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 Medicine for Finals
and Beyond

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 Medicine for Finals
and Beyond
THIRD EDITION

Edited by
John S. Axford
DSc MD FRCP FRCPCH
Emeritus Professor of Clinical Rheumatology
St George’s Hospital
University of London
London UK
Chris A. O’Callaghan
BM BCh MA DPhil DM FHEA FRCP
Professor of Medicine
Fellow of The Queen’s College
Nuffield Department of Medicine
University of Oxford
Hon Consultant Physician and Nephrologist
Oxford University Hospitals
Oxford, UK

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 First edition published 2023
by CRC Press
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and by CRC Press
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Boca Raton, FL 33487-2742
© 2023 John Axford and Chris O’Callaghan
This title is a reworked and condensed version of Medicine published by Blackwell, 2004
CRC Press is an imprint of Informa UK Limited
The right of John Axford and Chris O’Callaghan to be identified as the authors of the editorial material, and of the authors for their
individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to
publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors
or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual
editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information
or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a
supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s
instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug
formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering
or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is
appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her
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DOI: 10.1201/9781003193616
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 The editors

John Axford is a Consultant in Adult and Paediatric Rheumatology and Emeritus Professor of Clinical Rheumatology
at St George’s Hospital, University of London.
After training at University College Hospital he worked at The National Hospital for Neurology, The Hammersmith
Hospital, The Royal Brompton Hospital, King’s College Hospital and the New England Medical Center, Boston,
Massachusetts, USA.
He has enjoyed teaching medicine throughout his career and pioneered video teaching to developing countries with the
Royal Society of Medicine.
He is an author and editor of the textbook UpToDate.

Chris O’Callaghan is Professor of Medicine at the University of Oxford and a Consultant Physician (in Acute General
Medicine) and Consultant Nephrologist in the Oxford University Hospitals.
He is Chief Examiner in Medicine for the University of Oxford, runs a research group, teaches medical students, and is
a Fellow and former Dean of The Queens’ College, Oxford.
After training and working in Oxford he worked at Guy’s, St Thomas’, Hammersmith, Brompton and Lewisham
Hospitals in London, Royal Stoke University Hospital, the University of California, San Francisco, and the California
Institute of Technology.
His other books include The Kidney at a Glance and The MRCP Part I: a System Based Tutorial.

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 Contents

Contributors ix
Acknowledgements xi
Introduction xiii

1 The Human Aspects of Medicine 1

Chris O’Callaghan & Alison Maycock

2 The Scientific Basis of Medicine 7

Chris O’Callaghan & Rachel Allen

3 Infectious Disease 21
Susanna J. Dunachie, Hanif Esmail, Ruth Corrigan & Maria Dudareva

4 Rheumatic Disease 83
John Axford

5 Metabolic Bone Disease 141

Jeffrey Lee

6 Respiratory Disease 155

Ian Pavord, Nayia Petousi & Nick Talbot

7 Cardiovascular Disease 203

Alexander Lyon

8 Renal Disease; Fluid and Electrolyte Disorders 277

Chris O’Callaghan

9 Liver, Biliary Tract and Pancreatic Disease 331

James Neuberger

10 Gastrointestinal Disease 359

Gareth Davies, Chris Black & Keeley Fairbrass

11 Diabetes Mellitus, Obesity, Lipoprotein Disorders and other Metabolic Diseases 429
Kevin Baynes

12 Endocrine Disease 471

Pierre-Marc Bouloux

13 Neurological Disease 511

Malcolm Macleod

14 Psychological Medicine 541

Harrison Howarth, Jim Bolton & Gary Bell

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 CONTENTS

15 Haematological Disease 557

Thomas A. Fox & Emma C. Morris

16 Palliative Medicine 597

Adrian Tookman & Faye Gishen

17 Poisoning 607
Paul Dargan

18 Skin Disease 611

Christopher Bunker & Richard Watchorn

Index 657

viii

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 Contributors

Rachel L. Allen BSc (Hons) DPhil Ruth Corrigan BM BCh PhD

Professor & Director of the Institute of Medical and Academic Clinical Lecturer in Microbiology and Infectious
Biomedical Education Diseases
St George’s, University of London Nuffield Department of Clinical Laboratory Sciences
London, UK University of Oxford
Oxford, UK
John S. Axford DSc MD FRCP FRCPCH
Emeritus Professor of Clinical Rheumatology Paul I. Dargan MB BS FRCP FEAPCCT FAACT
St George’s Hospital Professor of Clinical Toxicology
University of London Guy’s & St Thomas’ NHS Foundation Trust
London, UK and King’s College Hospital
London, UK
Kevin C.R. Baynes BA (Oxon) MBBS PhD FRCP
Consultant in Diabetes & Endocrinology Gareth R. Davies BSc (Hons) MD FRCP
London North West University Healthcare NHS Trust Consultant Physician and Gastroenterologist
London, UK Harrogate District Hospital
Harrogate, UK
Gary Bell BA MB BS FRCPsych
Consultant Psychiatrist Maria Dudareva BM BCh PhD MRCP
Cognacity NIHR Doctoral Research Fellow
London, UK Bone Infection Unit
Oxford University Hospitals NHS Trust
Christopher J. Black MB BS(Hons) PhD MRCP Oxford, UK
Consultant Gastroenterologist
Leeds Teaching Hospitals NHS Trust Susanna Dunachie BM ChB PhD FRCP FRCPath
Leeds, UK Professor of Infectious Diseases
University of Oxford
Jim Bolton MB BS BSc(Hons) FRCPsych Oxford, UK
Consultant Psychiatrist
Department of Liaison Psychiatry Hanif Esmail MA MBBS MRCP PhD FRCPath
St Helier Hospital Associate Professor and Honorary Consultant in Infectious
London, UK Diseases
University College London and Hospital for Tropical
Pierre-Marc Bouloux BSc MB BS (Hons) MD FRCP Diseases
Director and Consultant Endocrinologist University College London Hospitals
Centre for Endocrinology London, UK
Royal Free Campus
UCL Keeley Fairbrass BSc(Hons) MBChB(Hons) MRCP
London, UK Gastroenterology Registrar and Clinical Research Fellow
Leeds Teaching Hospitals NHS Trust
Christopher B. Bunker MA MD FRCP Leeds, UK
Consultant Dermatologist
and Honorary Professor of Dermatology Thomas A. Fox BSc MB ChB MSc MRCP FRCPath
UCL and Chelsea & Westminster Hospitals, Department of Haematology
and University College Hospital
University College and Imperial College London, UK
London, UK

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 CONTRIBUTORS

Faye Gishen MB BS BSc FRCP EdD PFHEA Chris A. O’Callaghan BM BCh MA DPhil
Professor of Medical Education & Palliative Medicine DM FHEA FRCP
UCL Medical School Professor of Medicine
London, UK Fellow of The Queen’s College
Harrison Howarth BSc (Hons) MB BS MRCPsych Nuffield Department of Medicine
Core Psychiatry Trainee University of Oxford
Camden and Islington NHS Foundation Trust Hon Consultant Physician and Nephrologist
London, UK Oxford University Hospitals
Oxford, UK
Jeffrey Lee MB BS (Hons) FRCP
Consultant Rheumatologist Ian Pavord MA MBBS DM FRCP FERS FMedSci
Royal Free Hospital Professor of Respiratory Medicine
London, UK Respiratory Medicine Unit and Oxford Respiratory NIHR BRC
Nuffield Department of Clinical Medicine
Alexander Lyon MA BM BCh PhD FRCP FHFA University of Oxford
Senior Lecturer and Honorary Consultant Cardiologist and John Radcliffe Hospital
Imperial College London and Royal Brompton Hospital Oxford, UK
London, UK
Nayia Petousi MA MB BChir MRCP DPhil
Malcolm R. Macleod BSc(Hons) MB ChB PhD FRCP Consultant Respiratory Physician
FRSB Oxford University Hospitals NHS Foundation Trust
Professor of Neurology and Translational Neurosciences Oxford, UK
(University of Edinburgh)
and Honorary Consultant Neurologist (NHS Forth Valley) Nick Talbot BM BCh MA DPhil MRCP
Edinburgh, UK Departmental Lecturer
Department of Physiology, Anatomy and Genetics
Alison J. Maycock MB BChir (Cantab) MA MRCGP University of Oxford
General Practitioner Partner, Trainer and Appraiser Consultant in Respiratory Medicine
Hollow Way Medical Centre Oxford University Hospitals NHS Foundation Trust
Oxford, UK Oxford, UK

Emma C. Morris BA MA MB BChir PhD FRCP Adrian Tookman MB BS FRCP

FRCPath FMedSci Consultant Palliative Medicine
Professor of Clinical Cell & Gene Therapy Former Medical Director Marie Curie Hospice
UCL Division of Infection and Immunity London, UK
Hon Consultant Haematologist
University College London Hospitals NHS Foundation Trust Richard E. Watchorn MB BCh BAO MD FRCP
and Royal Free London Hospitals NHS Foundation Trust Consultant Dermatologist
London, UK Beaumont Hospital, Dublin
and Honorary Consultant Dermatologist
James Neuberger DM FRCP University College London Hospitals NHS Foundation Trust
Hon Consultant Physician Honorary Clinical Senior Lecturer
The Liver and Hepatobiliary Unit Royal College of Surgeons of Ireland
Queen Elizabeth Hospital and Imperial College London
Birmingham, UK London, UK

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 Acknowledgements

All those who contributed to editions of this book’s predecessor, Medicine—this new book builds on their work especially:
Stephen H. Gillespie (Chapter 3), Chris Sonnex (Chapter 3), Christopher Carne (Chapter 3), Emma M. Clark (Chapter 5),
Jon Tobias (Chapter 5), M.J. Walshaw (Chapter 6), Charles Hind (Chapter 6), C.W. Pumphrey (Chapter 6), J.C. Kingswood
(Chapter 8), D.K. Packham (Chapter 8), D.S. Rampton (Chapter 10), D.J. Betteridge (Chapter 11), Felicity Kaplan (Chapter 12),
Gerard S. Conway (Chapter 12), C.J. Mumford (Chapter 13), D.H. Bevan (Chapter 15), A.C. Kurowska (Chapter 16),
A.K. Fletcher (Chapter 17) and F.P. Morris (Chapter 17). Peter Saugman was a key supporter from the start.
Jo Koster and Jordan Wearing for superb editorial support with this edition. Nora Naughton for her outstanding
and incredibly efficient project management of the production of this book. Becky Freeman and Susan Smyth for their
tireless efforts copy-editing and proof-reading respectively.
M. Ali Abbasi, Christine Heron and Andrew Hine for radiology advice. Julia Steed for keeping the text under control.
The following doctors for reviewing the text and providing helpful feedback: Nina Agarwal, Pat Woo Mark Cassar, Vijay
Hadela, Marcus Hughes, Simon Lambracos, Brian Lunn, Mike Mendall, Muthana Al Obaidi, Sanjeev Patel, Johnathan
Rogers, Malcolm Rustin, Paddy Stone and Malcolm Walker.
Our excellent colleagues for their valued expertise and discussions of medicine.

xi

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 Introduction

Our focus in this condensed third edition is on helping

you to pass your final assessments and examinations
HOW TO USE THIS BOOK
with ease and confidence.
Chapter 1 provides an overview of the human dimension
Medicine for Finals and Beyond contains all the informa-
to clinical medicine and Chapter 2 reviews the basic sci-
tion that you need to qualify as a doctor. The contributing
ence. Together, these help you to understand what under-
authors are experts in their respective fields, as well as expe-
pins modern medical practice. The chapters which follow
rienced writers and teachers. The book has been strongly
cover systems. Navigation is aided by the coloured page
influenced by input from many students and colleagues.
end-tabs that label each chapter. Drugs are referred to by
Much has changed since the second edition was published
their Recommended International Non-proprietary Name
and some chapters needed further refinement as the pan-
(rINN) although, in a few cases, older names are also pro-
demic unfolded.
vided if they are still in use.

DESIGNED FOR LEARNING

CHAPTER LAYOUT
To pass examinations and to practise medicine well, it is
The system chapters cover structure and function, approach
important to understand the basics. There are many text-
to the patient and diseases and their management. Aids to
books of medicine, but we believe that they are generally
learning within each chapter highlight important material:
not well designed for learning. Some have grown thicker
• At a Glance boxes summarize core topics for rapid
with each edition and include detail that is beyond the
revision.
needs of students and, indeed, of many qualified doctors.
• History and Examination boxes outline key features
This can make it difficult to see the ‘wood for the trees’ and
to elicit from the patient.
slows and complicates learning.
• Emergency boxes summarize essential information
Medicine for Finals and Beyond has been carefully crafted
about emergencies.
to avoid the overwhelming. Each system is presented in an
• Must-know checklists highlight key points.
integrated chapter, with sections on the basic structure,
The editors and authors have enjoyed creating this third
function and biology of the system, on clinical presenta-
edition and are confident that students will find it a useful
tions, on the approach to the patient and on the diseases
and enjoyable book as they learn medicine and particularly
affecting that system. There is a clear focus on evidence-
in the pressured run-up to final exams. The editors suggest
based medicine as well as consideration of the social, caring
that you remember:
and communicative aspects of practice and the impact of
‘the patient is always right…’
disease and treatment on the lives of patients.
and therefore……….
The material in this edition has been arranged to aid
‘if in doubt, ask the patient.’
learning and recall. The amount of information on each
Enjoy your career and REMEMBER to have fun outside
topic has been carefully regulated. Important topics are
medicine too.
readily identifiable and deliberately presented in detail if
they are very common or are often examined. Illustrations
John Axford and Chris O’ Callaghan
have been used extensively to aid learning.
The book is written for students but will also be of use
to doctors and other healthcare workers who are trying to
understand or revise medicine, so it will remain useful as
you advance beyond your student years.

xiii

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 The Human Aspects of Medicine

1 CHRIS O’CALLAGHAN & ALISON MAYCOCK

Introduction 1 Clinical reasoning or judgement 5

Communication with patients 1 Maintaining patient trust 5
Communication with relatives and carers 3 Reflective practice 6
Communication with colleagues 4 Providing leadership 6
Communication in challenging circumstances 4 Life as a clinician 6
Communication and confidentiality 5

⚬⚬ Support patients in their self-care.

