
took no care to hide, we are forced to recognize in her some good
qualities. She was not grasping; her purse was open to her friends,
and Caelius was not ashamed to dip into it. She liked clever men, and
attracted them to her house. At one time she wished to persuade
Cicero, whose talents she much admired, to give up his foolish
Terentia for her and to marry her; but Terentia, who suspected it,
succeeded in mortally embroiling them. An old scholiast says that
she danced better than it was proper for an honest woman to do.[183]
This was not the only art for which she had a taste, and it has been
thought possible to infer from a passage of Cicero that she also wrote
verses.[184] To cultivate letters, to seek out clever men, to like refined
and elegant pleasures, does not seem at first sight to be
blameworthy; on the contrary, these are among us the qualities that
a woman of society is obliged to possess or to feign. They thought
otherwise at Rome, and, as the courtesans alone had then the
privilege of following this free and accomplished life, every woman
who sought this ran the risk of being confounded with them, and of
being treated with the same rigour by public opinion; but Clodia did
not care for public opinion. She brought into her private conduct,
into her affections, the same passionateness and the same ardour
that her brother did into public life. Ready for all excesses, and not
blushing to avow them, loving and hating furiously, incapable of self-
control, and hating all restraint, she did not belie that great and
haughty family from which she was descended, and even in her vices
her blood was recognized. In a country where so much respect was
shown for ancient customs, in that classic land of decorum (the thing
and the word are Roman), Clodia took pleasure in shocking the
established customs; she went out publicly with her male friends; she
was accompanied by them in the public gardens or on the Appian
road, constructed by her great ancestor. She boldly accosted people
whom she knew; instead of timidly lowering her eyes as a well-
brought-up matron should have done, she dared to speak to them
(Cicero says that she even kissed them sometimes), and invited them
to her repasts. Grave, staid, and rigid people were indignant; but the
young, whom this freedom did not displease, were charmed, and
went to dine with Clodia.[185]
Caelius was at that time one of the fashionable young men of
Rome. Already he had a great reputation as an orator. He was
dreaded for the satirical sharpness of his speech. He was bold to
temerity, always ready to throw himself into the most perilous
enterprises. He spent his money freely, and drew after him a train of
friends and clients. Few men danced as well as he,[186] no one
surpassed him in the art of dressing with taste, and the beauty and
breadth of the purple band that bordered his toga were spoken of on
all hands in Rome. All these qualities, the serious as well as the
trivial, were of a nature to attract Clodia. Neighbourhood made their
acquaintance more easy, and she soon became the mistress of
Caelius.
Cicero, notwithstanding his reserve, permits us to guess the life
they then led. He speaks in hints of those brilliant fêtes that Clodia
gave to her lover and to the youth of Rome in her gardens on the
banks of the Tiber; but it seems that Baiae was the chief theatre of
these amours. Baiae had been for some time already the regular
rendezvous of the fashionable people of Rome and Italy. The hot-
springs that are found there in abundance served as the occasion or
pretext for these gatherings. Some invalids went there for their
health, and their presence provided an excuse for a crowd of healthy
people who went there to amuse themselves. People flocked there
from the month of April, and during the fine season a thousand light
intrigues were carried on, the report of which reached Rome. Grave
folks took great care not to be seen in this whirl of pleasure, and later
Clodius accused Cicero, as if it were a crime, simply of having passed
through it; but Caelius and Clodia were not anxious to hide
themselves; consequently they gave themselves up without restraint
to all the pleasures that were to be found in that country that Horace
calls the most beautiful in the world. All Rome talked of their races
on the shore, the brilliancy of their feasts and water-parties in boats
carrying singers and musicians. This is all that Cicero tells us, or
rather only gives us a glimpse of, for, contrary to his habit, and to our
great loss, he has for once in a way been discreet, in order not to
compromise his friend Caelius. Fortunately we can learn more about
this society and satisfy our curiosity; to do so we have only to turn
ourselves to him who was, with Lucretius, the greatest poet of that
time, Catullus. Catullus lived among these persons who were so well
worthy of study, and had relations with them which permitted him to
depict them well. Everybody knows that Lesbia whom his verses have
immortalized; but it is not so well known that Lesbia was not one of
those fictitious persons that the elegiac poets often create. Ovid tells
us that this name covered that of a Roman lady, probably a great
lady, since he will not name her, and by his way of speaking we see
clearly that everybody then knew her.[187] Apuleius, who lived much
later, is less reticent, and he tells us that Lesbia was Clodia.[188]
Catullus, then, was the lover of Clodia, and the rival of Caelius: he
also frequented that house on the Palatine, and those fine gardens on
the Tiber, and his verses complete our knowledge of that society of
which he was one of the heroes.
I said just now that Clodia did not love money with the avidity of
the women of gallantry of that time and of all times. The history of
Catullus proves this well. This young provincial of Verona, although
he belonged to an honourable family, was not very rich, and after he
had lived a life of dissipation and pleasure for some time at Rome, he
