SUBJECT: INTRODUCTION TO THE STUDY OF MEDICINE

ACTIVITY N 4: INTEGRATIVE WORK AREAS EPISTEMOLOGY - APS 1

Prof. Dr. Roxana Quintana Prof. Mg. M. Gabriela Monteverde
STUDENT'S LAST NAME AND FIRST NAME: Andrade Cavalcante, Nadyne

READ THE INSTRUCTIONS CAREFULLY.

1) WATCH THE MOVIE "AWAKENINGS" (1990) STARRING: ROBIN WILLIAMS AND ROBERT DE
NIRO. (NETFLIX- YOUTUBE- OTHERS)
Original Title: Awakenings. Director: Penny Marshall. Country: United States.
Year: 1990.
Length: 121 min.
Genre: Drama, biographical.
Starring: Robert De Niro, Robin Williams, Julie Kavner, Ruth Nelson, John Heard, Penelope Ann
Miller, Alice Drummond, Judith Malina, Barton Heyman, George Martin. Screenplay: Steven
Zaillian.
Production Company: Columbia Pictures Corporation, Parkes/Lasker productions.
Photography: Miroslav Ondricek.
Editing: Gerald B. Greenberg.
Spanish premiere: March 15, 1991.

2) MAKE A DESCRIPTION OF THE TOPICS COVERED IN THE FILM, APPLYING THE

CONCEPTS/CONTENTS CORRESPONDING TO THE 4 MODULES OF THE EPISTEMOLOGY AREA
AND THE 4 UNITS OF APS 1.

In the epistemological we have the concept of Scientific Knowledge that are fundamental to
perform all the work;

a) Points of connection between what was seen in the film and what was prepared to
prepare:
Activation of a protocol when Leonard is ill. It starts with the care protocol, when the new
physician arrives and has to treat you, followed by the research protocol, when the
physician experiments with different quantities and treatments up to the one where
patients react. And finally, the evaluation protocol, when it evaluates the effects of the
drugs on the different patients.

b) Assessment of physician's performance in clinical trial protocols

The doctor took an early interest in Leonard and compares his situation and symptoms
with those of the other patients who were admitted to the hospital. He conducts an
investigation, which leads him to conclude that patients react to certain stimuli, such as
reacting to music, to hearing their names, etc. Observing this, he begins to look for
common factors in the past of these patients, he develops a hypothesis: all patients have
suffered from meningitis in the past, and Dr. Sacks believes that this disease causes
symptoms similar to Parkinson's disease, but that the symptoms are so accentuated that it
causes the patients total immobility. Thereafter, Dr. Sacks began experimenting with the
drug L-Dopa.
The hypothesis could have been wrong and could have caused the death of one of the
patients.
 c) Identification in the film of the steps of the scientific method:

1. Observation: When Dr. Sayer arrives new to the hospital, he starts this sentence,
from the first moment he dedicates himself to observe, to look at these patients
that called his attention, those who had the disease encephalitis lethargica.

2. Hypothesis: Consists in elaborating a provisional explanation of the observed facts

and their possible causes. Dr. Sacks elaborated a hypothesis "all patients have
suffered at some point in their lives from meningitis, so this is the common factor
that has led them to this situation. The immobility of their bodies is because they
have the same symptoms as Parkinson's disease, but so exaggerated that it causes
them to stiffen their bodies and become immobile." O After observing, the doctor,
dedicated himself to shuffle a hypothesis, with the small data, and concepts that he
had about the disease, he shuffled the possibility that this disease had a
relationship with Parkinson's, its symptoms were very similar.The symptoms were
very similar, so he wanted to experiment with a drug that had a direct relationship
with Parkinson's but so far had none with encephalitis lethargica.

3. Experimentation: Dr. Sacks begins a treatment for Leonard by supplying him with
L-Dopa. The first doses had no effect, but as the dose was increased, the results of
the experiments were successful and the hypothesis formulated, which proposed to
use a medicine related to a similar disease such as Parkinson's, is used to
experiment the effects it produces in patients with encephalitis lethargica and thus
determine whether it is effective or not.

4. Conclusion: Then, by confirming or denying the hypothesis through the

experiment, conclusions can be drawn, which in this case are: the drug L-DOPA
only cures the disease of encephalitis lethargica for a period of time, but as well as
this positive effect, there is also the negative one that leads certain patients not to
follow a normal life despite being "awake".

3) USE THE BIBLIOGRAPHY OF EACH AREA (EPISTEMOLOGY AND APS 1) OF THE SUBJECT TO
MAKE THE CITATIONS (AUTHORS/REFERENTS) AND BIBLIOGRAPHIC REFERENCES.