INTRODUCTION
This chapter considers the context in which the clinical facts
and details discussed in the other chapters are gathered
and deployed. It is intended to help the student or clinician
reflect on how to make the most effective use of the infor-
mation contained in the other chapters.
The effectiveness of doctors rests not just on their knowl-
edge of clinical facts but also on good communication, clear
clinical reasoning and reflective practice. The General Medical
Council (GMC), which regulates medical practice in the
UK, captures these elements in its guidance ‘Good medical
practice’. This is divided into different domains and speci-
fies how doctors should act.
• Knowledge, skills and performance
⚬⚬ Have patient-centred care as their first concern.
⚬⚬ Be competent and up to date.
⚬⚬ Recognize and work within their competence.
• Safety and quality
⚬⚬ Act promptly if patient safety, dignity or comfort
is at risk.
⚬⚬ Protect and promote the health of patients and the
public.
• Communication partnership and teamwork
⚬⚬ Treat patients politely and considerately.
⚬⚬ Respect patients’ confidentiality.
⚬⚬ Listen to patients and respond to their concerns
and preferences.
⚬⚬ Give patients the information they want or need in
a form they can understand.
⚬⚬ Respect patients’ right to contribute to decisions
about their management.
DOI: 10.1201/9781003193616-1
⚬⚬ Work effectively with colleagues in the patients’
interest.
• Maintaining trust
⚬⚬ Be honest and open and act with integrity.
⚬⚬ Never discriminate unfairly against patients or
colleagues.
⚬⚬ Never abuse patient trust or public trust in the
profession of medicine.
These elements form the basis of doctors’ mandatory annual
appraisal and the 5-yearly revalidation of their licence to
practise in the UK.
A key element of medical practice is communication and
the clinician is involved in a complex communication net-
work (Figure 1.1).
COMMUNICATION WITH PATIENTS
Being a skilled listener is fundamental to the process of
understanding the problems that patients present and
their significance for the patient across all aspects of
their life. Consultations are usually face-to-face, but
increasingly occur via telephone, video, email or even
social media, and each medium presents different
challenges.
Patient-centredness and shared decision-making should
be the defining features of the consultation. The patient’s
values and goals should be established by the clinician and
incorporated into a negotiated plan of action. Agreeing a
plan is important, as the patient has to live with its conse-
quences. A negotiated and agreed plan is much more likely
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 THE HUMAN ASPECTS OF MEDICINE
Figure 1.1 The network of clinical communication.
to be effective than an instruction given by the doctor to the
patient. We all engage more fully in plans we have helped
devise.
Consider the structure of a consultation, its main phases
and tasks (Figure 1.2).
During these processes, the clinician provides a structure
to the consultation for the patient to understand, tackles their
problem and also builds a relationship with the patient. Let us
look in more detail at some of these elements.
OPENING THE CONSULTATION
Preparation
• Gather any data already available (e.g. test results,
letters from other clinicians).
• Manage your own feelings and needs (e.g. hunger,
tiredness, anxiety or stress).
• Be clear about your own agenda (e.g. you may wish
to achieve an audit target or reduce your clinic
numbers).
• Choose a comfortable setting.
Establishing rapport
• Make eye contact and smile.
• Identify yourself by name and role.
• Confirm that the patient is ready to talk.
• Ensure the patent is comfortable, appropriately
covered and positioned.
• Ensure any other people in the room are appropriate
and the patient consents to their presence.
• Put the patient at their ease with a kind and gentle
manner.
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• Explain any use of computers or other technology as
needed.
• Involve the patient and ask questions in a friendly
manner. Use non-verbal gestures such as smiling,
nodding and allowing silence.
• Acknowledge and respond to each point made by the
patient.
• Notice how the patient looks and behaves and draw
this into the consultation, if appropriate.
GATHERING INFORMATION
People generally consult doctors because they think that
they have a medical problem that should be diagnosed and
treated, or because something is adversely affecting them
and their coping mechanisms are failing.
Start by asking open and wide questions to capture all
the important information from your perspective and the
patient’s, such as:
• Why have you come to see me today?
• What outcome are you hoping we will achieve?
• What is it about this problem that worries you?
• What do you think the problem is?
• What next steps do you have in mind?
• Is there anything else that has been bothering you?
Follow each of these by an open prompt, such as:
• Can you tell me a bit more about that?
Clarify with open specific questions, such as:
• Do you have a cough?
Pin down your diagnosis by asking increasingly specific
closed questions, such as:
• Does anything bring the cough on?
• Does exercise bring the cough on?

Figure 1.2 The tasks and processes of the consultation.
Avoid negative leading questions, such as:
• You do not have the cough at night then?
• You don’t get any side effects from these medications?
PHYSICAL EXAMINATION
Tailor your examination according to the history and your
differential diagnosis.
EXPLANATION AND PLANNING
Achieve a shared understanding of the problem
• Clarify and summarize what has been said.
• Establish in your own mind your differential
diagnosis.
• Use non-specialist language to explain your
conclusions.
• Ask for the patient’s opinions, suggestions and
preferences.
• Relate explanations to the patient’s own terms or
concepts.
• Explicitly check the patient’s understanding.
Provide the correct type and amount
of information
• Deliver information in small chunks.
• Provide written material, such as patient information
leaflets or web links.
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COMMUNICATION WITH RELATIVES AND CARERS
Make a plan
• Agree the forward plan with the patient.
• Empower the patient to manage their own illness and
self-care.
• Document key points carefully.
CLOSING THE CONSULTATION
• Check for any outstanding patient concerns.
• Advise whom the patient may contact with further
questions.
• Advise what to do in situations that need action and
especially those which are a threat to patient safety.
COMMUNICATION WITH RELATIVES
AND CARERS
It is important to bear in mind the following, when talking
to relatives and/or carers.
• Obtain appropriate consent from the patient for the
discussion.
• Establish the identity and role of the carer or relative.
• Be sensitive to the impact of the patient’s illness on the
individual carer or relative.
• Establish what they already know and what more they
wish to know.
3
 THE HUMAN ASPECTS OF MEDICINE
• Use the skills of the patient consultation, such as
active listening, breaking information into small
chunks and providing written material, as appropriate.
COMMUNICATION WITH COLLEAGUES
Most doctors work in teams and this can be challenging,
rewarding and enjoyable. Good team working requires
showing respect and consideration for others. This includes
listening to the concerns and points of view of other peo-
ple and acknowledging and valuing their contributions.
Effective communication is needed to optimize efficiency
and patient safety.
• Keep accurate and concise records, which are signed
and dated or appropriately validated electronically.
• Formulate requests for help as clearly as possible, to
obtain the most useful response.
• Be sensitive to the roles and competencies of
colleagues.
• Promote a fair and supportive work environment.
• Be willing to help colleagues but realistic about what
can be done.
• Obtain patient consent for discussion with outside
teams or agencies.
COMMUNICATION IN CHALLENGING
CIRCUMSTANCES
Communication with patients or relatives or carers can be
especially challenging in certain situations, such as the
following:
• The patient and clinician do not speak the same
language. An interpreter should be used.
• The patient has impaired hearing. A hearing aid or
signing interpreter should be used as appropriate.
• The patient has impaired cognitive skills or lacks
capacity. The clinician must establish the level of
understanding and the capacity of the patient for each
specific decision. Mental capacity is always assumed
and is demonstrated for a specific decision when a
patient can:
⚬⚬ Understand the information given and the
decision required
⚬⚬ Retain the information
⚬⚬ Weigh up the information to make a decision
⚬⚬ Communicate that decision
• The patient displays strong emotions. The clinician
should remain calm, speak quietly, acknowledge the
emotion displayed and show a willingness to listen
further.
• The clinician must break bad news. The clinician should
choose a quiet, comfortable place, ask if the patient
wants someone else to be present and check what
4
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they already know. It can be helpful to offer a warning
along the lines of ‘I am sorry, but I have some difficult
information for you…’.
• The clinician is communicating a complex concept
such as risk. Advise the patient of absolute risk (not
relative). Give numbers not percentages. Use visual
decision-making aids if possible (e.g. Figure 1.3, a
patient decision-aid chart). Discuss the likelihood of a
problem both occuring and not occuring. For example,
in the hypothetical situation illustrated in Figure 1.3, if
discussing the option of taking a statin with a patient
who has a 10-year cardiovascular disease (CVD) risk
of 30%, you might say:
‘If there were 100 people like you in the room, over
the next 10 years, on average it is likely that 30 of them
would have heart pain, a heart attack or stroke and
70 of them would not. If they all take this medicine every
day for the next 10 years, then 20 of them would be likely
to have a problem and 80 would not. Therefore, 10 people
would be likely to avoid the problem.’
• There is uncertainty of diagnosis, prognosis or benefits
of intervention options. The doctor should be honest
with patients about the limitations of medical certainty
and predictability, but should offer reassurance
regarding what is known and can be done.
• There are medically unexplained symptoms. Medically
unexplained symptoms can be frustrating for both the
doctor and patient. The doctor should be explicit about
the limitations of current medicine to explain every
symptom. It is important to acknowledge that even
when no organic illness can be diagnosed, a patient
may be significantly affected by their symptoms and
Figure 1.3 Patient decision aid to communicate the benefit of a
statin on cardiovascular risk. This hypothetical decision aid could
be used to demonstrate how taking a statin might reduce the
likely number of cardiovascular events over a 10-year period from
30 to 20 per 100 people.

the doctor can still offer to support the patient in
•
managing their problem.
The patient is making a complaint. Clinicians have
a statutory duty of candour in the UK. This means
they must tell patients about any medical errors.
Complaints should be handled according to local
complaints procedures, which usually involve
providing the complainant with:
⚬⚬ A clear written description of what happened
⚬⚬ A clear description of how it was investigated
⚬⚬ An apology for any errors and acknowledgement
of the impact on the patient
⚬⚬ An indication of how future problems will be
avoided
⚬⚬ An invitation to meet to discuss the matter
• Obtaining informed consent. When obtaining consent
for a procedure, the emphasis is now on providing
the information which a reasonable patient can be
expected to want to know. This includes side effects
or consequences which are common and those which
are uncommon or rare but which are serious. In the
UK, this follows the High Court findings in the case of
Montgomery v Lanarkshire. In this situation, a mother
sued the hospital trust for not informing her of the
risks of a vaginal delivery to her unborn baby. The
mother was small and the baby was large. The baby
suffered injury during delivery and the court ruled
that she should have been informed of this small but
important risk.
• The patient has strong cultural or personal values
and beliefs which may affect the medical process. This
may be refusing certain treatments, such as blood
products in the case of some Jehovah’s Witnesses,
or gelatin-containing capsules for some Muslims.
Clinicians must be sensitive to diversity and avoid
making assumptions. They must be alert for cues
indicating embarrassment regarding being examined
or talking about intimate issues.
• The clinician is working outside their area of competence.
In this case, the doctor should explain to the patient
that this is so and further advice should be sought
from a colleague with appropriate expertise.
COMMUNICATION AND
CONFIDENTIALITY
Patients’ trust in doctors is, in part, founded on confidenti-
ality. The clinician should not disclose identifiable patient
details without consent. Implied consent can be assumed
for aspects of direct patient care and local audit as specified
in GMC guidance in the UK. All other disclosure requires
explicit consent except in the following circumstances:
• Disclosure is in the public interest if it is required
to prevent serious crime or communicable disease.
For example, clinicians have a duty to inform the
ISTUDY
MAINTAINING PATIENT TRUST
sexual contact of a patient who has HIV infection
if the patient is not prepared to prevent the risk of
transmitting the infection. A doctor also has a duty
1
in the UK to inform the police or Driver and Vehicle
Licensing Agency (DVLA) if a patient is not fit to drive
and is continuing to do so.
• The patient lacks capacity and disclosure is in the best
interest of the patient.
• A court orders disclosure of information.
In any case of disclosure without consent, the clinician must
carefully document the efforts they made to obtain consent
and inform the patient of their plans before disclosure or, if
this is not possible, as soon as possible thereafter.
Patient confidentiality must be safeguarded when patient
information is shared electronically, and any such commu-
nication must use systems which are compliant with the
appropriate security standards. In the UK, nhs.net accounts
currently fulfil these requirements. Outside this facility, clini-
cians should check the security of the system they are using
or remove all patient-identifying data from the communi-
cation. When emailing patients, the clinician should make
them aware of the potential limitations for security and docu-
ment the patient’s consent for this type of communication.
In the UK, the British Association of Dermatologists has
published GMC-approved guidance on how to take clinical
images and email these images for direct patient care. This
guidance states that securely configured devices and NHS
email or secure data transfer apps must be used. The images
must then be deleted immediately after transfer. In any other
circumstance, patient data must be completely anonymized.
CLINICAL REASONING
OR JUDGEMENT
Clinicians make sense of the information they gather by
a process of clinical reasoning, which aims at making a
working or differential diagnosis and management plan.
Clinical reasoning has several stages which may be reit-
erated until a best course of action is identified. We have
already identified some of the key components of this and
a framework for understanding clinical reasoning is sum-
marized in Figure 1.4.
MAINTAINING PATIENT TRUST
Patients often put enormous trust in the medical profession.
When interacting with doctors, patients may feel, and be,
very vulnerable. Their health and well-being may be under
serious threat. It is unlikely that they are familiar with the
concepts and information which form the basis for the
decisions they are being asked to make. There is therefore
a duty on clinicians to respect and safeguard patient trust
by acting honourably and in the patient’s best interests at
all times. These requirements are identified by the GMC
5
 THE HUMAN ASPECTS OF MEDICINE

best to address the learning or other need required to enable

better practice in future. The final step is to identify what will
confirm that practice has improved.
The professional development of doctors also involves
looking after ourselves and building resilience to withstand
the demands of the job. We need to have enough time and
energy to pursue our interests, both medical and non-med-
ical. We need to nurture ourselves as individuals as well as
professionals in order to deal with stress and to avoid burn-
out. Time for reflection and planning is part of this self-care,
as is sharing worries or dilemmas with peers or seniors,
forming small peer-support groups or finding a mentor or
coach. It is important to remember that doctors are normal
people and may, like their patients, need help at times.

