Gasex

By R. Daryl. Savannah College of Art and Design.

The scares took off when doctors’ own anxieties led them to turn to their contacts with government and the media to generate wider publicity around the focus of their concerns purchase 100 caps gasex amex gastritis diet honey. A number of factors have encouraged medical and scientific experts to project their anxieties into the public realm generic 100 caps gasex gastritis quick fix. One is the wider crisis of medical confidence in tackling the ‘modern epidemics’ of coronary heart disease and cancer, now that the threat of infectious diseases has receded. In the 1970s and 1980s, the recognition that effective treatments for these conditions remained elusive led to a swing towards health promotion in the cause of prevention, the subject of the next two chapters. The emergence of Aids, ironically an infectious disease, but one for which neither vaccine nor treatment appeared likely to emerge in the near future, struck terror into the hearts of doctors throughout the West. Their immediate response was to put their hopes in raising public awareness of the danger of epidemic transmission. In the case of Aids in Britain, given the low incidence of HIV infection in the late 1980s, the fact that it is a fragile virus that is fairly difficult to transmit, and given also that it remained virtually exclusive to clearly 29 HEALTH SCARES AND MORAL PANICS defined high-risk populations, the risks of a major epidemic were negligible. However, the medical establishment’s anxieties about Aids, transmitted to the government, contributed to an official campaign that grossly exaggerated public risks and thereby exacerbated popular anxieties. The unfolding mad cow panic revealed the increasing irrationality of expert advice to the government and its consequences. When in early 1996, after some years of dismissing suggestions of a link between BSE and CJD, the scientists first noticed a handful of cases that raised this as a real possibility, they were understandably rattled. But instead of calming them down and encouraging further research, ministers themselves panicked and made dramatic public statements which did nothing to reduce risk, but had the effect of inducing mass anxiety and causing the collapse of the beef trade. In December 1997, some twenty months after the initial panic, the government’s committee of scientific and medical experts discussed a preliminary report of research which suggested the remote possibility that BSE could be transmitted in dorsal root ganglia (tiny knots of nerve tissue close to the spinal cord) of cattle slaughtered for consumption as beef (Fitzpatrick February 1998) The report estimated that in 1997 some six infected animals might get through the system, and in 1998 possibly three (out of more than two million cattle slaughtered). The committee noted that before the system was tightened up in 1988– 89, the figure was many thousand times greater. In response to the expert advice that emerged from these deliberations, the government immediately banned the sale of ‘beef on the bone’ (which might contain a microscopic amount of BSE infectivity in its dorsal root ganglia), though we were all eating BSE-infected beef by the plateful in the late 1980s (which may or may not have been a factor in the twenty-three cases of nvCJD which had been identified up to the end of 1997). The interaction between scientists and politicians appeared to amplify insecurities on both sides, leading to policy of increasing absurdity. The role of the media in relation to all the major health scares, and most of the minor ones, has been secondary to that of the medical and political authorities. In the past, investigative journalists have exposed the dangers of medical treatments, such as Thalidomide in the 1960s and the Dalkon shield, an intra-uterine contraceptive device (coil), in the 1970s. Recent health scares usually emanate from official—medical, scientific, government—sources, and are amplified by news media which are sensitive to the public resonance 30 HEALTH SCARES AND MORAL PANICS for such stories. Far from being critical of the medical and political establishments, media coverage of most of the major scares has been strikingly subservient to the official agenda. In relation to the HIV/ Aids panic in particular, the overwhelming bulk of the vast journalistic output has been dedicated to amplifying the themes proclaimed by health ministers and their prominent medical advisers. Indeed when critical articles have appeared, these have been either attacks on the government for not promoting the panic vigorously enough, or directed against critics of the official line like Duesberg, who have been characterised, in a revealing choice of metaphor, as ‘Aids heretics’. In some recent cases, such as MMR- autism, silicone implants, Gulf War syndrome, scares have been encouraged by lawyers pursuing ‘class actions’ in pursuit of compensation for illnesses alleged to result from diverse toxins. Though the public cannot be fairly blamed for initiating health scares, its ready response certainly revealed a predisposition to panic. The popular appetite for health scare stories and the generally postive public response to related government health promotion initiatives indicated a climate of opinion that was both vulnerable to health-related anxieties and sympathetic to official intervention in the cause of curtailing threats to health. The role of government Up to the late 1980s (with the exception of wartime) governments in Britain have always been reluctant to interfere in the personal behaviour of citizens, even in the cause of improving health. This reluctance can be traced back to nineteenth-century traditions of liberal resistance to quarantines and other measures of state repression to prevent the spread of infectious epidemics. Such policies were favoured by the absolutist dictatorships on the European continent, but were regarded as anathema to capitalist principles of individual freedom (especially in matters of trade). Yet these traditions were cast aside in the great health scares of the last decade, in the government’s quest for enhanced popularity and authority. In the run up to the 1982 Conservative Party conference, Mrs Thatcher was obliged to reassure the public that ‘the NHS is safe with us’, following the leak of proposals for privatisation of health care drawn up by an influential right-wing think tank (Timmins 1995:393).