 He started quoting the effects of the drug, which were only temporary, his activity
did not cease to be science, even with the characteristics of scientific knowledge as
systematic, accurate and rational, it continues to be very fallible, and, thus, needs to
be verified, as taught by Quintana, R., & Monteverde, M. G. (2020, p. 32).
 In the film, the doctor's work followed the scientific method applied to medicine,
which, according to Monteverde, M. G., & Quintana, R. (2020, p. 12) must follow the
steps, respectively: observation, hypothesis, experimentation, conclusion.
 We observed that the method used in the research was the inductive method, since
this part, according to Monteverde, M. G., & Quintana, R. (2020, p. 22), of an exact
observation of particular phenomena of a sick person, which is done by the
physician.
  According to Monteverde, M. G., & Quintana, R. (n.d., p. 19), one of the general rules
of clinical research is the need for ethical-legal considerations. In the film, the doctor
is right to seek permission from a relative of Leonard's and the hospital
administration to begin investigations. However, the physician's behavior of
increasing the patient's dosage without the authorization of the person legally
responsible for the incapacitated person may be considered an illegal attitude.
 Also regarding the communication of research results, this can be classified as
immediate personal, since, according to the definition of R. Quintana, M. G.
Monteverde (n.d., 10), which is characterized as an interaction between sender and
receiver.
 We note that the levels of prevention, according to the definitions of Giménez, J.,
were also addressed. C., Piwen, M. C., Monteverde, G., & Doria, R. (2020, p. 8): the
tertiary, which takes care of a rehabilitation attempt; and, with the discovery of L-
Dopa treatment, there was a timely treatment attempt, characterizing secondary
prevention.

4) MAKE A CONCLUSION, FROM THE BASES OF THE APS, THAT HAVE NOT BEEN VISUALIZED IN
THE DEVELOPMENT OF THE CONTENT OF THE FILM, IN FUNCTION OF THE IMPROVEMENT OF
THE PATIENT'S QUALITY OF LIFE.

The first thing you notice is that, as the film begins, all these factors are controlled by the
nurses and doctors in the hospital. However, after all the patients wake up, the psychosocial
factors become more complex, even leading to attempts to revolt against the hospital
administration, generating a revolt among the sick.
Also, depending on the concept of health used, the change in the picture of the treated
patients can be observed in a different way in relation to their health improvements.
Guided by the definitions of health, according to Piwen, C., & Giménez, J. C. (pp. 2 y 5, 2020):
Classical conception (negative definition): health is a state of total absence of disease and
disability;
2. Utopian conception: adopted by the WHO in 1946, it considers health as a "state of
complete physical, mental and social well-being, and not merely the absence of disease or
infirmity"; and
3. Dynamic conception: greeting would be a dynamic state of well-being in the physical,
social and mental aspects.
In the classical definition of health, it could be considered that sick people had a
transient moment of health, since they were outside the state of disability at the beginning
of the treatment. Already by the utopian definition, the conception is the opposite: the
patients never had a state of health, because, even with the improvement provided by L-
Dopa, they never achieved a complete social well-being. In the dynamic conception, it would
be unknown whether the patients were healthy, since the social aspect was too much
affected by the decades of catatonism of the patients, and the apparent absence of
specialized personnel for the reintegration of the mentally ill.
That is, a big mistake of the sanatorium. The World Health Organization (1997, pp. 3 and 9)
states that health "is about empowering people to exercise greater control over and improve
their health," and that "Empowering each person requires secure and more consistent
access to decision-making and the knowledge and skills to effect change. Moreover, that this
increased self-control is observed in scenes such as Leonard brushing his own teeth alone or
making friends, it can be seen that the sanatorium had no plan for the reintegration of the
recovered patients into society, as well as a wide range of professionals necessary for such a
new situation, such as psychologists or social workers, were not observed, both for the
patients and their families.In addition, the fact that this increased self-control is observed in
scenes such as Leonard's brushing his own teeth alone or making friends, shows that the
sanatorium had no plan for the reintegration of the recovered patients into society, just as
the actions of a wide range of professionals necessary for such a new situation, such as
psychologists or social workers, both for the patients and their families, were not observed.
That is compounded when you see that the World Health Organization, Health and Welfare
Canada, & Canadian Public Health Association (1986 pp. 2), health promotion must ensure
and provide the means for the entire population to develop its full potential.
Finally, improvements in the quality of life of the sick should not be seen in a purely
biological way. In addition to the advances made in the last decades, the integral health of
the human being must also work on his or her psychological health.

SUMMARY OF THE MOVIE "AWAKENINGS".