PROVIDING LEADERSHIP
As doctors gain in experience and become more senior, they
take on more leadership activities, although any doctor may
be required to show leadership at any stage. For example,
any junior doctor may be asked to organize how the team
divides up the tasks they need to do. Being a leader means
taking responsibility for the functioning of the team as a
whole. Again, the basic skills of communication are key:
achieving rapport, listening, clarifying issues and sharing
decisions as far as is practical. However, it is the leader of a
team who has to take the final decision and, with that, the
final responsibility for the actions taken.

LIFE AS A CLINICIAN
The role of the clinician makes enormously varied demands
on the individual. These include demands on memory and
knowledge, experience, logical reasoning, emotional intel-
ligence, social skills, self-reflection and self-management.
Demands are also made on the imagination and creativity
of the doctor, as they must help generate a plan with the
patient in every circumstance they encounter. It is, however,
a role that can reward the individual with a marvellously
varied professional life.
Figure 1.4 Stages in clinical reasoning.

as outlined earlier. They contribute to what we think of as MUST-KNOW CHECKLIST

professionalism.
REFLECTIVE PRACTICE
In the UK, the ongoing professional development of doc-
tors has been formalized in statutory annual appraisal and a
5-yearly revalidation process. The GMC has recently drawn
attention to the key role played by reflection in enabling individu-
als to develop professionally. In essence, reflection involves tak-
ing time to step back and think about a particular event and
consider what went well, what could have gone better and how
6
• Effective communication is an essential aspect of clinical
medicine.
• If time permits, prepare and plan each consultation.
• Always listen to patients.
• Patient confidentiality is of the utmost importance.
Questions and answers to test your understanding of
Chapter 1 can be found by clicking ‘Support Material’
at the following link: https://www.routledge.com/Medicine-
for-Finals-and-Beyond/Axford-OCallaghan/p/book/
9780367150594

ISTUDY
 The Scientific Basis
of Medicine
2 CHRIS O’CALLAGHAN & RACHEL ALLEN
Biological macromolecules 7 Pharmacology
Cell biology 8 Genetics
Molecular biology 11
In this chapter, we outline some of the scientific foundations
of modern medicine, highlighting how scientific advances
have opened up the potential for new therapies and diag-
nostic tests.
BIOLOGICAL MACROMOLECULES
NUCLEIC ACIDS
Genetic information is stored and transferred in the form of
the nucleic acids deoxyribonucleic acid (DNA) and ribonucleic
acid (RNA). These molecules provide the necessary infor-
mation for protein production. Like many biological mol-
ecules, nucleic acids are multimers of smaller units; which in
this case are known as nucleotides. A set of four nucleotide
components is used to generate DNA or RNA. Adenine (A),
guanine (G) and cytosine (C) are common to both DNA and
RNA. Thymine (T) is found in DNA but absent from RNA,
with uracil (U) present in its place.
DNA strands consist of nucleotides joined by phospho-
diester bonds linking the sugar of one nucleotide to the
phosphate group of the next. DNA coils into a double helix
of two antiparallel strands (Figure 2.1). Complementary base
pairing of adenine with thymine and guanine with cytosine
ensures the fidelity of DNA transcription and replication.
When DNA is copied, each parental strand acts as a tem-
plate for replication: incoming nucleotides form hydrogen
bonds with an appropriate base on the template strand.
Base mispairing, induced by damage or mutation, intro-
duces structural alterations which can be detected and/or
removed by DNA repair proteins.
RNA differs from DNA in its sugar content and usu-
ally exists as a single strand. RNA is a versatile molecule
that is fundamental to protein synthesis; information from
a DNA strand is copied (transcribed) into a new strand of
DOI: 10.1201/9781003193616-2
ISTUDY
13
13
Immunology and inflammation 17
RNA, which acts as a template for protein production. Some
viruses use RNA as their hereditary material; retroviruses
such as human immunodeficiency virus (HIV) encode their
genome on a single strand of RNA, which is reverse tran-
scribed into DNA upon infection of a host cell.
PROTEINS
Proteins are long chains of amino acids held together by
peptide bonds. Each amino acid is composed of an amino
group, a carboxyl group and the particular side chain that
defines their chemical nature. Individual proteins are con-
structed from a library of 20 amino acids, which may be sub-
grouped according to the acidic, basic, uncharged polar or
non-polar character of their side chains (Figure 2.2). Like
all large molecules, proteins adopt a conformation that con-
fers the most stability. Protein modifications can result from
the addition of other substances, such as metal ions (e.g.
iron in haemoglobin), lipids (lipoproteins) or carbohydrates
(glycoproteins).
CARBOHYDRATES
Carbohydrates are composed of carbon, hydrogen and
oxygen with a general formula Cx(H 2O)y. They range from
simple monosaccharides of three to six carbons to large com-
plex polysaccharides (Figure 2.3). Glycoproteins are usually
generated by covalent attachment of carbohydrate groups to
the amino acids asparagine, threonine or serine. Some dis-
eases, such as cancers and arthritis, may have characteristic
glycosylation patterns, which can be useful for diagnosis
and for predicting prognosis.
Long-term complications associated with diabetes can
result from hyperglycaemia. In a non-enzymatic process,
glucose attaches to the amino group of proteins such as
collagen (e.g. in blood cell walls). Consequent chemical
7
 THE SCIENTIFIC BASIS OF MEDICINE

rearrangements irreversibly generate advanced glycosylation

end products (AGE). AGE have a range of pathological effects
including peptide cross-linking.

LIPIDS
The structural units of lipids are fatty acids, containing long
chains of 4–24 carbon atoms joined to a carboxylic acid
group (Figure 2.4). Fatty acids may be saturated or non-
saturated depending on the presence of double bonds within
their hydrocarbon tail. Polyunsaturated fatty acids contain
multiple double bonds. One of the most important in vivo
functions performed by lipids is the formation of cellular
membranes. Phospholipids contain a hydrophilic phosphate
group, linked by glycerol to a hydrophobic fatty acid tail. The
amphipathic nature of phospholipids allows them to form
a sealed membrane bilayer in aqueous solution. Another
physiologically important group of lipids are the cholesterol
derivatives (steroids). These molecules contain four hydro-
carbon rings, one of which carries a hydroxyl group which
gives the molecule an amphipathic nature.
Figure 2.1 The DNA double helix.

CELL BIOLOGY
(a) (b)
CELL STRUCTURE
Amino R
O Acid Cells are the basic structural unit of all living organisms.
group group
N C C N C Each cell has the means to maintain itself within the
NH2 C
C N C C
organism and interact with other cells and body systems.
CH OH Subcellular organelles compartmentalize processes such as
R R respiration or digestion (Figure 2.5).
N C The fluid nature of the outer phospholipid membrane
Side chain
terminus terminus that surrounds the cell allows proteins to move around its
surface. The cytosol is the site of many cellular reactions and
contains all the necessary machinery for protein synthesis.
(c)
A cytoskeleton of microfilaments, intermediate filaments
and microtubules provides physical support for the various
organelles and forms transport routes between them.
The membrane-bound nucleus acts as a store for genetic
information. Nuclear pores facilitate exchange of protein and
RNA between the nucleus and the rest of the cell. Newly
formed proteins destined for transport to lysosomes or the
cell surface are inserted into the endoplasmic reticulum (ER),
a system of folded membranes. Initial protein glycosylation
may also occur within the ER. From the ER, proteins prog-
ress through a related system of compartments known as
the Golgi complex, where further modifications take place.
The Golgi complex sorts macromolecules for onward trans-
port and, on leaving it, proteins progress through a system of
vesicles until they reach their ultimate location.
Endocytosed proteins and other materials are degraded
Figure 2.2 (a) Amino acid side chains (designated by a black
box) may be acidic, basic or hydrophobic in nature. (b) Amino within membrane-bound lysosomes, which store the hydro-
acids join to form a polypeptide chain. (c) Protein secondary lytic enzymes required for such degradation. Deficiency of
structure is composed of α-helices and β-sheets, both of which a lysosomal enzyme causes the neurological condition Tay–
can be seen in the structure of human tyrosine phosphatase 1B.
An example of an α-helix is shown in red and an example of a Sachs disease in which gangliosides accumulate in the brain
β-sheet is shown in green. causing neural degeneration and early death.
8

ISTUDY
 CELL BIOLOGY

(a) CH2OH (b) CH2OH

O O
OH OH
OH
OH
OH CH2OH OH

OH

β– D–Fructose β– D–Glucose

(c) CH2OH
CH2OH
O
O
OH

OH
O
OH
OH
2
OH
OH

Lactose

(d) COO– CH2OSO3–

O O
OH
O
OH OH

OSO3– NHSO3–

Heparin

Figure 2.3 Carbohydrate structures. Most common monosaccharides adopt a ring conformation in aqueous solution. (a) Fructose
and (b) glucose are examples of 5-carbon (pentose) and 6-carbon (hexose) monosaccharides, respectively. (c) Lactose is a
disaccharide formed from galactose and glucose subunits. (d) Heparin is a polysaccharide.

Mitochondria are the powerhouses of the cell. These mater-
nally inherited organelles carry their own small genome
encoding various components of the respiratory process.
CELL DIVISION
Mitosis
that every part of the mitotic process is completed correctly
before the next stage begins. Because uncontrolled prolif-
eration is a hallmark of cancer, the cell cycle provides an
obvious target for therapy. CDKIs often act as tumour sup-
pressors and are potentially useful anticancer agents.
Meiosis

In order to divide successfully, a cell must copy its DNA so
that each daughter cell receives its full set of chromosomes.
This is achieved by a tightly regulated mitosis following the
cell cycle pathway (Figure 2.6). Passage through the cell
cycle is controlled by cyclin proteins, in a cascade of phos-
phorylation events. Each cyclin acts as a catalytic subunit
in partnership with a cyclin-dependent kinase (CDK). Upon
cyclin binding, CDKs phosphorylate target proteins that
are required for cell-cycle progression. CDK-specific inhibi-
tors (CDKIs) bind cyclin–CDK complexes to regulate their
activity and can themselves be regulated by other proteins.
During mitosis, one member of each chromosome pair
becomes attached to a centriole. Centrioles move to oppo-
site ends of the cell, taking the chromosomes with them. In
order to prevent inappropriate proliferation of cells, mito-
sis is tightly controlled, with various checkpoints to ensure
A more specialized form of cell division generates gam-
etes bearing a single set of chromosomes. Meiosis requires
two rounds of cell division, with DNA replication occur-
ring during the first round of division. The second divi-
sion results in each daughter cell inheriting a single set of
chromosomes.
APOPTOSIS
An effective mechanism is required to remove cells that
are damaged or no longer necessary. This programmed
cell death is generally known as apoptosis (Figure 2.7), and
follows a carefully controlled series of events allowing the
cell to condense its cytoskeleton and fragment its DNA.
Apoptosis is driven by members of the caspase protein fam-
ily. Bcl proteins regulate caspase activity. Programmed cell
9

ISTUDY
 THE SCIENTIFIC BASIS OF MEDICINE

(a) (b) HO
HO C [CH2]2 C C [CH2]4 CH3
C [CH2]8 CH3 O
O Double
bond

(c) CH3 CH2 CH2 CH3 (e)

CH CH2 CH
CH3
Aqueous
CH3
CH3
Hydrophilic
heads

HO Hydrophobic Aqueous
Cholesterol tails

(d)
O H

Hydrophobic H3C [CH2]16 C O C H

H3C [CH2] C C [CH2] C O C H

7 7

H H
O

H C O P O CH2 CH2 NH2

H O–
Hydrophilic

Figure 2.4 Lipids. (a) Saturated and (b) unsaturated fatty acids are termed according to the presence of double bonds within
their hydrocarbon tail. (c) Steroid molecules such as cholesterol are based on a skeleton of four carbon rings. (d) Phospholipids are
amphipathic molecules with two hydrophobic (green) hydrocarbon tails attached to a hydrophilic polar head group (blue). (e) In aqueous
solution, phospholipids form a bilayer with a hydrophobic interior. This arrangement forms the basis for eukaryotic cellular membranes.

death can be triggered in response to stimuli such as cell sur-
face signals or mitochondrial stress. Following ligand bind-
ing, cell-surface death receptors such as Fas recruit adaptor
proteins to trigger procaspase activation, and thus elicit
apoptosis. Mitochondria can initiate an alternative apop-
totic pathway in response to DNA damage or intracellular
oxidative stress. A dying cell will show membrane blebbing,
cell shrinkage and protein fragmentation as it collapses in
upon itself. Within the nucleus, chromatin condensation
and DNA degradation occur. Finally, the cell is flagged for
uptake by phagocytic cells.