Surgical intervention: needle and surgical cricothyrotomy In situations in which the vocal cords remain obstructed—for example purchase gasex 100caps on line gastritis y sus sintomas, by a foreign body buy 100caps gasex with visa gastritis young living, maxillofacial trauma, extrinsic pressure, or inflammation—and the patient can neither self-ventilate nor be ventilated using the airway adjuncts discussed below, urgent recourse to needle jet ventilation or surgical cricothyrotomy, or both, should be considered. Narrow-bore oxygen tubing connected to a wall or cylinder flowmeter supplying oxygen up to 4 bar/60p. A hole 27 ABC of Resuscitation cut in the oxygen tubing enables finger tip control of ventilation. Minimise barotrauma or pneumothorax by maintaining a one second:four second inflation to exhalation cycle to allow adequate time for expiration. A second open transcricoid needle or cannula may facilitate expiration but spontaneous ventilation by this route will be inadequate and strenuous inspiratory efforts will rapidly induce pulmonary oedema. Beware of jet needle displacement resulting in obstruction, gastric distension, pharyngeal or mediastinal perforation, and surgical emphysema. Jet ventilation can maintain reasonable oxygenation for up Hand operated to 45 minutes despite rising CO levels until a cricothrotomy or pump 2 definitive tracheostomy can be performed. If needle jet ventilation is unavailable or is ineffective, cricothyrotomy may be life saving and should not be unduly delayed. In the absence of surgical instruments any strong knife, scissors point, large bore cannula, or similar instrument can be used to create an opening through the cricothyroid membrane. An opening of 5-7mm diameter is made and needs to be maintained with an appropriate hollow tube or airway. Tracheostomy is time consuming and difficult to perform well in emergency situations. It is best undertaken as a formal surgical procedure under optimum conditions. Jet ventilation is preferred to cricothyrotomy when the patient is less than 12 years of age. Foot pump Airway support and ventilation devices Hygiene considerations Because of concerns about transmissible viral or bacterial Resuscitation airways may be used to infections, demand has increased for airway adjuncts that ensure airway patency or isolation, to prevent direct patient and rescuer contact. This subject is provide a port for positive pressure considered further in Chapter 18. Although these devices are compact and inexpensive, they generally do not seal effectively nor maintain airway patency, and may present a high inspiratory resistance, especially when wet. Using an anaesthetic style disposable filter heat and moisture exchanger device on the airway devices described below affords additional protection to patient and rescuer and prevents contamination of self-inflating bags and other equipment. Tongue support The oral Guedel airway improves airway patency but requires supplementary jaw support. A short airway will fail to support the tongue; a long airway may stimulate the epiglottis or larynx and induce vomiting or laryngospasm in lightly unconscious patients. Soft nasopharyngeal tubes are better tolerated but may cause nasopharyngeal bleeding, and they require some skill to insert. These simple airways do not protrude from the face and are therefore suitable for use in combination with mask ventilation. Life key and face Ventilation masks shield The use of a ventilation mask during expired air resuscitation, especially when it has a non-rebreathing valve or filter, offers the rescuer protection against direct patient contact. The rescuer seals the mask on the patient’s face using a firm 28 Airway control, ventilation, and oxygenation two-handed grip and blows through the mask while lifting the patient’s jaw. Transparent masks with well-fitting, air-filled cuffs provide an effective seal on the patient’s face and may incorporate valves through which the rescuer can conduct mouth-to-mask ventilation. Detachable valves are preferred, which leave a mask orifice of a standard size into which a self-inflating bag mount (outside diameter 22mm, inside diameter 15mm) may be fitted. Tidal volumes of 700-1000ml are currently recommended for expired air ventilation by mouth or mask in the absence Mouth-to-mask ventilation of supplementary oxygen. Given the difficulty experienced by most rescuers in achieving adequate tidal volumes by mouth or mask ventilation, such guidelines may be difficult to achieve in practice. If the casualty’s lips are opposed, only limited air flow may be possible through the nose, and obstructed expiration may be unrecognised in some patients. The insertion of oral or nasal airways is, therefore, advisable when using mask ventilation. Rescuers risk injury when performing mouth-to-mask ventilation in moving vehicles. Some rescue masks incorporate an inlet port for supplementary oxygen, although in an emergency an oxygen delivery tube can be introduced under the mask cuff or clenched in the rescuer’s mouth. Bag-valve devices Self-refilling manual resuscitation bags are available that attach Bag-valve-mask to a mask and facilitate bag-valve-mask (BVM) ventilation with ventilation air and supplementary oxygen.