had nothing left. His poor little estate was soon deeply mortgaged.
“It is not exposed, he says gaily, either to the impetuous north wind,
or to the fury of the auster: it is a hurricane of debts that blows on it
from all sides. Oh! the horrible and pestilent wind!”[189] By the
picture that he draws of some of his friends, still poorer and more
indebted than himself, we see clearly that he could not reckon upon
them, and that his purse which was “full of spiders” had no great
help to expect from them. It was not, then, fortune or birth that
Clodia loved in Catullus, but wit and talent. What attracted him in
her, what he so passionately loved, was distinction and grace. These
are not usually the qualities of women who live like Clodia; but,
however low she might have descended, she was still a great lady.
Catullus says so in an epigram in which he compares Lesbia to a
celebrated beauty of that time—“Quintia is considered beautiful by
many men. I think her tall, fair, erect: these are her attractions; I
recognize them all. But that their union forms beauty, that I deny.
There is nothing graceful in her, and in all that vast body there is not
a spark of wit or charm. It is Lesbia who is beautiful, more beautiful
than all, and she has so much grace that there is none left for the
rest.”[190]
A woman like Clodia, who had such a decided taste for clever
people, must have been pleased to frequent the society in which
Catullus lived. We see plainly, by what he relates to us of it, that
there was none more witty and agreeable in Rome. It united writers
and politicians, poets and noblemen, differing in position and
fortune, but all friends of letters and pleasure. There were
Cornificius, Quintilius Varus, Helvius Cinna, whose verses had then
much reputation, Asinius Pollio, who was as yet only a youth of great
promise; there was above all Licinius Calvus, at once statesman and
poet, one of the most striking figures of that time, who, at twenty-
one, had attacked Vatinius with so much vigour, that Vatinius,
terrified, had turned towards his judges, saying: “If my opponent is a
great orator, it does not follow that I am guilty!” In the same group
we must place Caelius, who, by his wit and tastes, was worthy to
belong to it, and over it Cicero the protector of all this brilliant youth,
which was proud of his genius and renown, and which saluted in
him, according to the expression of Catullus, the most eloquent of
the sons of Romulus.
In these assemblies of clever men, of whom many were political
personages, politics were not excluded; they were very republican,
and from them issued the most violent epigrams against Caesar. We
know the tone in which those of Catullus are written; Calvus had
composed others which are lost, and which were, it is said, still more
cutting. Literature, however, we can well understand, held in them at
least as high a place as politics. They did not fail to laugh at bad
writers from time to time, and in order to make an example,
ceremoniously burnt the poems of Volusius. Sometimes, at the end
of the repast, when wine and laughter had heated their brains, they
sent each other poetic challenges; the tablets passed from hand to
hand, and each wrote the most incisive verses he could make. But it
was pleasure more than anything else that occupied them. All these
poets and politicians were young and amorous, and whatever
pleasure they may have found in rallying Volusius, or tearing Caesar
to pieces, they preferred to sing their loves. It is this which has made
them famous. The lyrical poetry of the Latins has nothing to compare
with those short and charming pieces that Catullus wrote for Lesbia.
Propertius mingles too much mythology with his sighs; Ovid is only
an inspired debauchee, Catullus alone has tones that touch the heart,
because he alone was mastered by a deep and sincere love. Till then
he had led a gay and dissipated life, and his heart was wearied with
passing connections; but the day that he met Lesbia he learnt the
meaning of passion. Whatever we may think of Clodia, the love of
Catullus elevates her, and we never see her in a more favourable light
than in this exquisite poetry. The verses of Catullus seem to make
real and living those fêtes that she gave to the youth of Rome, and of
which we regretted just now the absence of sufficient details; for was
it not for these charming parties, for these free and sumptuous
repasts, that he composed his finest works? It was there, no doubt,
under the groves on the banks of the Tiber, that he sang that fine
imitation of Sappho’s most fervid ode that he made for Lesbia. It
was, perhaps, on the shore of Baiae, fronting Naples and Capreae,
under that voluptuous sky, in the midst of the attractions of that
enchanted land, that for the first time were read those verses in
which so much grace is mingled with so much passion, and which are
so worthy of the exquisite landscape in the midst of which I take
pleasure in placing them:
“Let us live, let us love, my Lesbia, and laugh together at all the
reproaches of stern old age. The sun dies to be born again; but we,
when our short-lived light is once extinguished, must sleep an
eternal night without awakening. Give me a thousand kisses, a
hundred, a thousand, a hundred once more, then a thousand and a
hundred again. Afterwards, when we have embraced thousands of
times, we will confuse the reckoning to know it no longer, and leave
the jealous no pretext to envy us by letting them know how many
kisses we have given each other.”[191]
That is a remarkable moment in Roman society, when we meet
with these polished assemblies, in which everything is talked of and
all ranks are mingled, where the writers have their place beside the
politicians, where they dare openly express their love for the arts and
treat imagination as a power. We may say, to use a quite modern
expression, that it is here that the life of society begins. There was