CELLULAR HOMOEOSTASIS AND

COMMUNICATION
The human body maintains a stable environment for its
cells and tissues through a combination of physiological
and biochemical processes. Cell membranes form a barrier
to large molecules, allowing the cell to maintain a constant
internal environment. Specific transport mechanisms are
therefore required to transfer material in and out of the cell.
Membranes contain many different proteins that actively or
Figure 2.5 Cell structure. passively facilitate the movement of ions or molecules across
10

ISTUDY
 MOLECULAR BIOLOGY

membranes. Three major classes of transport protein are

membrane channels, pumps and transporters.
Cells can use extracellular molecules to communicate
with one another. Signal transduction pathways translate
these stimuli into an appropriate cellular response, usu-
ally through a series of phosphorylation reactions leading
to novel gene transcription in the nucleus. Signalling path-
ways play a role in the development of many cancers.

Figure 2.6 The cell cycle. Cells resting between divisions are
held indefinitely in the quiescent (G 0) phase. Upon appropriate
stimulation (e.g. exposure to growth factors) cells enter ‘gap 1’
(G1), the first stage of the cell cycle, during which various RNAs
and proteins are synthesized. The cell then enters a period of
DNA synthesis termed the ‘S-phase’. Once each chromosome
has been replicated, a second ‘gap’ phase, G 2 takes place.
When the cell is ready to divide, mitosis begins (M phase).
During mitosis, chromosomes condense and the nuclear
envelope breaks down, allowing paired chromosomes to attach
to centrioles by a microtubule spindle. Chromosome pairs
separate and are moved to opposite ends of the cell preceding
cytoplasmic division (cytokinesis). Positive and negative control
points operate throughout the cell cycle. Various commitment
points and regulatory checkpoints are marked in red and green,
respectively. Cell cycle control proteins include p21, p53 and Rb
(the retinoblastoma protein).
MOLECULAR BIOLOGY
CHROMOSOMES
The human genome organises our entire genetic infor-
2
mation into a set of 46 chromosomes, which segregate our
DNA for storage or transcription. Humans have 23 pairs
of chromosomes, with one set inherited from each parent.
These include 22 pairs of standard chromosomes and one
pair of sex chromosomes (XX in females, XY in males). In
the absence of transcription or replication, DNA is packed
into chromosomes as chromatin with DNA wrapped tightly
around very many nucleosome cores. The most densely
packed form, heterochromatin, has a closed structure to
maintain genes in a transcriptionally inactive state. In

Figure 2.7 Apoptosis. There

are two major pathways of
apoptosis. (A) Death signals from
cell surface receptors such as
Fas (CD95) trigger activation of
caspase 8 to initiate a signalling
cascade through downstream
enzymes. Mitochondria host a
range of pro-apoptotic factors
including cytochrome C, which
is necessary for downstream
caspase activation. A second
apoptotic pathway (B) operates
through these organelles. Triggers
such as DNA damage (signalled
through p53 and Bax) initiate the
release of pro-apoptotic factors
from mitochondria. Bcl2 acts as
an anti-apoptotic regulator of this
process.
11

ISTUDY
 THE SCIENTIFIC BASIS OF MEDICINE
contrast, genes that are being expressed in order to produce
protein are located within open euchromatin, to allow access
for the necessary transcriptional machinery.
To neutralize the tendency of chromosomes to shorten
with each round of DNA replication, the telomerase enzyme
elongates the ends of each chromosome to form a blocked
telomere structure. Telomerase is usually active in stem cells
and germ cells or during oncogenesis, but is not found in
healthy somatic tissues. Modulation of telomerase enzyme
has therefore become a subject of interest for anti-ageing
and anticancer research.
GENE STRUCTURE
Every protein is encoded by a DNA sequence within a gene
at a defined locus on a chromosome. Codons of three sequen-
tial nucleotides encode a single amino acid or a stop signal.
Regulatory regions containing target sites for various DNA-
binding proteins flank the coding sequence and control gene
expression. These regions form a vital part of the gene and
their loss can have profound effects on protein expression.
Mutations in control regions can cause disease, as evidenced
by some of the haemoglobin gene mutations that cause thal-
assaemia. An upstream promoter provides binding sites for
RNA polymerase and transcription factors. Functionally
related enhancer sequences are located further afield and
recruit various DNA-binding proteins that can regulate the
efficiency of gene transcription. The transcriptional unit
(a)
(b)
(c)
Figure 2.8 Gene transcription, mRNA processing and translation.
12
ISTUDY
contains exons of coding DNA separated by introns, which
play no part in the finished protein. A large portion of our
genome is composed of repetitive DNA of unclear function.
FROM GENE TO PROTEIN –
TRANSCRIPTION AND TRANSLATION
When a gene is active, the chromatin structure loosens
to allow access for RNA polymerase to generate an RNA
molecule (Figure 2.8). This messenger RNA (mRNA) pre-
cursor is then processed for translation into an amino acid
sequence. Gene splicing removes introns from the coding
sequences to leave a continuous series of exons for transla-
tion. Once within the cytosol, mRNA attaches to large ribo-
nucleoprotein particles known as ribosomes. Ribosomes
read along mRNA, generating proteins by polymerizing
amino acids donated by transfer RNA (tRNA) molecules
bearing an appropriate anticodon.
GENE EXPRESSION PATTERNS
Every somatic cell carries an identical set of genes.
Housekeeping genes are required for basic cellular functions
and are constitutively expressed. Additional subsets of
expressed genes determine the phenotype and differentia-
tion state of the cell. Access of transcriptional proteins to the
gene promoter will be restricted if it is tightly packed within
heterochromatin. CpG islands are stretches of cytosine

and guanine found at the 5’ end of genes. Methylation of
cytosine (C) within CpG islands can prevent a gene from
becoming expressed. An extreme form of methylation con-
trol is exercised on one of the X chromosome pair in every
somatic female cell. This process results in hypermeth-
ylation of the inactive chromosome to prevent gene tran-
scription. The field of epigenetics studies how processes
such as DNA methylation or the modification of histone
proteins in nucleosomes are regulated, how they control
gene expression and their influence in health and disease.
Epigenetic modification of cell cycle control genes is com-
monly observed in cancer.
Gene activation can occur in response to various internal
or external stimuli through the action of receptor proteins
and signalling pathways. The end point of these pathways
is usually the expression or activation of one or more DNA-
binding proteins that, in turn, stimulates gene expression.
In addition to the regulation of transcription, factors such as
mRNA stability, transcriptional regulation and differential
splicing may influence protein expression.
Developmental regulation of gene expression has clini-
cal significance in a number of areas. For example, differ-
ent haemoglobin genes are activated in the fetus compared
to those expressed by adults. One therapeutic approach for
thalassaemia is to reactivate fetal haemoglobin genes to
compensate for abnormalities in their adult counterparts.
PHARMACOLOGY
At their site of action, drugs interact with molecules termed
drug ‘receptors’ or ‘targets’. These are often actual biological
receptors, such as hormone receptors, but they may also be
any other type of molecule, such as an enzyme or mem-
brane channel. The affinity of a drug-receptor interaction is
a measure of how tightly the two molecules bind. An agonist
is a substance that has an effect on a specific drug receptor,
causing activation of the function of the receptor molecule.
A partial agonist has the same type of effect on the function
of the receptor molecule, but even at the maximal effect of
the drug, the function of the receptor molecule is not acti-
vated to its maximal level. An antagonist is a drug that binds,
to but opposes, the natural activity of the receptor molecule.
Competitive antagonists compete with agonists for the same
receptor, but they do not exert an agonist effect themselves
and so reduce the effect of any agonist present. In these cir-
cumstances, the overall effect will depend on the relative
concentrations of agonist and antagonist. A non-competitive
antagonist does not compete for the same site but opposes
the effect of the agonist by another mechanism. Finally, an
irreversible antagonist is an antagonist that inactivates the
receptor molecule permanently once it has bound. This
effect cannot be reversed, even at high concentration of
agonist. Many drug receptors are bound by naturally occur-
ring agonists and antagonists, including hormones and
neurotransmitters.
ISTUDY
GENETICS
Pharmacodynamics describe the distribution of a drug
through various body compartments as a function of time.
In contrast, pharmacokinetic studies follow the actions and
effects of drugs on living tissue. Dose–response curves relate
the biological effect of a drug to its administered dose.
Sometimes, this effect is directly proportional to the dose,
so that doubling the dose will double the effect. However,
this is often not the case and it may, for example, take
a 10-fold increase in dose to achieve a doubling of effect.
Drug dosage is affected by many factors including the
absorption, distribution, metabolism and excretion of the
drug. Although these effects are complex, clinically use-
ful decisions about drug dosage can be made if the drug
half-life is known. The half-life of a drug is the time taken
2
for plasma levels of the drug to fall to half of their origi-
nal value. Drugs are usually administered orally, intrave-
nously (IV), subcutaneously (subcut) or intramuscularly
(IM). Before distribution to its site of action, a drug must
first be absorbed from its administration site (e.g. gut, skin
or muscle) unless it is injected IV. The most rapid effects are
obtained by IV administration, which immediately delivers
the drug into the blood for direct transport to the tissues.
When a drug has been absorbed, it equilibrates throughout
its volume of distribution, which may not include all tissues.
Most orally administered drugs are absorbed in the small
bowel and must pass through the liver before they can reach
the systemic arterial circulation. This means that they may
be altered by metabolism in the liver, a process known as
‘first pass metabolism’. Once any drug has been adminis-
tered, it may be inactivated by metabolism (especially in the
lungs) or excreted by the kidney in urine or, less commonly,
by the liver in bile. Metabolism frequently alters drug activ-
ity. Phase 1 reactions cause oxidation, reduction or hydrolysis
of the drug and involve cytochrome p450 mixed-function
oxidases. Phase 2 reactions add groups such as glucuronides
or sulphates to the drugs, increasing their water solubility
and making them suitable for excretion by the liver in bile or
by the kidney in urine. Within the kidney, anion and cation
transporters are capable of transporting drugs into the renal
tubules for excretion in the urine.
Many drugs are bound by plasma proteins; acidic drugs bind
albumin and basic drugs bind to α1 acid glycoproteins. If a drug
is strongly bound by a plasma protein, it will tend to remain
within the circulation. If a drug is poorly bound by plasma pro-
teins, its distribution will depend upon its lipid-solubility. Water-
soluble drugs tend to remain within extracellular fluids, whereas
lipid-soluble drugs cross cell membranes to enter cells and may
even become concentrated in adipose tissue.
GENETICS
MUTATIONS
There is genetic variation between individuals and poly-
morphic genetic variants (known as alleles) are distributed
13
 THE SCIENTIFIC BASIS OF MEDICINE
throughout populations. These genetic variations may
influence disease susceptibility. Defects in a single gene
may be responsible for a particular disease such as cystic
fibrosis, but within a given gene, mutations may occur at
multiple sites. These mutations may vary in their penetra-
tion – the most common mutation seen for cystic fibrosis
is a deletion in the CFTR protein that results in misfolded
protein, which is then retained inside the cell leading to a
severe disease phenotype. Other mutations allow the CFTR
protein to reach the cell surface, but reduce its activity and
cause less severe forms of disease.
Point mutations are the simplest form of DNA alteration
(Figure 2.9). In this case, a single nucleotide of the DNA
sequence is affected. If a mutation affects the protein-cod-
ing sequence of a gene, it is termed silent if it does not alter
the encoded amino acid. A missense mutation occurs when
DNA alterations encode a different amino acid. Sometimes,
the effects are more drastic; a mutation which introduces an
early stop codon (nonsense mutation) will terminate protein
translation and full-length protein will not be produced.
Figure 2.9 Point mutations.
14
ISTUDY
Similarly, gain or loss of one or two nucleotides will alter the
subsequent reading frame of the protein and the remainder
of the correct sequence will be lost. Pathogenic mutations
may also occur outside a protein-coding sequence; altera-
tions to promoter regions or splice sites can have profound
effects on gene expression.
Background levels of mutation arise from normal cellular
and environmental interactions. Mutation rates also reflect
the fidelity of DNA replication and its proofreading and/
or correction potential. Trinucleotide repeats are known to
be particularly unstable and are associated with a range of
genetic diseases including Huntington’s chorea, myotonic
dystrophy and fragile X syndrome. Disease severity is usually
proportional to the increase in repeat length.
MONOGENIC AND POLYGENIC DISORDERS
Monogenic diseases are the simplest genetic disorders to
study as they tend to follow Mendelian genetics. Dominant
and recessive diseases have characteristic patterns of
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until he drove him to Cholula, and latterly to Tlapallan, where he died, and where his
followers burnt his body, thus inaugurating the custom of burning the dead. 84

The interpreter of the Codex Telleriano-Remensis says regarding Quetzalcoatl:

“Quetcalcoatl they say was he who created the world; and they bestowed upon him the
appellation of Lord of the Wind, because they said that Tonacatecotli when it appeared
good to him breathed and begat Quecalcoatle. They erected round temples to him
without any corners. They said that it was he (who was also lord of these thirteen signs
which are here represented) who formed the first man. They celebrated a festival on
the sign of four earthquakes, to the destroyer with reference to the fate which again
waited the world; for they said that it had undergone four destructions and would again
be destroyed. He alone had a human body like that of men; the other gods were of an
incorporeal nature.

“After the deluge the custom of sacrificing commenced. Topilcin Quetcalcoatle was
born on the day of seven canes; and they celebrated on this same day of seven canes
a great festival in Cholula, to which they came from all parts of the country and the
cities and brought great presents to the lords and papas of the temple; and they did the
same on [129]the day on which he disappeared or died, which was the day of One
Cane. These festivals happened at the expiration of every period of fifty-two years.