SYNOPSIS

Film based on the autobiography of neurologist Oliver Sacks. "Awakenings" tells the true story
of the discovery, in 1969, of a drug called L-dopa and its application to catatonic patients who
survived the epidemic of lethargic encephalitis that occurred between 1917-1928.
Film project directed by Penny Marshall, director of "Big" (1988) and "The Men in My Life"
(2001), and based on the book of the same title by Oliver Sacks. It received three nominations
at the 62nd Academy Awards (1990): Best Picture, Best Leading Actor (Robert De Niro), and
Best Adapted Screenplay (Steven Zaillian). The soundtrack is a masterpiece in itself. Highly
praised by international critics, it turns out to be an exquisite combination of orchestral pieces
with the piano as the main standard in the main melodies. Randy Newman does a magnificent
job throughout the film, perfectly combining images and plot.
Oliver Sacks is played by a masterful Robin Williams as Malcolm Sayer. Dr. Sayer is a medical
researcher who has been involved in animal experimentation studies throughout his
professional career. Finally, he gets a job in a New York hospital, where he begins to care for
patients who are in an irreversible vegetative state. His patients are vigilant, yet disconnected
from the world. They also present an absolute loss of voluntary movements and sometimes
some of them adopt fixed postures as if they were real "wax statues". The film shows us a
professional absolutely devoted to his profession and to the continuous care of his patients.
One morning he watches in a patient room as one of the patients instinctively picks up his
glasses before they reach the floor. At that time, Dr. Sayer began to investigate with even
more emphasis on the disease suffered by his patients and began to formulate hypotheses
about its possible causes and, above all, its treatment. The way to achieve this is not

He has to fight against the skepticism of his colleagues, his superiors and the patients'
relatives, among others. Almost everyone is suspicious of his theory in which he advocates the
high chances of "waking up" his patients from their chronic lethargy as well as the possibility of
them regaining their previous quality of life with proper treatment.
Among his various trials, he is working with a newly discovered pharmacological substance, L-
dopa, which is used for the treatment of Parkinson's disease. He decides to test it initially with
one of his patients, Mr. Leonard Lowe (Robert De Niro). After many failed attempts, one night
Leonard "wakes up". From then on, the doctor received recognition from his colleagues,
managers and relatives of those affected, and even received financial support, thanks to which
he was able to start treating all his patients with this drug. Problems arise again when Mr.
Leonard's symptoms return, and both the doctor and his patients and family are deeply
affected. As patients "wake up", a true doctor-patient relationship begins to develop; on the
one hand, patients feel very grateful and, not least, they have great confidence in their
physician, Dr. Sayer. On the other hand, it "awakens" the more human side of the physician
whose previous professional experience was only in the field of research and scientific
method. It is the "awakening" of the patients that generates the "change" in the doctor; his
professional ambitions take second place to the well-being of his patients. For his part, the
physician, without being fully aware of it, improves his interpersonal relationships in a
qualitative and quantitative way. Without a doubt, Mr. Leonard and Dr. Mayer's relationship
turns out to be "magical" and the two end up getting to know each other very well. Thus, for
example, at the end of the film, when Mr. Leonard relapses, Dr. Sayer, aware of the interest
shown by his patient in knowing "the reality" of his process, informs the patient of the current
state of his illness. He explains it to you in a clear, close and unhurried language, while
explaining that he will provide you with the best treatments within his possibilities. All of this
seems quite normal to us today and even the laws of the so-called "developed" countries
reflect it, but at that time when the film is recreated, it was not so usual and much less was it
recognized by law. Another remarkable aspect of this film is that Dr. Sayer does not take his
patients' relapse as a failure. This is very important in all areas, but especially in the area of
care and attention to the sick. The attitude of all physicians in this type of situation should be
to admit their own mistakes and understand the limitations of science, which unfortunately
does not cure everything.
Encephalitis lethargica
Also called epidemic encephalitis, Von Economo's disease or sleeping sickness. He made his
debut as an epidemic between 1915 and 1928. It usually presented with acute inflammation of
the pharynx followed by sleep disturbances, movement disorders and psychiatric disturbances.
Despite the temporal association between encephalitis lethargica and the 1918 influenza
epidemic, no association between the two processes has been demonstrated. It was thought
for some time that the cause of this disease could be due to a virus and it was considered that
vaccination of the population against influenza or other viruses could in turn prevent this
disease. The truth is that many of the cases Dr. Sacks treated at that time were previously
diagnosed with schizophrenia.