nothing like it among the old Romans. They lived on the Forum or in
their houses. Between the multitude and the family they knew little
of that middle point that we call society, that is to say, those elegant
and select assemblies, numerous without confusion, where we are at
once more at liberty than among unknown persons in public places,
and yet less at home than in the family circle. Before reaching this
point it was necessary to wait until Rome was civilized and literature
had won her place, which scarcely happened until the last age of the
republic. And yet we must not exaggerate. That society which then
had its beginning, seems to us at times very coarse. Catullus tells us
that at those luxurious entertainments where such fine poems were
read, there were guests who would even steal the napkins.[192] The
conversations they held were often risky, to judge by certain
epigrams of the great poet. Clodia who assembled at her house these
clever men, had singular eccentricities of conduct. The elegant
pleasures sought by a woman of society were far from satisfying her,
and she fell at last into excesses that made her former friends blush.
They themselves, those heroes of fashion, whose good taste was
vaunted on all sides, who talked with so much charm and made such
tender verses, did not behave much better than she, and were not
much more delicate. They had much to reproach themselves with
while their connection with Clodia lasted; when it ended, they
committed the unpardonable fault of not respecting the past, and of
failing in that consideration that is always due to a woman whom one
has once loved. Catullus stung with coarse epigrams her who had
inspired his finest verses. Caelius, alluding to the price paid to the
vilest courtesans, called her, in open court, the quarter of an as
(quadrantaria) woman, and this cruel epithet stuck to her. We see
that this society had still much progress to make; but it will do it
quickly, thanks to the monarchy which was about to commence.
Everything changed with Augustus. Under the new government,
these remains of coarseness which savoured of the old republic,
disappeared; men made such progress, and became so fastidious,
that the refined were not slow in laughing at Calvus and Catullus,
and that Plautus passed for a barbarian. They polish and refine
themselves, and at the same time become insipid. A courtly tone is
spread over gallant literature, and the change is so sudden, that little
more than a quarter of a century was needed for the descent from
Catullus to Ovid. The amours of Clodia and Catullus ended very
sadly. Clodia did not pride herself on being faithful, and justified her
lover only too well when he wrote to her: “A woman’s promises must
be confided to the wind, or written on running water.”[193] Catullus,
who knew he was deceived, was angry with himself for submitting to
it. He reasoned with himself, he chid himself, but he did not cure
himself. Notwithstanding all the trouble he took to gain courage, love
was the stronger. After painful struggles which rent his heart, he
returned sad and submissive to the feet of her whom he could not
help despising, and whom he yet continued to love. “I love and I
hate, said he; you ask me how that can be, I cannot tell; but I feel that
it is so, and my soul is in tortures.”[194] So much suffering and
resignation touched Clodia very slightly. She plunged deeper and
deeper in obscure amours, and the poor poet, who had no more
hope, was compelled to separate from her for ever. The rupture
between Clodia and Caelius was much more tragic. It was by a
criminal trial that their amour was ended. This time Caelius wearied
first. Clodia, who, as we have seen, usually took the first step, was not
used to such an end to her amours. Enraged at being abandoned, she
concerted with the enemies of Caelius, who were not few, and had
him accused of several crimes, and particularly of having tried to
poison her. This, it must be admitted, was a very sad morrow to the
charming fêtes of Baiae! The trial must have been very amusing, and
we may believe that the Forum that day did not lack curious hearers.
Caelius appeared accompanied by those who had been his protectors,
his friends, and his teachers, the wealthy Crassus and Cicero. They
had divided his defence between them, and Cicero specially
undertook the part regarding Clodia. Although he declared, in the
opening of his speech, “that he was not the enemy of women, and
still less of a woman who was the friend of all men,” we may well
believe that he did not miss such a good opportunity of avenging
himself for all the ill this family had done him. That day Clodia
suffered for her whole family. Never had Cicero been so sharp and
stinging; the judges must have laughed much, and Caelius was
acquitted.
Cicero had solemnly promised in his speech that his client would
alter his conduct. In fact, it was quite time for him to reform, his
youth had lasted only too long. He was then twenty-eight, and it was
really time for him to think of becoming aedile or tribune, if he
wished to play that political part that had been his father’s ambition
for him. We do not know whether, in the sequel, he rigorously
carried out all the undertakings Cicero had made in his name;
perhaps he avoided henceforth compromising himself by too open
scandals, and perhaps the ill success of his amours with Clodia had
cured him of these noisy adventures; but it is very difficult to
suppose that he became austere and lived after the manner of the old
Romans. We see that, several years later when he was aedile and
taking part in the most serious business, he found time to learn and
repeat all the scandalous tales of Rome. This is what he wrote to
Cicero, then proconsul of Cilicia:—
“Nothing new has happened except a few little adventures that, I
am sure, you will be glad to hear about. Paula Valeria, the sister of
Triarius, has divorced herself, without any reason, from her