“They here fasted the last four days to Quecalcoatl of Tula, who is he who was named
after the first Calcoatle; and now they name him One Cane, which is the star Venus, of
which they tell the fable accredited amongst them.

“Tlavizcalpantecutli is the star Venus the first created light (Civahteltona) before the
deluge. They say that it was a fire or a star: it was created before the sun. This star
(Venus) is Quecalcoatle. They say this is the star which we call Lucifer from its light;
and they accordingly paint it with the sign of one Cane, which was the day dedicated to
it. He took this name on the occasion of his departure or disappearance.
Tlavizcalpantecutli is the God of Morning when it begins to dawn: he is also the Lord of
Twilight on the approach of Night: he presided over these thirteen days during the four
last of which they fasted. It properly was the first light which appeared in the world; it
here signifies the light which diffuses itself over things, or the surface of the earth.”

The interpreter of Codex Vaticanus A says:

“They invented dreams, the result of their own blindness, relating that a god of the
name of Citallatonac, which is the sign seen in heaven called St. James’s or the Milky
Way, sent an ambassador from heaven on an embassy to a virgin of Tulan called
Chimalman (a shield) who had two sisters, the one named Tzochitlique and the other
Couatlique; and that the three being alone in the house, two of them, observing the
ambassador of heaven, died of fright, Chimalman alone remaining alive, to whom the
ambassador announced that it was the will of this god that she should conceive a son;
and having delivered to her the message, he rose and left the house, and as soon as
he had left it she conceived a son without connection with man, who they called
Quetzalcoatle, who they say is the god of air, and his temples are round in the manner
of churches, although till that time such was not the fashion of their temples. He was
the inventor of [130]temples of this form as we shall show. He it was, as they say, who
caused hurricanes and in my opinion was the god who was called Citaladuali and it
was he who destroyed the world by winds. This painting is here wanting, together with
another which represented that as soon as the son of this virgin was born he
possessed the use of reason. The son of the virgin, Topilcin Quetzalcoatle, knowing
that the vices of men were necessarily the cause of the troubles of the world,
determined on asking the goddess Chalchiutlicue (this was the heavenly designation of
the virgin Chimalman) who is she who remained after the deluge with the man in the
tree, and is the mother of the god Tlaloque, whom they have made goddess of water,
that they might obtain rain when they stood in need of and accordingly Quetzalcoatle
commenced offering sacrifices to obtain rain, as a period of four years had elapsed
since it had rained.

“Quetzalcoatltopilzin does penance and makes offerings of prayers, sacrifice, gold

gems, incense, etc., to appease divine wrath against the people; draws his own blood
with thorns. After the expiration of a long period during which he continued his penance
a lizard appeared scratching the ground giving him to understand that the scourge of
heaven was past and that the earth would with joy produce its fruits, which quickly
came to pass; and accordingly they relate that on a sudden such abundance followed
that the earth, which had remained so many years barren, bore many kinds of fruit and
from that even they took four signs.

“Quetzalcoatl’s example teaches men to do penance, make offerings. He founded four

temples—the first for the nobles; second, for the people; third, House of Fear or
Serpent; fourth, Temple of Shame.

“Of Quetzalcoatle they relate that, proceeding on his journey, he arrived at the Red
Sea, which is here painted, and which they named Tlapallan; and that entering into it,
they saw no more of him, nor knew what became of him, except that they say that he
desired them at the time of his departure to restrain their grief and to expect his return,
which would take place at the appointed time; and accordingly [131]they expect him
even to the present time: and when the Spaniards came to this country they believed
that it was he, and when at a later period of 1550 when the Çapotecas revolted, they
alleged, as the cause of their insurrection, the report that their god who had to redeem
them had already come. Quetzalcoatle was born on the sign One Cane; and the year
of the Spaniards’ arrival commenced on the sign One Cane, according to their ancient
Computation: whence the occasion arose of their believing that the Spaniards were
their gods; because they say that he had foretold that a bearded nation would arrive in
those countries who would subject them. They adored him as a god, as will be seen:
for they believed it certain that he had ascended into heaven and was that star which
was visible at the north of the sun before the break of day, which is the planet Venus;
and they represented him accordingly as has already been shown.

“Quetzalcoatle was the first inventor of sacrifices of human blood, amongst the various
other things which they offered to the gods; and this was the manner in which they
pierced their tongues, that the blood might flow … and their ears and penis; till at last,
as we shall presently mention, the custom of human sacrifices was introduced, when
they tore out the hearts of the victims to present them to the face of the idol which they
considered the image of their wretched god.

“They declare that their supreme deity Tonacatecotle, whom we have just mentioned,
who by another name was called Citinatonali, when it appeared good to him, breathed
and begot Quetzalcoatle, not by connection with woman, but by his breath alone, as we
have observed above, when he sent his ambassador, as they say, to the virgin of Tula.
They believed him to be the god of the air and he was the first to whom they built
temples and churches, which they formed perfectly round without any angles. They say
that it was he who effected the reformation of the world by penance, since as,
according to his account, his father had created the world and men had given
themselves up to vice, on which account it had been frequently destroyed, Citinatonali
sent [132]his son into the world to reform it.… They assigned to him the dominion over
the other thirteen signs, which are here represented, in the same manner in which they
assigned the preceding thirteen to his father. They celebrated a great festival on this
sign, as we shall see on the sign of four earthquakes, which is the fourth in order here,
because they feared that the world would be destroyed in that sign, as he had foretold
to them when he disappeared in the Red Sea, which event occurred on the same sign.
As they considered him their advocate, they celebrated a solemn festival and fasted
during four signs.”

The Anales de Quauhtitlan or Codex Chimalpopocâ states that Quetzalcoatl was born
in no natural manner, but was a nine years’ child. He created the four classes of men:
the men of the four “suns” or periods of the world were made by him on the day
chicome ehecatl, or “seven wind.” The record proceeds to relate the circumstances of
his rule at Tollan, the manner in which he discovered the value of precious stones, gold
and silver, red and white shells, quetzal feathers, the cotinga and red sparrowbill
feathers, the various species of cocoa and cotton. When he had drunk the octli offered
him by Tezcatlipocâ, he forgot his chastity in the intoxication and indulged in
intercourse with Quetzalpetlatl, for which sin he was forced to quit Mexico. When he
was driven from Tollan in the year one reed, he arrived on the sea-shore, wept, and
divested himself of his garb and turquoise snake-mask. Then he immolated himself by
burning, his ashes became dust and changed into birds and his heart was converted
into the morning star. Lastly, it is said of him that when he died he was not visible for
four days, during which period he tarried in the Underworld. For a subsequent four
days “he was bones.” “After eight days appeared the great star which they called
Quetzalcoatl. They said that he thus mounted the throne as a god.”

In its second or historical portion the codex states that Quetzalcoatl discovered maize
which was concealed in the mountain Tonacatepetl. Many of the gods searched for it,
but Quetzalcoatl, taking the form of a black ant, was guided [133]to the spot by a red
ant. As he was unable to lift the mountain, it was split open by the magical prowess of
Xolotl in his manifestation of Nanahuatl, and the maize became the spoil of
Quetzalcoatl. But it was stolen from him by Tlaloc, the rain-god proper, perhaps an
allegorical manner of alluding to the more direct influence of that deity upon growth.

Other myths relating to Quetzalcoatl, chiefly as a creative agency, will be found in the
précis of the opening chapters of the Historia de los Mexicanos por sus Pinturas, in the
chapter on Cosmogony.

In Codex Borgia we find a passage (sheets 35–46) which appears to refer to the
progress of Quetzalcoatl and Tezcatlipocâ through the infernal regions, and which
might be described as the Mexican “Harrying of Hell.” On this passage Seler has briefly
commented (see his Commentary on Codex Vaticanus B, p. 119).

CENTRAL AMERICAN MYTHS RELATING TO QUETZALCOATL

Quetzalcoatl is, perhaps, singular among the deities of Mexico in that a number of well-
authenticated Central American myths cluster around his name in its forms of
Kukulcan, Gucumatz, and Votan. Certain of these must be considered here, for
purposes of comparison and analogy.

Nuñez de la Vega: A book in the Quiche tongue, said to have been written by Votan, a
local name for Quetzalcoatl, was at one time in the possession of Nuñez de la Vega,
Bishop of Chiapas, who included portions of it in his Constituciones Diocesianos de
Chiapas, but nevertheless destroyed it in his holocaust of MSS. at Heuheutlan in 1691.
Ordoñez de Aguilar had, however, made a copy of it before its destruction, and
incorporated it in his Historia de Cielo MS. In this work Votan declared himself “a
snake,” a descendant of Imos, of the line of Chan 85 of the race of Chivim. Taking
Aguilar’s account along with that of Nuñez de la Vega, as both rely upon the same
authority, we find that Votan proceeded to America by divine command, his mission
being to lay the [134]foundation of civilization. With this object in view he departed from
Valum Chivim, 86 passing the dwelling of the thirteen snakes, and arrived in Valum
Votan, whence, with some members of his family, he set out to form a settlement,
ascending the Usumacinta River and ultimately founding Palenque. By reason of their
peculiar dress the Tzendal Indians called them Tzequitles, or “men with shirts,” but
consented to amalgamate with them. Ordoñez states that when Votan had established
himself at Palenque he made several visits to his original home. On one of these he
came to a tower which had been intended to reach the heavens, a project which had
been brought to naught by the linguistic confusion of those who conceived it. Finally he
was permitted to reach “the rock of heaven” by a subterranean passage. Returning to
Palenque, he found that others of his race had arrived there, and with them he made a
friendly pact. He built a temple by the Heuheutan River, known, from its subterranean
chambers, as “the House of Darkness,” and here he deposited the national records
under the charge of certain old men called tlapianes, or guardians, and an order of
priestesses. Here also were kept a number of tapirs. A quotation of the passage
dealing with this temple may be made from Nuñez de la Vega:

“Votan is the third heathen in the calendar (that is the deity who is ascribed to the third
division of the calendar), and in the little history written in the Indian language all the
provinces and cities in which he tarried were mentioned; and to this day there is always
a clan in the city of Teopisa that they call the Votans. It is also said that he is the lord of
the hollow wooden instrument which they call tepanaguaste (that is, the Mexican
teponaztli); that he saw the great wall, namely, the tower of Babel, which was built from
earth to heaven at the bidding of his grandfather, Noah; and that he was the first man
whom God sent to divide and apportion this country of India, and that there, where he
saw the great wall, he gave to every nation its special language. It is related that he
tarried in Huehueta (which is a city in Soconusco), [135]and that there he placed a tapir
and a great treasure in a slippery (damp, dark, subterranean) house, which he built by
the breath of his nostrils, and he appointed a woman as chieftain, with tapianes (that is,
Mexican tlapiani, “keepers”) to guard her. This treasure consisted of jars, which were
closed with covers of the same clay, and of a room in which the picture of the ancient
heathens who are in the calendar were engraved in stone, together with chalchiuites
(which are small, heavy, green stones) and other superstitious images; and the
chieftainess herself and the tapianes, her guardians, surrendered all these things,
which were publicly burned in the market place of Huehueta when we inspected the
aforesaid province in 1691. All the Indians greatly revere this Votan, and in a certain
province they call him ‘heart of the cities’ (Corazon de los pueblos).”

In his ninth Pastoral Letter Nuñez says of Quetzalcoatl:

“In most of the Calendars, the seventh sign is the figure of a man and a snake, which
they call Cuchulchan. The masters have explained it as a snake with feathers which
moves in the water. This sign corresponds with Mexzichaut (Mixcoatl), which means
Cloudy Serpent, or, of the clouds. The people also consult them in order to work injury
on their enemies, taking the lives of many through such devilish artifices, and
committing unspeakable atrocities.”

The Popol Vuh.—The myths relating to Quetzalcoatl under his name of Gucumatz in
the Popol Vuh, the sacred book of the Quiche of Guatemala, are difficult to summarize.
In the first chapter he is alluded to as “the serpent covered with feathers, the heart of
the lakes, the heart of the sea, master of the sky, master of the blue expanse,” and is
connected with the creative gods. Along with Hurakan (Tezcatlipocâ) he creates the
world by uttering the word “earth.” The creation of man having been considered, the
wherewithal for his sustenance is debated. Gucumatz, who is sometimes alluded to in
the plural, like the Hebrew Elohim, succeeds in discovering maize in Paxil by the aid of
the fox, jackal, parrot, and crow, and obtains the seeds of other alimentary plants (pt. iii,
c. i.) Gucumatz then created man by a [136]“miracle” (c. ii). In c. v, pt. iii, Quetzalcoatl is
alluded to as Tohil, a parallel for which we have justification in ver. 19 of c. x, where in
the song called Kamucu (“We see”) the first men sing: “Truly Tohil is the name of the
god of the Zaqui nation, which was called Yolcuat-quetzalcuat when we separated in
the place Tolan in Zuiva.” But the myths relating to this deity are obviously tribal and
local, and I am of opinion that they refer to some tribal deity who possessed some of
the characteristics of Quetzalcoatl and who was identified with him by the Quiches in
rather an arbitrary fashion. 87

FESTIVALS

Atlacahualco.—The festival of Atlacahualco or Quaitl Eloa was, says Sahagun, sacred

to Quetzalcoatl, as well as to the Tlaloque. For an account of it see the section which
deals with Tlaloc.

Ce Acatl.—Says Sahagun: “On the first day of the sign ce acatl the great folk made a
feast to Quetzalcoatl, the god of winds. This was celebrated in the calmecac, and here
they offered rich gifts to his idol, perfumes and things to eat. They said it was the sign
of Quetzalcoatl.”