One of his proudest days was in the summer of 1979 gasex 100caps fast delivery chronic gastritis flare up, when the American Academy of Orthopedic Surgeons sponsored a course in Indianapolis on resurfacing arthroplasty of the hip order gasex 100caps on line gastritis and duodenitis. He would internally stabilize intertrochanteric fractures on a standard operating table, using two plain radiographs to verify the correct position after placement of the nail. These nails were not cannulated, and the inferior fin was several millimeters longer than the other two. EICHER lectual stimulation and camaraderie, and traveled 1904–1988 frequently with fellow members to Europe and Canada. Eicher was an associate clinical professor in Berne, Indiana, to Mennonite parents whose of orthopedic surgery at the Indiana University ancestors came from Bern, Switzerland. He was at his fun-loving best attended Indiana University and received his MD with medical students, interns, and residents. After internship at Indianapolis and his wife, Pluma, often entertained students General Hospital, he began the practice of general and house staff in their home, and he greatly medicine, in 1933, in Decatur, Indiana. He repeatedly Had it not been for World War II, he probably insisted that the years of postgraduate training would not have chosen to enter orthopedic train- were the best because of the rapid pace of ing. He joined the United States Army Medical assimilation of knowledge and the absence of Corps in 1942 and served a tour of duty in the the socioeconomic pressures of practice. On returning to the United States, When Pluma died of neoplasia in January he requested assignment to an orthopedic service, 1978, Dr. In even if it meant that he would not receive a 1982, after a bilateral cataract operation, a urinary promotion. He was assigned to the orthopedic tract infection led to a brain abscess. Next came service at Cushing General Hospital, Springfield, a mitral valve replacement and then a mediastinal Massachusetts, of which Nelson Hatt was chief. Hatt for his innovative except the severe visual impairment, which was a ideas. Eicher attained the rank of Major before great setback because of his insatiable reading being discharged, in 1945. In addition to his wife, his oldest son, 1948, strong Hoosier ties brought Dr. A son, Dan, and a his family to Indianapolis, where he practiced daughter, Julie, survive. Eicher’s primary interest, and he became a pioneer in the develop- ment of the intramedullary stemmed femoral prosthesis. Müller in Saint Gallen, Switzerland, he became interested in the double-cup type of 94 Who’s Who in Orthopedics strengthened by his knowledge of medicine in general, of medical administration, of public affairs and by his ability to assess the characters of other men. Ellis was, above all, a wise man and he possessed the urbanity and detachment that would have made him a good judge or colonial governor. Yet these qualities were not such as to attract the attention of the crowd or even of the profession at large. He was not a brilliant inno- vator or a popular orator, and his talents were con- cealed by a natural reserve that could be a little forbidding. Those who knew him well instinctively sought his opinion, and even his verdict, not only on clini- cal problems but on difficult matters of adminis- tration. It was natural that he found himself on the governing bodies of both of his teaching hospitals and he was chairman of the Medical Committee Valentine Herbert ELLIS of the Royal National Orthopedic Hospital and of 1901–1953 the Academic Board of the Institute of Orthope- dics. His colleagues in the Institute had particular Valentine Herbert Ellis was born in India on reason to be grateful to him; a young postgradu- February 24, 1901, and was the son of Major- ate school is very vulnerable to the influence of General Philip Ellis of the Army Medical Service. He gradu- the great weight of his authority to keep the ated in 1925, became a Fellow of the Royal course steady and the pace even. When he spoke College of Surgeons of England in 1928 and at as treasurer of the British Orthopedic Association, about that time turned his attention to orthope- he was no tame book-keeper but a maker of dics. He would have been one of the associa- National Orthopedic Hospital, was appointed tion’s greatest presidents. He had already served assistant surgeon in 1931 and served the hospital with distinction as president of the Orthopedic faithfully until he died. Ellis was wholly free from self-importance and No happier choice could have been made. He was it seems never to have occurred to him to seek no narrow-minded specialist, and it was fitting his own advancement; his thoughts were for that the first and moving tribute paid to his the benefit of his patients and of any organiza- memory came from his friend and colleague, tion with which he was connected.