husband, the very day he was to arrive from his province; she is
going to marry Decimus Brutus. Have you never suspected it? Since
your absence incredible things of this kind have happened. No one
would have believed that Servius Ocella was a man of intrigue, if he
had not been caught in the act twice in the space of three days. You
will ask me where? In truth it was where I should not wish it to be,
[195]
but I leave you something to learn from others. I should be glad
to think that a victorious proconsul will go and ask everybody with
what woman a man has been caught.”[196]
Evidently he who wrote this entertaining letter was never so
thoroughly converted as Cicero made believe, and it seems to me that
we still find the harebrained young fellow who made so much racket
in the streets of Rome, and the lover of Clodia, in the man of wit who
recounts so pleasantly these trifling intrigues. We may affirm, then,
without temerity that, although from this moment his private life is
unknown to us, he never entirely renounced the dissipations of his
youth, and that, magistrate and politician as he was, he continued to
the end to mix pleasure with business.
II.
But Caelius was not only a hero of amorous adventures, and did
not content himself with the empty honour of giving the tone for
elegance of manners to the youth of Rome. He had more solid
qualities. Thanks to Cicero’s lessons he speedily became a great
orator. A short time after he had escaped from this honourable
tutelage, he made a brilliant commencement in a case in which he
was opposed to Cicero himself, and this time the disciple beat the
master. Since this success his reputation had continued to increase.
There were orators in the Forum that men of taste admired more,
and whose gifts they considered more perfect; there were none more
dreaded than he, such was the violence of his attack and the
bitterness of his raillery. He excelled in seizing the ridiculous side of
his opponents, and in making, in a very few words, those ironical and
cutting observations on them which are never forgotten. Quintilian
quotes one as a model of its kind, which well exemplifies the talent of
this terrible wit. He is speaking, in this passage, of that Antony who
had been the colleague of Cicero in his consulship, and who, in spite
of all the eulogies that the Orations against Catiline lavish on him,
was but an inferior intriguer and a coarse debauchee. After having,
according to custom, pillaged Macedonia, which he governed, he had
attacked some neighbouring tribes in order to obtain a pretext for a
triumph. He counted upon an easy victory, but as he was more taken
up with his pleasures than with the war, he was ignominiously
beaten. Caelius, who attacked him on his return, described, or rather
imagined, in his speech, one of those orgies during which the
general, while dead drunk, allowed himself to be surprised by the
enemy.
“Women, his ordinary officers, fill the banqueting-hall, stretched
on all the couches, or lying about on the ground. When they learn
that the enemy is come, half-dead with fright, they try to awaken
Antony; they shout his name, they raise him up by the neck. Some
whisper soft words in his ear, others treat him more roughly and
even strike him; but he, who recognizes their voices and touch,
stretches out his arms by habit, seizes and wishes to embrace the first
he meets with. He can neither sleep, so much they shout to awaken
him, nor wake, so drunk is he. At last, powerless to shake off this
drowsiness, he is carried off in the arms of his centurions and his
mistresses.”[197]
When a man possesses such a biting and incisive talent it is natural
for him to have an aggressive temper; nothing therefore suited
Caelius better than personal struggles. He liked and sought
disputation because he was sure to succeed in it, and because he
could make use of those violent modes of attack that could not be
resisted. He wished to be contradicted, for contradiction excited him
and gave him energy. Seneca relates that one day one of the clients of
Caelius, a man of pacific temper, and who, no doubt, had suffered
from his rudeness, confined himself during a meal to agreeing with
him. Caelius at last grew enraged because the man gave him no
opportunity for getting angry, and exclaimed: “Do contradict me that
there may be two of us.”[198] The talents of Caelius, such as I have just
depicted them, marvellously suited the time in which he lived. This
thoroughly explains the reputation that he enjoyed, and the
important position he took among his contemporaries. This fiery
debater, this pitiless wit, this vehement accuser would not have been
altogether in his place in quiet times; but in the midst of a revolution
he became a valuable auxiliary whom all parties contended for.
Caelius was moreover a statesman as well as an orator, and it is for
this that Cicero most frequently praises him. “I know no one, he told
him, who is a better politician than you.”[199] He knew men
thoroughly, he had a clear insight into situations; he decided quickly,
a quality that Cicero much appreciated in others, for it was just that
which he most lacked, and when once he had decided, he set to work
with a vigour and force that gained him the sympathies of the
multitude. At a time when power belonged to those who were bold
enough to seize it, the audacity of Caelius seemed to promise him a
brilliant political future.
Nevertheless, he had also great defects, which sometimes arose
from his very good qualities. He knew men well, a great advantage no
doubt, but in studying them it was their bad side that struck him
most. By dint of trying them in every way, his startling penetration
succeeded in laying bare some weakness. He did not reserve his
severity for his adversaries only; his best friends did not escape his
clear-sighted analysis. We see in his private correspondence that he
knew all their defects, and did not stand on ceremony in speaking of