PRIESTHOOD

The order of priests devoted to the service of Quetzalcoatl 88 was called

Tlamacazcayotl, and its members Tlamacazque. Of these Clavigero, who was well
informed regarding the Mexican priesthood, says: “Amongst the different orders or
congregation, both of men and women, who dedicated themselves to the worship of
some particular gods, that of Quetzalcoatl is worthy to be mentioned. The life led in the
colleges or monasteries of either sex, which were devoted to this imaginary god, was
uncommonly rigid and austere. [137]The dress of the order was extremely decent; they
bathed regularly at midnight, and watched until about two hours before day, singing
hymns to their god, and observing many rules of an austere life. They were at liberty to
go to the mountains at any hour of the day or night, to spill their blood; this was
permitted them from a respect to the virtue which they were all thought to possess. The
superiors of the monasteries bore also the name of Quetzalcoatl, and were persons of
such high authority, that they visited but the king when it was necessary. The members
of this religious order were destined to it from their infancy. The parents of the child
invited the superior to an entertainment, who usually deputed one of his subjects. The
deputy brought the child to him, upon which he took the boy in his arms and offered
him with a prayer to Quetzalcoatl, and put a collar about his neck, which was to be
worn until he was seven years old. When the boy completed his second year, the
superior made a small incision in his breast, which, like the collar, was another mark of
his destination. As soon as the boy attained his seventh year he entered into the
monastery, having first heard a long discourse from his parents, in which they
advertised him of the vow which they had made to Quetzalcoatl, and exhorted him to
fulfil it, to behave well, to submit himself to his prelate, and to pray to the gods for his
parents and the whole nation.”

The high-priest of Quetzalcoatl was stationed at Cholula and was, perhaps, the most
venerated ecclesiastic in Mexico.

TEMPLES

The principal temple of the cult of Quetzalcoatl in Mexico was the well-known teocalli at
Cholula. He had also a shrine in the great temple court at Mexico, built in circular form,
and thus typical of the Wind-god.

NATURE AND STATUS

The latest of the myths concerning Quetzalcoatl are obviously those which regard him
as a culture-hero who enters the country as an alien, and, his beneficent work
performed, [138]withdraws to the place whence he came, under pressure of malignant
opposition. Had the basic outline of his myth been more carefully examined, fewer
unsatisfactory hypotheses concerning Quetzalcoatl’s nature might have been ventured
upon. The Mexicans themselves recognized Quetzalcoatl as a wind-god, but Dr. Seler
has not seen fit to accept their assurance upon this point in toto, and at various times
has advanced the hypotheses that Quetzalcoatl represents the wind, the planet Venus,
or the moon, latterly confining his personality almost entirely to the lamp of night. 89

In my view the physical phenomena which occur in connection with the courses of the
winds typical of the Mexican plateau provide by far the most simple and natural
explanation of the nature of the god Quetzalcoatl. From April or May to the beginning of
October the trade-wind blows from the east coast over the Plateau of Anahuac,
bringing with it abundance of rain, and accelerating vegetable growth, thus actually
“sweeping the ways for the rain-gods.” Its advance is comparatively slow, the rains
beginning three or four weeks earlier in Vera Cruz than in Puebla and Mexico. At the
beginning of October, however, it is invariably modified by the local monsoon, which
interrupts it over wide areas, or in certain districts invades it in violent cyclonic storms,
dissipating its energies and altering its course. Quetzalcoatl represents the gentle
trade-wind, which ushers in the growth-making rains. His reign of peace, plenty, and
fertility over, he comes into opposition with Tezcatlipocâ, who represents the monsoon
and who chases his rival “from city to city,” ravening at him like a tiger, says Mendieta,
and at last hustling him out of the country. That Tezcatlipocâ is also a god of wind is
certain, as is proved by one of his names, Yoalli Ehecatl, “Wind of Night,” and that he is
the monsoon or hurricane is proved beyond all doubt by the circumstance that he is
said to have rushed along the highways at night at extraordinary speed, and that
Hurakan, his Quiche name, is still employed for the very wind he represented, and has
[139]become a generic name for a tempestuous wind in practically all European
languages, which have without question adopted it from the American word. 90

If this simple elucidation of the original myth be accepted, it will be seen how naturally
its later modifications arise out of it or adapt themselves to it. But before we examine
the manner in which they crystallized around it, it becomes necessary to disentangle
from the whole mass that portion of it which alludes to the advent of a civilizing agency
upon the Mexican plateau.

This speaks of the advance of a body of men from the neighbourhood of Vera Cruz to
the Mexican plateau, and precisely in the direction whence the trade-wind comes—that
is, from the east, the direction of the land of the Huaxtecs, a people of proto-Maya
stock.

Quetzalcoatl is dressed in Huaxtec garb, and wears the truncated sugar-loaf hat and
shell-ornaments of this people. This may signify nothing more than that he was so
attired because he represented a wind which blew from the direction of the land of the
Huaxtecs. Yet, it is certain that several of the deities adopted by the Mexicans had
undoubtedly a Huaxtec origin, and this is markedly the case with Tlazoltcotl. There
seems to be some ground, then, for the hypothesis that Quetzalcoatl was a god of
Huaxtec origin. But the acceptance of such a theory will entail the acknowledgment of
certain hypotheses which are among the most controverted questions in Mexican
archæology. In the first place, it makes Quetzalcoatl the deity of a people of Maya
stock, and secondly it would seem to imply a Huaxtec or Maya origin for the much-
debated Toltec culture.

A discussion of these points must begin with the question, “Has the myth of
Quetzalcoatl’s civilizing mission to the Mexican plateau any historical justification?”
Regarding the reality of the civilization known as Toltec there is now no question,
although I fully admit that it took me a long time to realize this, thanks principally to my
acceptance of Brinton’s well-known theory on the subject, to which I [140]attached far
too much weight. But admitting Toltec reality, what proof do we possess that such a
civilizing agency as that of Quetzalcoatl gave an impetus to the “prehistoric” culture of
Tollan? But little—that is if we are to regard Quetzalcoatl as a man. But in his guise as
the gentle trade-wind that ushers in the rains, we have every reason to see in him the
founder of the Toltec civilization. Such a culture as the Toltec must undoubtedly have
had its origin in agricultural efficiency. Only through agricultural efficiency can the
corvée system arise and extensive building become possible. The god whose bountiful
patronage of growth assisted the arts in this manner seems in time to have been
‘humanized.’ 91 Legends of his civilizing prowess clustered around his supposititious
memory, he was thought to have been a culture-hero who actually moved and had his
being among the people. Kings or rulers were called by his name—a lucky name of
happy associations—and the illusion that he actually existed was thereby heightened.
These rulers seem to have flourished in Mexico ere yet the offices of king and priest
had become separate, so that it is not surprising that Quetzalcoatl was regarded as
having been the priest of his own cult, or that the Mexican pontiffs of historical times
bore his name. From this point of view, then, Quetzalcoatl was certainly the “founder” of
the Toltec civilization. If this theory be accepted, I do not see how the myth of
Quetzalcoatl can be regarded as having any basis in actual fact, unless one can find in
the rather vague statements of certain early writers on Mexico a further basis for
discussion as to his reality. To me the meaning of the myth seems very plain. It may be
that Huaxtec influence was brought to bear upon Toltec civilization, but my hypothesis
does not seem to me to require assistance from such an admission.

CRITICISM OF THE LATER ELEMENTS OF QUETZALCOATL’S MYTH

In short, the myth of Quetzalcoatl as recorded by Sahagun is obviously developed from

a much older one which referred [141]to a season of plenteous rain—the period of the
rule of the gentle and beneficent god representing the trade-wind. As it was connected
with prosperous conditions in agriculture, it was naturally brought into connection with
the Toltec time, the “good old times of long ago,” when conditions were greatly better,
and no mouth knew want. Such a concept was obviously of later origin. The revised
myth took on a cultural complexion. In terms of allegory, it tells how the powers of the
rain-making priest-god fail him; he becomes sick, and is beguiled and defeated by
Tezcatlipocâ, the rival wind-god, who tells him that “another old man” awaits him in
Tlapallan. And here we seem to find interpolated a reference to the guardian genius of
the fountain of perpetual youth, the reservoir of rain and all refreshment, which
Quetzalcoatl must visit if he would be cured of the ills of old age, and he is counselled
to speak with its keeper if he would return to Mexico “as a boy.” The destruction of his
treasure by the banished god seems to point to a reminiscence of the downfall of the
Toltec state, and the concealment of his gold and gems by burial to analogous Toltec
practice on the defeat or decline of that civilized folk. With his departure the reign of
plenty ceases, the trees wither, the birds migrate, the season of the trade-wind rains
has come to an end. History and myth are perhaps combined in this story of the latter
days of the Toltec régime and those of the revivifying rains. The priest-god withdraws
eastwards to the “flute-playing” of the retreating trade-winds. Nahua sorcerers detain
him in order to learn the Toltec arts, perhaps a mythical manner of showing how the
Nahua barbarians forced captive Toltecs to teach them the mysteries of stone- and
metal-craft. He is given the draught of the dead, “that none of the living can drink,” a
mythical episode common in all parts of the world. His dwarfish followers (the rain-
gods, the Tlaloque, with whom Sahagun associates him elsewhere) are frozen to death
in the cold of the mountains, otherwise the rain is congealed into snow.

Torquemada’s version of Quetzalcoatl’s myth is eloquent of the pre-eminence of his cult

at Cholula. The priest-god’s [142]prophecy of his return bears an extraordinary
resemblance to that given in the Books of Chilan Balam, a Guatemalan native
production, regarding the coming of white men to Central America. 92

Motolinia’s story of the fixing of the strap on Quetzalcoatl’s arm is merely a grotesque
explanation of the name Acolhua, which in reality signifies “the folk of the great
shoulder,” “the pushers,” “the hustling invaders.”

Mendieta, in dwelling upon Quetzalcoatl’s dislike of war, merely retains for us a

characteristic of the effeminate people of Cholula. The appearance of Tezcatlipocâ as a
spider is typical of the god of the dry season, or of the dry-rot prevalent in that period of
the year. As a tiger he symbolizes the fierceness of the hurricane, and the tlachtli game
which he and Quetzalcoatl engage in is undoubtedly symbolic of the seasonal strife
between the wind-gods.
DEVELOPMENT OF THE CONCEPTION OF QUETZALCOATL

Summarizing the myths relating to Quetzalcoatl we find:

(1) That all of them have their origin in or refer back to an original nature-myth, in which
Quetzalcoatl, the trade-wind, is, at the end of the rainy season, regarded as driven from
the Mexican Plateau by Tezcatlipocâ (Hurakan) in his guise of the monsoon, or
hurricane.

(2) That this myth in the first place became confounded with traditions of the Toltec
civilization, naturally enough, as that civilization was the direct outcome of the
agricultural wealth stimulated by the god representing the trade-wind.

(3) That it seems to have been associated with a myth relating to the fountain of youth,
that is, the fountain in which the refreshing and revivifying rains were stored, to which
Quetzalcoatl must return for rejuvenation and a fresh rain-supply.

(4) That the conception of the god Quetzalcoatl became humanized in the light of the
agricultural and other manifestations of Toltec culture, thus bringing about the [143]idea
of his existence as a priest-king, and culminating in the establishment of a line of
priestly rulers bearing his name, which endured as long as Mexican civilization.

(5) Out of these conceptions there naturally arose other related ideas, as those of:

(a) Quetzalcoatl as inventor of the tonalamatl, the instrument by which the festal days
of the rain-cult were originally noted, but which on the adoption of the solar calendar as
time-count degenerated into what may be regarded as an astrological table.

(b) The lunar basis upon which the tonalamatl was founded connected Quetzalcoatl
with the moon. 93

(c) Regarded as inventor of the tonalamatl, he gained a reputation as the possessor of

profound hieratic wisdom, and came to be looked upon as the magician or sage par
excellence, the patron of education, the rain-maker who knew precisely when the blood
shed in penance should be spent in order that it might return to the soil of Anahuac in
an abundant rainfall.

(d) Quetzalcoatl as the god of wind was also regarded as the breath of life, a
phenomenon encountered in many mythologies, and therefore came to be conceived
as the agency by which souls were originally placed in human bodies. From this, too,
we may argue his appearance as a creator, or cosmic deity, although it may have been
in his character as fertilizer that he came to be regarded in this light.
(e) Quetzalcoatl is the great penitent, the supreme protagonist of the penitential
system, because without the blood spent in penitential exercise no rain might fall. The
secondary character of this conception is probable.

(f) Quetzalcoatl seems at a later date to have been regarded as the god of the four
quarters of the compass, a conception of him indubitably evolved from his status as a
wind-god. I think I also perceive signs that from this latter [144]idea was further evolved
a conception of him as god of the four elements—fire, air, earth, and water. He is the
fire and the flint, because of the lightning which in Mexico accompanies the fall of the
trade-wind rain. He is the air in his rôle of Wind-god, and as such is symbolized by the
bird, the natural inhabitant of the air, the beak of which he uses as a funnel from which
to expel the wind. He is earth, and, his myth says, a builder of subterranean houses,
and sometimes bears the earth-staff of agriculture. 94 He is water, or rain, in which guise
he is typified by the feathered snake.