We were beginning to do what Perkins advocated and sometimes apprehensive and occasionally dis- to appreciate fully the enormous value of allow- mayed by the staccato succession of ideas that ing (no order gasex 100caps with amex gastritis atrophic symptoms, the word is too passive for Perkins) buy generic gasex 100 caps on-line gastritis loss of appetite, of seemed to threaten intellectual inebriation. Tire- demanding active movement as early as possible less himself, he demanded constant effort from and at every relevant joint. Those who the fracture site did not represent an important lagged behind were quickly lost to view; they problem; it would, he felt, be adequately con- thought him impatient, austere, almost forbid- trolled by muscles, and difficulties arose only at ding. Those who stayed the course saw his true anatomical sites such as the femoral neck and self: helpful, abundantly stimulating and with a carpal scaphoid, where one or both fragments warm friendliness hidden from the world at large. After his devoted wife Jill had died, Elizabeth, Much to the surprise of his colleagues, Perkins his only child, and herself a doctor, provided him proclaimed Hugh Owen Thomas a genius. But he seemed paradoxical therefore that he should has also left behind another family, of surgeons, discard the famous splint, together with its who worked with him at St. Only those who George Perkins’ greatest service to the Journal worked with Perkins could accept that so simple of Bone and Joint Surgery was as true begetter of a method embodied so penetrating a truth. He came to the presidency surgeons smiled pityingly and persisted with of the British Orthopedic Association in 1946 splints; naturally they had not given his technique fully resolved that there must be created a proper a trial. He first raised the matter at a dinner methods are being more and more widely used, of the Association and received wide support; and those who seek an uncluttered exposition of informal discussion went so far as naming the fundamentals of contemporary fracture man- Watson-Jones as the obvious prospective editor. Authors preferred indigenous journals; consequently the few communications submitted to the journal from the UK were usually deplorable and rightly rejected. The American sponsors also were unhappy about the journal, largely because its circulation had long been too small to sustain it and so its survival depended upon the great generosity of its sponsors besides the outstanding dedication of its successive editors, Elliot Brackett and William Rogers. The familiar tale of friendly discussion between representatives of the bodies concerned does not need recapitulation. PERTHES chairman he seems always to have been Perkins, and it was he who successfully brought proposals 1869–1927 for joint publication to the British Orthopedic Association. Perthes was born in the Rhineland and He also chaired the meeting that set up an educated in Freiburg, Berlin, and Bonn. When his independent British editorial board to include the chief, Trendelenburg, moved to Leipzig, Perthes editor and other officers besides representatives of accompanied him. Shortly after, Perthes served in Australia, Canada, New Zealand and South the expeditionary force sent to China during the Africa, as well as the United Kingdom. Upon his return Platt accepted its chairmanship in the initial from China, he was made professor and director stages, but then handed over to Perkins, who of the Surgical Polyclinic Institute in Leipzig, served till retiring in 1952. In 1911, he In a number of the journal dedicated to George succeeded van Braunns as professor and director Perkins at that time, Sir Reginald Watson-Jones of the Surgical Clinic in Tübingen, where he wrote: “He inspired the British Volume of The finished out his career. Without him also wrote on vascular and chest diseases and on there would probably never have been a British maxillofacial injuries and war surgery. He thought of it long one of the early exponents of the clinical use of before it started. In a second publication he was able to describe accu- rately the gross and microscopic changes in a hip obtained at autopsy. Phelps graduated from Princeton Born on a farm near Carbondale in Southern Illi- University in 1916 and from the Johns Hopkins nois, Dr. After serving a year of after graduation from high school, continued his internship at the Johns Hopkins Hospital and education at the Normal School of Northern another at Massachusetts General Hospital, he Indiana. While there he decided to become a began his orthopedic training in the Harvard physician, and entered Rush Medical College of program at Boston’s Children’s Hospital in 1923. After graduation from Rush in 1904, he Department of Orthopedic Surgery in 1931. He Because of his interest in the problems of patients then entered private practice in LaGrange, Illi- with cerebral palsy, he gave up this position and nois, continuing at the same time his interest in in 1936 went to Baltimore to establish the Chil- teaching and research as a member of the Rush dren’s Rehabilitation Institute. In this period of American medicine, ciated with this Institute for the rest of his career. Here began what became the most Institute, he had great influence in bringing the absorbing interest of his career—the study of the problems of these patients to the attention of pathology of bone diseases. He pointed out the to Chicago to resume his teaching position at importance of a holistic approach, i. Phelps’ paper on the classification the Presbyterian Hospital Unit, and at the end of and treatment of cerebral birth injuries, written the war returned to Rush Medical College, where early in his career, is considered by orthopedic he soon became professor of surgery. Bick to be the most important carried on a large private practice, he devoted publication on the subject since the original much time to teaching and laboratory research. Many of his contributions to the knowledge of bone and joint diseases, as well as to the field of general surgery, owe their inception to this period in his life.