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(eBook PDF) Principles of

Pathophysiology, 2nd Edition

About the authors xii Autosomal dominant inheritance 55

7 IMMUNE DISORDERS 112

Antimicrobial drugs 140 15 MENTAL HEALTH DISORDERS 291

21 BLOOD DISORDERS 420 26 PULMONARY DYSFUNCTION 544

Fluid deficits 670 Chronic inflammatory bowel diseases 790

31 ELECTROLYTE IMBALANCES 683 38 DISORDERS OF THE LIVER, GALL

42 BONE AND JOINT DISORDERS 919 44 SKIN CANCERS, BURNS AND

ORGANISATION OF THE TEXT

NEW FOR THIS EDITION

NEW CHAPTER: DETERMINANTS OF HEALTH AND ILLNESS

INDIGENOUS HEALTH FAST FACTS AND CULTURAL CONSIDERATIONS

LANGUAGE AND TERMINOLOGY

Shane Bullock and Majella Hales

Features of the text

M01_BULL7676_02_SE_C01.indd 15 28/07/18 6:11 PM

M01_BULL7676_02_SE_C01.indd 15 28/07/18 6:11 PM

between pathophysiology, clinical Intestinal

manifestations and management.

They are a key feature for integrating

components of the text. Ideal for

visual learners, the boxes in the pain heart failure

(pathophysiology), blue (clinical

CHAPTER 21 Blood disoRdERs

Key clinical issues

central to providing safe, informed,

essential to understanding the

pathophysiological knowledge in C H A PT ER R EVI EW R EVI EW Q U EST I O N S

each chapter is provided. Questions

enable the student to assess, is -itis.

review and consolidate what they

have learnt in the chapter.

Health professional connections

importance of the various health

work in an inter-professional team.

This information is presented in the M03_BULL7676_02_SE_C03.indd 48

specific disorders discussed in each

Clinically accurate and realistic lymphadenopathy. Her observations were as follows:

scenarios allow students to apply, Temperature

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M03_BULL7676_02_SE_C03.indd 49 06/07/18 1:33 PM

DIGITAL IMAGE POWERPOINT SLIDES

Cellular and tissue

KEY TERMS LEARNING OBJECTIVES

INTRODUCTION CLINICAL MANIFESTATIONS

Source: E.J. Roh & M. Hales © Sciencopia.

THE ROMAN YOUTH IN THE TIME OF CAESAR

Caelius did not come of an illustrious family. He was the son of a

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