This conception of him, evidently strongly sophisticated by priestly theological science,

is illustrated in the Codex Magliabecchiano, where he is represented on one sheet
along with Tezcatlipocâ, Tlaloc, and Uitzilopochtli. This group, in my opinion, represents
the four elements: Fire (Uitzilopochtli), as possessor of the tlachinalli symbol, a
hieroglyph for water and fire, and as sun-god; Air (Quetzalcoatl); Earth (Tezcatlipocâ),
who as Tepeyollotl was an earth-deity; and Water (Tlaloc). The picture may also be
descriptive of the four points of the compass over which he rules. But above and
beyond this, as Seler has shown, it implies that these deities were later embodied in
the idea of Quetzalcoatl. When Cortéz, coming from the East, landed at Vera Cruz, the
Mexicans naturally believed that Quetzalcoatl had returned, and Motecuhzoma sent
him as an offering “the dress appropriate to him,” four kinds of attire, the ceremonial
costumes of Uitzilopochtli, Tezcatlipocâ, Tlaloc, and Quetzalcoatl.

ETYMOLOGY

There but remains the etymology of Quetzalcoatl’s name. It is compounded of the

element quetzalli and coatl. The first denotes the bright green tail-feathers of the
quetzal bird, and coatl = “snake,” so that the whole implies “feathered snake.” The
generally accepted belief is that [145]this name applies to the rain-bearing clouds which
accompany the trade-wind, although others have seen in it a description of the rain
itself, and still others the ripples made by wind on water. But quetzal in a secondary
sense means “precious,” and coatl is capable of being translated “twin.” The Mexicans
themselves, however, frequently drew and sculptured the god as a feathered serpent,
although this may easily have possessed a merely pictographic significance. In any
case, after prolonged consideration on the etymology of the name, I do not, so far, see
any reason to quarrel with the currently accepted rendering of it. [146]

1 As it has been found impossible to include every illustration from the codices which is mentioned in
the text, those pictures not supplied may be consulted in the reproductions of the codices themselves.
A full bibliography of the codices will be found at the end. When the letter K appears with reference to a
codex, its reproduction in Kingsborough’s “Mexican” antiquities is implied. ↑
2 This stellar mask is so called from being worn by the stellar deities. It is usually connected with the
red-and-white striped painting of the body. The Sahagun Aztec MS. calls it “face-cage marking” and
“face-star marking which is called darkness,” the former referring to stripes over the face, the latter to the
mask design, which seems to me to symbolize night surrounded by the “eyes” of the stars. ↑
3 Hist. Nat. Ind., pp. 352 ff., English translation in Purchas his Pilgrimes, bk. v, c. 9. Maclehoses’
edition. ↑
4 Hist. Conq. Mex., tom. i, pp. 396–398. ↑
5 Gage’s trans. of Herrera, in New Survey, pp. 116–117; for Spanish text, see Hist. Gen., tom. i, dec. ii,
bk. vii, c. xvii. ↑
6 Monarq. Ind., tom. i, p. 293. ↑
7 Quarter, district. ↑
8 House of the youths, where the acolytes or junior priests resided. ↑
9 Governors. ↑
10 Vassals, burghers. ↑
11 Dance. ↑
12 This custom was in vogue among certain prehistoric races, and is still practised on the death of a
relative by African bushmen, who first remove a finger-joint. ↑
13 More correctly quauhxicalli, a stone vase for the reception of the hearts of victims, from quauh (tli)
“eagle,” and xicalli, “cup.” ↑
14 Monarq. Ind., tom. ii, p. 73. ↑
15 Hist. Mex., English translation by C. Cullen (London, 1787), vol. i, bk. vi. ↑
16 Idea de una Hist., pp. 60–61. ↑
17 Bk. i, c. i. ↑
18 So Uitzilopochtli addresses his half-brother. “Uncle” among the ancient Mexicans was an honorific
title. ↑
19 Bk. iii, c, i, par. i. ↑
20 Monarq. Ind., tom. i, p. 294. ↑
21 See chapter on Cosmogony. ↑
22 Sahagun, Appendix to bk. iii, c. ix. ↑
23 Hist. Nat. Ind. in Purchas his Pilgrimes, bk. v, c. xiii. See also Manuel Gamio, Proc. 19th Cong. Amer.,
Washington, 1915, for account of discoveries when the foundations of this temple were partly laid
bare in 1913. ↑
24 C. i. ↑
25 Sahagun, bk. ii, c. xxxiv; Uitzilopochtli himself, as we shall see, was oracular. In this case I take it that th
octli distilled from the plant conferred the boon of oracular speech. ↑
26 The first pulque or octli, which was called uitztli, was offered at this festival as first-fruits to
Uitzilopochtli. The spirit distilled from the pulque is still known as mexcal or mescal, and is probably
identical with the fiery fluid given to the braves in the service of the god before going into battle. ↑
27 Bull. of U.S. Bureau of Ethnology, No. 28, p. 210. ↑
28 Monarq. Ind., tom. ii, p. 41. ↑
29The Historia de los Mexicanos por sus Pinturas calls Uitzilopochtli omitecilt. I think this should be read
ome tecitl, “twice-wizard,” but it may read ome tecutli, “twice-lord.” But the latter is certainly a title of
Tonacatecutli, the creative deity. ↑
30 Bk. i, c. i. ↑
31 Sahagun, bk. ii, c. xxiv. ↑
32 As does an Egyptian sun-god. ↑
33 The Centzonuitznaua appear to be the same as the Tzitzimimê, whom Tezozomoc calls the “gods of
the air who bring the rains, floods, thunderclaps, and thunders and lightnings and had to be placed
round Uitzilopochtli” in order to complete the construction of the great teocalli of Mexico. These “gods of
the signs and planets,” in other words the stars, were regarded as demons of darkness, thinks Seler,
“only because during a solar eclipse the [87]stars became visible in the day sky.” I think it much more
probable that they were looked upon as demons of darkness because they peopled the darkness every
night. “These,” says the interpreter of the Codex Telleriano-Remensis, “are the sons of Citlalicue.” Now,
Citlalicue means “Starry-skirt,” and I think that here we are not very far from Coatlicue, “Serpent-skirt.”
We know, too, that Citlalicue, like Coatlicue, was connected with the cipactli, the earth-beast, and with
Chicomecoatl (“Seven Serpents”). The later fusion of Citlalicue with her husband Citlaltonac or
Tonacatecutli, lord of the heavenly vault, as has been shown in the remarks on these gods, would give
her stellar attributes; hence the seeming discrepancy between her and Coatlicue. ↑
34 Appendix to bk. ii. ↑
35 Hist. de los Indios de la Nueva España, tom. ii, p. 240. ↑
36 See Rendel Harris, The Ascent of Olympus, passim. In his Ascent of Olympus Dr. Rendel Harris has
shown that the sacred oak of Zeus was regarded as “the animistic repository of the thunder, and in
that sense the dwelling-place of Zeus … that the woodpecker who nested in it … was none other than
Zeus himself, and it may turn out that Athena, who sprang from the head of the thunder-oak, was the owl
that lived in one of its hollows” (p. 57).
In the same way, it may be that the maguey plant may have been regarded by the Mexicans as a
repository of thunder and the heavenly fire. Octli, its sap, was connected with fire (see octli gods, “Nature
and Status”), and Uitzilopochtli was the humming-bird who dwelt among its leaves. He springs from his
mother’s body fully armed, as does Athena from the head of Zeus. A similar train of thought appears to
be present in both ideas. ↑
37 Manuel de Ministros, p. 35. ↑
38 Commentary on Codex Vaticanus B, p. 91. ↑
39 Maguey is an Antillean word imported into Mexico by the Spaniards, but the use of a post-Columbian
word does not exclude the possibility of a synonymous pre-Columbian form. ↑
40 Manuel de Ministros, p. 37. ↑
41 Myths of the New World, pp. 129 ff. ↑
42 Hist. Nat. Ind., c. ix, bk. v (English translation from Purchas his Pilgrimes). ↑
43 Obviously an error for tlachialoni. ↑
44 More probably like a jaguar, one of the forms of the god. ↑
45 See précis in chapter on Cosmogony. ↑
46 The Morelosia huañita of the family Styraciñes. ↑
47 Inga circinalis. ↑
48 Paper hand. ↑
49 Face of the temple. ↑
50 Young brother. ↑
51 Hist. Gen., bk. i. c. iii. ↑
52 Hist. Nat. y Moral, c. ix. ↑
53 Hist. Mex., English translation, vol. i, bk. vi, p. 243. ↑
54 Hist. Gen., bk. iii, c. vi–ix. ↑
55 These both mean the same thing, “shield of precious stones.” ↑
56 Diccionario Universal, Appendix, s.v. ↑
57 See ante, Aspect and Insignia. ↑
58 Commentary C. Fejérváry-Mayer, p. 34. ↑
59 See the Stone of Tizoc for examples of this practice. ↑
60 This figure conventionally represents the turkey and strikingly exhibits the large red wattles and lobe
of that bird. In most of the MSS. it wears Tezcatlipocâ’s smoking mirror at the temple, the warrior’s
headdress of heron-feathers, and in Codex Borbonicus it appears as a naualli or disguise of the god,
having his crown painted with stars and his anauatl or ring of mussel-shell. On sheet 6 of Codex
Fejérváry-Mayer the bird appears as an image of Tezcatlipocâ and is represented along with the signs of
mortification and blood-letting, as it is on sheet 17 of the Aubin tonalamatl, where it wears the bone-
piercer in its ears and a red robe edged with blue and brown. Indeed, it represents the blood-offering
connected with the worship of Tezcatlipocâ. The turkey-cock’s foot, too, is sometimes symbolic of the
god, and the interpretative codices tell us that “of the demons we often see nothing more than a cock’s or
eagle’s foot.” The turkey-cock is to be conceived as representative of rain, which was believed by the
Nahua to be nothing else than the magically altered blood he shed in penitence or sacrifice. It may be
that the red wattles and lobe of the turkey suggested the idea of blood, and that the shades in his
plumage were equally suggestive of water. Thus it would come to be regarded as the blood shed by the
stone knife of sacrifice. It is also obvious that Tezcatlipocâ’s patronage of slaves, who were strictly
regarded as his property, arose out of the idea that those unfortunates, whenever used for the purposes
of sacrificial ritual, constituted the “food” of the obsidian knife. ↑
61 Bk. xi, c. 8, § 5. ↑
62 Bernal Diaz also states that the eyes of Tezcatlipocâ’s idol were “mirrors.” See ante, “Aspect and
Insignia.” ↑
63 In the myth which recounts his discomfiture of the Toltecs it will be recalled that he rained stones upon
them. See also Introduction for identification of obsidian with wind and breath. ↑
64 Gomme, Ethnology in Folklore. ↑
65 Myth, Ritual, and Religion, vol. i, p. 266. ↑
66 See Itzlacoliuhqui, pp. 341 ff. ↑
67 See my article on “Cherokee Religion” in vol. iii, Encyclopædia of Religion and Ethics. ↑
68 Brinton, Myths of the New World. ↑
69 Sahagun, bk. xii, c. iv. ↑
70 Bk. iii, c. ii. ↑
71 Bk. xi, c. xlvii. ↑
72 Bk. v, c. ix. ↑
73 Seler, The Wall-paintings of Mitla, Bull. 28, Bureau of American Ethnology. ↑
74 “The swift ones who serrate the teeth.” ↑
75 “Mount of the crier.” ↑
76 Sahagun’s statement that the draught would make Quetzalcoatl remember those evils is obviously a
slip which even his copyist Torquemada is capable of avoiding. ↑
77 Bk. iii, c. 3 and 4. ↑
78 The names throughout the myth merely describe the incident which took place at the locality alluded
to. ↑
79 Sahagun, bk. iii, c. xii, xiii, xiv. ↑
80 Monarq. Ind., tom. ii, pp. 48–52. ↑
81 Monarq. Ind., tom. i, pp. 254–256. ↑
82 Hist. de los Indios. ↑
83 Hist. Ecles., pp. 82, 86, 92–93, 97–98. ↑
84 Hist. Ecles., p. 82. ↑
85 A Lacandone Indian tribe near Palenque. ↑
86 Land of Chivim. ↑
87 The myths relating to him under the name of Tohil appear to me to identify Tohil more with
Tezcatlipocâ. See Brassuer, Le Vuh Popol, passim. ↑
88The circumstance that the two high-priests of Mexico, the pontiffs of the cults of Uitzilopochtli and
Tlaloc, had the name Quetzalcoatl prefixed to their official descriptions merely indicates that it had
passed into a sacerdotal title. They were in no special sense attached to the worship of the god. ↑
89 He was, of course, all of these, but as regards the two latter, in a subsidiary sense only. ↑
90 Spanish, hurican; French, ouragan; English, hurricane. ↑
91 Sahagun reverses the process by calling Quetzalcoatl “a man who became a god,” bk. i, c. v. ↑
92 See my article on these books in vol. iii of Hastings’ Encyclopædia of Religion and Ethics. ↑
93This, too, accounts for his identification with the planet Venus, which also had a calendric connection,
and therefore as the herald of the dawn, and the child of the virgin goddess Chimalman or
Chalchihuitlicue in her guise as Moon-goddess. ↑
94Votan was likewise a builder of subterranean houses and was worshipped in caves. The god of the
rain-cult is, indeed, regarded as master of the streams which flow under the earth. See Brinton,
Nagualism, p. 41. ↑
[Contents]
CHAPTER IV
 THE CREATIVE DEITIES

[Contents]

TONACATECUTLI—TONACACIUATL
(TONACATECUTLI = “LORD OF OUR
SUBSISTENCE”)

Area of Worship: Mexico; originally Atlantic coastlands, the

Olmeca lands and Tlaxcallan. Anciently Toltec.
Minor Names:
Ometecutli = “Twofold lord.”
Tlachinale = “Lord of Creation.”
Tlatecque = “Lord of the Earthly World.”
Teotlale = “Lord of the Steppe.”
Matlaua = “Lord of the Net.”
Topeua = “Lord of the Mountains.”
Tloque Nahuaque = “Lord of the Close Vicinity.”
Relationship: Father of Quetzalcoatl.
Calendar Places: Ruler of the first day, ce cipactli, of the first
week and of the fourth day-hour.
Compass Direction: West.
Symbol: The human pair beneath the coverlet.