catatonic. The film does not investigate the etiology of this strange disease. Instead, the
diagnosis appears as an important part of Dr. Sayer's investigation and he discovers a common
link in all his patients, a previous encephalitis lethargica.
Signs and symptoms
Most of the patients had symptoms of parkinsonism. Parkinson's disease is a degenerative
disorder of the central nervous system with no known clear cause. There are some cases
where the cause is known or suspected or where the symptoms are a consequence of another
disorder, then called secondary parkinsonisms. Exposure to an infectious agent, as responsible
for the pandemic encephalitis lethargica, has been recognized as a cause of parkinsonism, and
was even considered for some time as the primary cause of Parkinson's disease. Symptoms of
this disease include fever, excessive sleepiness (hypersomnolence) of long standing and
ophthalmoparesis (paralysis of one or more extraocular muscles responsible for eye
movements), followed by parkinsonian symptoms: inability to initiate movement (akinesia),
rigidity, tremor and postural disorders. These accompanying signs include involuntary eye
movements, eyelid twitching, jaw tremor, open-mouth posturing, movement disorders,
inability to hold still (akathisia), abnormal tic-like movements, central respiratory
abnormalities, excessive sweating and saliva production, skin peeling, low blood pressure,
sexual disturbances, joint pain, depression, dementia-like cognitive impairment, fatigue and
gait disturbances.and saliva production, skin desquamation, low blood pressure, sexual
disorders, joint pain, depression, dementia-like cognitive impairment, fatigue and gait
disturbances. Akinesia or bradykinesia is a highly disabling slowing of movement. It frequently
affects some complex movements such as writing, oral language, the normal swinging of the
arms when walking or facial expression. The tremor usually occurs at rest. It usually affects the
hands, arms, legs and jaw or head. Stiffness consists of a permanent contracture of the muscle
groups, which results in increased difficulty in mobilizing the joints and trunk. Postural
disorders usually appear in the advanced stages of this disease. The patient's usual posture
tends to forward flexion of the trunk and head. Therefore, postural instability is relatively
frequent in these patients. Gait is also altered, with a tendency to propulsion and short steps
(festination) and decreased arm swing. Oculogyric crises, characteristic of encephalitis
lethargica, consist of a tonic deviation in the position of the head and eyes that occurs
sporadically and can last from minutes to hours. Normally, patients look supero-laterally and it
is accompanied by other movement disorders as mentioned above. Sometimes these
abnormal movements include trunk and limb movements.
Treatment
The therapy for Parkinson's disease is the drug Levodopa (or L-dopa). It is the most effective
drug for the treatment of this pathology and at some point all patients will need to take it.
Improvement of some symptoms such as stiffness, slowing of movements, gait impairment,
loss of facial expressiveness (hypomimia).

and excessively tiny handwriting (micrographia), and to a lesser extent tremor, only in the
early stages of the disease. Symptoms such as postural instability and various neurosensory
problems are not as responsive. The response to treatment is rapid, so that if patients do not
improve with doses of 1,000 mg/day, it should be thought that it is not idiopathic Parkinson's
disease, but secondary parkinsonism, as shown in the film. In addition, a wide variety of
supportive and complementary therapies can be used for Parkinson's disease, such as physical,
occupational and speech therapies, which can help with problems such as gait and voice
disorders, tremor and rigidity, and cognitive impairment. According to several studies on the
side effects of Levo-dopa, at least part of the neurological damage seen in patients suffering
from encephalitis lethargica seems to be caused not by the drug itself, but by other substances
derived from the metabolization of this medication.

References

Giménez, J. C., Piwen, M. C., Monteverde, G., & Doria, R. (2020). APS I: Theoretical Note.
Barceló Foundation. https://distancia.barcelo.edu.ar/pluginfile.php/94558/mod_resource/
content/1/APS I - APUNTTE.pdf
Monteverde, M. G., & R., Q. (s. f.). Chapter 3 - Scientific Method applied to Research. Barceló
Foundation. Retrieved October 27, 2020, from
https://distancia.barcelo.edu.ar/pluginfile.php/148138/mod_resource/content/1/
EPISTEMOLOGIA 3 scientific method applied to research.pdf
Monteverde, M. G., & Quintana, R. (2020). Module 2 - Scientific Method. Barceló Foundation.
https://distancia.barcelo.edu.ar/pluginfile.php/111063/mod_resource/content/1/
EPISTEMOLOGIA 2 scientific method.pdf
Piwen, C., & Giménez, J. C. (2020). Class 1 Concept of Health - part 1 - with audio. Barceló
Foundation. https://distancia.barcelo.edu.ar/mod/resource/view.php?id=66113
Quintana, R., & Monteverde, M. G. (s. f.). Chapter 4 - Interpretation and communication of
results. Barceló Foundation. Retrieved October 27, 2020, from
https://distancia.barcelo.edu.ar/pluginfile.php/170296/mod_resource/content/1/
EPISTEMOLOGIA_5_ interpretation_and_communication_of_results.pdf.
Quintana, R., & Monteverde, M. G. (2020). Chapter I - Scientific Knowledge. Barceló
Foundation. https://distancia.barcelo.edu.ar/pluginfile.php/98967/mod_resource/content/1/
EPISTEMOLOGIA 1 scientific knowledge.pdf