ASPECT AND INSIGNIA

Codex Vaticanus A.—In the Codex Vaticanus A Tonacatecutli’s

body-paint is red and pink. His headdress is bound by a fillet richly
encrusted with turquoises, having in front the conventional bird’s
head which is so frequently encountered in representations of the
Mexican gods in the codices. He wears the nasal ornament of
serpentine shape peculiar to the octli- or drink-gods, as to some of
the deities of fertility, and his fruitful or life-giving nature is
symbolized by a foot-stool composed of maize ears.

Codex Borgia.—In the Codex Borgia (sheet 61, lower half) the lower
portion of his face is painted red, but its upper [147]part, as well as the
rest of his body which is visible, is coloured yellow. On the cheek is
seen a rectangular surface divided into compartments, each of which
is tinted a different colour, the distinctive painting of the maize-gods,
which, it is believed, symbolizes the maize-field with its many hues.
A “gobber” tooth hangs from his mouth as a sign of great age, for as
creator he was regarded as one of the most venerable among the
gods. Around his forehead is a head-band enriched with precious
stones, which recalls that frequently worn by the Sun-god. His
necklet consists of a casket of jewels, with lid and feet, on which is
represented the symbol of the chalchihuitl jewel. 1 On sheet 60
Tonacaciuatl, the female form of this deity, is depicted in the act of
handing Tonacatecutli a flower, symbolic of life or blood. Above this
figure is the picture of a red snake, also symbolizing blood. The god
wears a jaguar-skin and the goddess an eagle’s, thus illustrating
their patronage of the military orders who wore those dresses. (For
similar readings, see Codex Laud, 34–5 K). In sheet 57 (lower right-
hand corner) he is represented as wearing a beard of black eagle-
feathers.

Codex Vaticanus B.—In Codex Vaticanus B (sheet 87) Tonacatecutli

is represented with Quetzalcoatl’s head and neck ornaments,
combined with the jewelled fillet and bird’s head on forehead. He
wears a long beard reaching to the feet.
[Contents]

TONACACIUATL = “LADY OF OUR SUBSISTENCE”

Minor Names:
Omeciuatl = “Twofold Lady.”
Citlalinicue = “Starry Skirt.”
Calendar Place: Same as that of Tonacatecutli.
Compass Direction: Same as that of Tonacatecutli.
Symbol: Same as that of Tonacatecutli.

ASPECT AND INSIGNIA

General.—In Codex Fejérváry-Mayer (sheet 10) the drawn-in angle

of the mouth and the female figure point to the inference that here is
depicted Tonacaciuatl, who is identified [148]by the interpreters with
Xochiquetzal. In Codex Telleriano-Remensis and Codex Vaticanus A
we find her standing in front of the male creative god Tonacatecutli.
In the latter MS. the first interpreter calls her Tonagacigua, and the
third Xochiquetzal, Oxomoco, and Chicomecohuatl. The picture
shown under the nineteenth week of Codex Telleriano-Remensis
pictures her with precisely the same dress and emblems as
Xochiquetzal (q.v.).

MYTHS

These deities were identified by the Mexicans with the Creator, the
Tloque Nahuaque, of whom almost every one of the post-Conquest
Spanish writers speaks. Indeed the Codex Telleriano-Remensis
expressly identifies them with the creative force. The passage runs:
“All those epithets (God, Lord, Creator) they bestowed on their god
Tonacatecutli, who, according to their account, was the god who
created the world; and they painted him alone with a crown as lord of
all. They never offered sacrifices to this god, for they said that he did
not regard them.” Of the female deity the Codex Vaticanus says:
“Tonacacigua was the wife of Tonacatecutle; for, as we have
observed, although their gods were not, as they affirm, united
together for matrimonial purposes, still they assigned to each a
goddess as a companion. They called her by another name,
Suchiquetzal and Chicomecoual, which means Seven Serpents, for
they say that she was the cause of sterility, famine, and all the
miseries of life.” 2

In further descriptive passages concerning Tonacatecutli the same

Codex says: “This is the representation of Tonacatecotle, which
name signifies the Lord of our Bodies; others say that it means the
First Man, or perhaps it means that the first man was so called.”
“These are the figures which have been mentioned; and the first is
that of their greatest god Tonacatecotle. It represented the first god
under whom they affirm was the dominion of the world; who, when it
appeared good to him, breathed and divided the waters of [149]the
heavens and the earth, which at first were all confused together, and
disposed of them as they now are; and accordingly they called him
Lord of our Bodies; and also of abundance, who bestowed
everything upon them; and on this account they paint him alone with
a crown. They called him besides Seven Flowers, for they say that
he disposes of the principalities of the earth. He had no temple, nor
did they offer sacrifices to him, for they say that he did not require
them, as if on account of his superior majesty.… They say that
Tonacatecotle presided over the thirteen signs which are here
marked (the day-signs of the tonalamatl, q.v.). Those above denote
the thirteen causes or influences of the sky which are under
subjection to him, and the others below are the thirteen signs of their
superstition and sorcery. This man and woman represent the first
pair who existed in the world; their names are Huehue (very old
ones). Between them is placed a knife or razor and an arrow above
each of their heads, typifying death, as in them death originated.”

“They called this god Tonacatecotli and by another name

Citallatonalli 3; and they said that he was the constellation which
appears by night in the sky, St. James’s or the Milky Way. They paint
these figures and all the others which follow, each of them in its own
manner; because as they considered them their deities, each had its
peculiar festival. It was necessary to wear in these festivals the habit
of the god.”

The Historia de los Mexicanos por sus Pinturas regards these deities
as appearing at the commencement of creation, but says nothing of
their relations to the precise creative act.

The Anales de Quauhtitlan says of them:

And they say

that in the inner heaven
he [Quetzalcoatl] dedicated a cult
and called on them:
her with the star-studded robe, together with the astral Sun-god.
the mistress of our flesh, the lord of our flesh,
who is clothed in charcoal, clothed in blood,
who giveth food to the earth; [150]
and he cried aloft
—as they (the old people) were informed—
to the Omeyocan,
to the heaven lying above the nine that are bound together.
And—as they learnt—
those having their abode there,
those he called upon, those he worshipped.
(See also chapter on Cosmogony for further mythical material
relating to these deities.)

NATURE AND STATUS

In examining the characteristics of these deities we find:

(1) That they were among the oldest of the Mexican divinities.
Tonacatecutli is called, among other names, “Lord of the Steppe,” 4
which does not necessarily indicate that he was a deity of the
Chichimec or hunting tribes, who from generation to generation
raided the Mexican valley, but may apply to his stellar or heavenly
significance. Reference is also made in the Anales de Quauhtitlan to
the circumstance that he and his female counterpart were gods of
the ancient Toltecs, and that their cult was founded by Quetzalcoatl,
the typical Toltec priest-king.

(2) That these gods were regarded by the Mexican priesthood in

more modern times at least, as abstractions, ideal beings who arose
out of philosophic speculation. That they had become rather
neglected in the popular Mexican faith is clear from the circumstance
that they had no temples and that no offerings were made them.
Tonacatecutli represented, indeed, that great invisible and intangible
figure which at all times and in all religions has loomed behind most
pantheons—the great god behind the gods—the principle of
causality, that first cause beyond which the speculations of theology
cannot proceed.

(3) They presided over the food supply. Although other deities
occupied the positions of maize and vegetable gods, the creative
deities were in the ultimate the great givers of all food. Thus they
were designated “Lords of Food Supplies” and “Lords of
Superabundance.” [151]

(4) They must be regarded as the direct creators of the spirit of man.
To the Mexican man flesh was merely maize in another form. But
apart from this conception the pair typified the first human couple,
and as such they are represented in all the MSS. lying side by side
and cross-legged under a blanket, in the attitude of procreation.
They are, indeed, the great initiators of life, and must be
comprehended as sending the human soul to occupy the body made
by human procreation, giving warmth and breath to the infant before
birth. 5

(5) They commence the series of twenty day-signs, and this alone
symbolizes their creative and original nature.

(6) They represent the sign cipactli, the animal from which the earth
was made.

(7) They are gods of the Omeyocan, the highest or thirteenth

heaven, which fact further illustrates their supreme character.

CONCLUSIONS

From these facts we may be justified in concluding:

(1) That in the most early times Tonacatecutli and his consort typified
the father-sky and mother-earth respectively, but that this aspect of
them had been forgotten and they came to have a purely abstract
creative significance for both priests and people. That Tonacaciuatl
originally represented the earth there is no doubt, and her
identification with Xochiquetzal and Chicomecoatl alone would show
this to be so. Again, the association with the sign cipactli proves the
connection of one of the divine pair with the earth, and from what
has been said regarding this sign in the introduction, and by the
constant association of goddesses in the Mexican mind with the
terrestrial sphere, it is plain that Tonacatecutli, her male counterpart,
is not likely to have represented it in early times. The suggestion that
he symbolizes the sky is perhaps assisted by the nature of his
abode, the uppermost heaven, and from his close identification with
Citlallatonac, [152]the god of the night heaven, who was supposed to
represent the Milky Way.

(2) That in later times the early concepts of these divinities became
fused almost into one, and that in some measure they had come to
be regarded as androgynous. This view may be traversed by the
circumstance that they are frequently represented separately, but on
the other hand their names appear as one in the form Tonacatecutli-
Tonacaciuatl in many passages. The same may be posited of their
counterparts in the Quiche Popol Vuh, Xpiyacoc and Xmucane. 6

Tonacatecutli and his spouse are to be regarded as the parents of

Quetzalcoatl, but this is probably a theogonic myth of late origin,
brought about by the constant association of Quetzalcoatl with the
creative gods as deities of the ancient Toltecs, and the frequent
references to him as the founder of their cult.

Ixtlilxochitl states in his fourth Relacion that Tonacatecutli and his

wife were the chief gods of the Toltecs, who represented them as the
sun and the moon, and he goes on to say that at certain seasons of
the year criminals were sacrificed to them by a method called
Telimonamiquian, “which is to say grinding between the stones.” Two
great stones, he says, were balanced opposite each other, and the
victim was crushed between them as they fell—the slain man thus
representing the corn-spirit, or, indeed, the corn itself in the process
of being ground. [153]

1 A generic name for green precious or semi-precious stones—turquoise, jadeite,

nephrite, emerald, etc. ↑
2 In Kingsborough, Antiquities of Mexico, vol. vi. ↑
3 On this identification see also Torquemada, bk. vi, c. xix. ↑
4 Codex Telleriano-Remensis. ↑
5 Seler, Codex Vaticanus B, p. 132. ↑
6 Spence, Popol Vuh. London, 1908. ↑
[Contents]
CHAPTER V
 DEITIES OF THE EARTH AND GROWTH PROPER

[Contents]

INTRODUCTORY

So numerous were the manifestations and variants of the Earth-goddess conceived by the Nahua or
adopted into their pantheon, that this has been the cause of considerable misconception on the part of
students of Mexican religion, who have confounded them in a manner which in the circumstances is
scarcely surprising. An attempt will be made here to provide the reader with a list of the most important
of these deities, briefly and barely outlining their various origins and attributes, in order that he may be
the better able to comprehend what follows when we come to discuss them more fully.

Chicomecoatl (Seven Serpents)—the Mexican name of the Earth-goddess and that of the seventh day
of the seventh week of the tonalamatl. She was probably of Toltec origin. The third interpreter of the
Codex Vaticanus A identifies her with Xochiquetzal, and, perhaps more correctly, with Xumoco and
Tonacacigua or Tonacaciuatl. She had two temples dedicated to her, the chicome iteopan and the
cinteopan, and seems to have become a variant of Tonacaciuatl on the adoption of an agricultural basis
of existence.

Tlazolteotl, Tlaelquani, Teteo innan or Toci—an earth-goddess whose worship had its origin among the
tribes of the Atlantic seaboard, where maize grew abundantly. She possessed warlike propensities, as
became a goddess to whom human sacrifice was much in vogue, and the myth of her impregnation by
Uitzilopochtli was enacted at the ochpaniztli festival in August, typifying, perhaps, the impregnation of
[154]the “earth-mother” by the “sky-father.” As Ixcuine she represented a plurality of goddesses. Seler 1
believes that Chicomecoatl represents the young maize ear, and Tlazolteotl, the ripe ear of the plant.

Cihuacoatl (Serpent Woman)—an earth-goddess of Xochimilco and Colhuacan.

Coatlicue or Coatlantonan (Serpent Skirt)—a Mexican earth-goddess, mother of Uitzilopochtli.

Xochiquetzal—originally a mountain goddess of the Tlalhuica. An earth-and-maize goddess as well as a

deity of flowers and vegetation.

Xilonen—originally a maize-goddess of the Huichol tribes. She represented the young maize-plant.

Cinteotl (Maize-god)—son of Tlazolteotl, originally a god of the peoples of the Atlantic seaboard. He is
occasionally alluded to as a female deity, but is always male in the MSS. of the Borgia group, executed
by a people of Nahua speech dwelling in the south. He is the equivalent of Xochipilli and had a separate
temple, the cinteopan.

Xipe—an earth-god of the Teotitlan district, a god of spring vegetation. His temples were called yopico.
His great festival was the Tlacaxipeuliztli, or “flaying of men.”

Only three of these deities, Tlazolteotl, Xipe, and Xochiquetzal, appear as rulers of one or other of the
twenty day-signs of the tonalamatl. But Cinteotl figures in the ochpaniztli feast and appears as one of
the “Lords of the Night.”