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He was sur- orthopedic surgery in his city and state purchase keftab 500mg on line antibiotic eye drops for dogs, and the vived by his wife purchase 375mg keftab fast delivery virus finder, who was Jeannette Freiberg, present position of orthopedic surgery in that and two sons. He was Chief of the Orthope- dic Service at the Cincinnati General Hospital, at the Children’s Hospital, and at the Jewish Hospi- 106 Who’s Who in Orthopedics Jules FROMENT 1878–1946 Jules Froment was Professor of Medicine at Lyons, and devoted his life to neurology, com- bining diligent observation, a philosophical ap- proach and debating skill. Graduating in 1906 with a thesis on disease of the heart in thyrotoxicosis, he remained at Lyons until the Great War. After a year at the front, he joined a nerve injuries unit at Rennes, and later was at Paris with Babinski. During this time he evolved a series of tests for nerve dysfunction, the best known being his sign of ulnar nerve weakness; another was loss of the hollow of the anatomical snuff box in radial nerve injury. After the war he ran a Red Cross Hospital in Lyons, and the encephalitis epidemic of 1918–1922 provided another intellectual chal- Ronald FURLONG lenge. In 1926 he nearly died as a result of being 1909–2002 severely injured by one of his patients. Froment pointed out the difference between a pinch grip and grasping, both of which are Ronald Furlong, the pioneer of hydroxyapatite- impaired by a low ulnar nerve palsy due to weak- coated hip replacements, died on August 12, 2002 ness of adductor pollicis. Today it is used to assess flexor polli- Switzerland, which fittingly reflects his strong cis brevis. He was honored by Pope Pius XII with a special blessing for his work among the civilian popula- tion in Milan at the end of World War II. In Italy with the Royal Army Medical Corps (RAMC), Furlong developed a particular expertise in plating fractures of the femur and, at the base hospital in Caserta, accumulated a per- sonal series of 200 cases. After the Allied Army took Italy, he was responsible for inspecting a German military hospital. Here, he recognized something very unusual in the treatment of a frac- tured femur and, at the end of the war, was instructed by Whitehall to find out about this new device. After a hair-raising journey through war-torn Europe, he eventually located Professor Küntscher in Kiel via the good offices of Profes- sor Böhler (a friend of Ronnie Furlong’s old chief, Rowley Bristow), whom he found in hiding in Vienna. The currency for this extraordinary adventure was cigarettes and the mode of trans- port a jeep. He returned to Britain much impressed by Küntscher’s work, together with a precious trefoil-shaped intramedullary nail, which he personally delivered to Maurice Down of Down Brothers, the famous old British manu- 107 Who’s Who in Orthopedics facturing company. Thomas’ comprehended that he had ad- Later in his career he would once again turn mitted a 16-year-old is not recorded, but Ronald toward continental Europe for inspiration and probably appeared far older. He was giant of a man, tall, broad shouldered, undoubt- one of the very few British surgeons to be a per- edly handsome and always elegant; even as a sonal friend of Professor Pauwels and one of only schoolboy he doubtless had an imposing style. Thomas’, that was it and the Dean, poor wrote only in “High German” so, in his early man, was probably not given an option to refuse. It is a tribute to his his early admission, winning the Cheselden remarkable intelligence that it took only 3 months Medal for Surgery. As was possible in those days, of early-morning daily German lessons for him to he passed his primary before he qualified in 1931. It seems unlikely his friend, Paul Maquet, one of Pauwels’ disciples he ever actually applied for a job; certainly he and the pioneer of the understanding of the never seems to have attended an interview. He leg alignment in knee surgery, he was translating was appointed a house surgeon to Sir Max Page, the works of Pauwels, Braun and Fischer into a fine clinician who clearly had a tremendous English. He appointed himself sold well in Germany, as the text was more com- to his next post, informing Rowley Bristow at a prehensible when written in English than in the garden party that he proposed to come and work complexity of classical German! Bristow was the first orthopedic consult- 1960, I can recall the often animated debates on ant at St. Thomas’ and had been placed there by biomechanics that would take place among his mentor, Sir Robert Jones. Even though the Messrs Furlong, Maquet, Kummer, the distin- First World War had given a great boost to ortho- guished anatomist and pioneer of comparative pedic and trauma surgery, the specialty was, in the biomechanics from Cologne, and Bombelli, the 1930s, still tiny. Such expansion that had occurred Italian guru of proximal femoral osteotomy. Finally, it was the link with the From the former Furlong learned the art of clini- German faciomaxillary surgeon Dr.

You should remember that ‘arrest’ or ‘failure’ of a physiological system is not a legitimate cause of death keftab 750 mg cheap virus martin garrix, for example cardiac arrest order keftab 375 mg visa antibiotics for sinus chest infection, cardiac failure and renal failure. If there is any doubt the cause of death should be discussed with the coroner (see below). It is important that you write your name and bleep number in capital letters on the certificate and the stub by your signature (Figure 4. This enables you to be traced by hospital staff, relatives or the coroner if there are any queries regarding the cause of death. It is good medical practice to identify yourself every time you write on patient notes (see the section on clinical governance). Cremation Forms This is a legal form in which you give your medical opinion that the body is not required for any further medical investigation (that is autopsy) and that there is no doubt as to the cause of death (Figure 4. Furthermore, you must state that the body contains no substances that may be harmful when burnt (for example a pace- maker, which explodes quite dramatically, radioactive substances, which disperse or inflatable orthopaedic nails, which are not dangerous but explode with a very loud bang). Once you have filled the form identifying yourself clearly, the form is sent to patient affairs where the relatives pick up a copy of the form and give it to the funeral directors. The undertaker must present this form to the mortuary officer in order to collect the body for cremation. No body may be cremated in the UK without a Surviving the Pre-registration House Officer Post 27 properly filled cremation form. Once the undertaker has collected the body he will leave a cheque for you with patient affairs to cover the cost of your time. The amount varies from region to region, but is usually approximately £45–55. In some trusts a percentage is skimmed off, which goes directly into the mess fund or,on rare occasions,all ash cash goes directly to the mess fund (hard luck – I hope you get some good parties! The Coroner and Post-mortems Many juniors perceive the coroner as a scary person who will berate you when you tele- phone him or her because you have let your patient die. In actual fact the coroner is simply another doctor who works to establish the cause of death in patients where there is doubt or if the patient has had an accident, operation or violent insult prior to death. Most often coroners are very friendly and obliging people who are more than happy to talk to you and discuss the death of your patient. Usually when you get through you will talk to the coroner’s assistant who will require certain details before handing you on to the coroner. Increasingly, it is the coroner’s assistant who decides whether or not you actually need to speak to the coroner and these assistants can occa- sionally be a little supercilious. G name and address of the patient G date of birth and the time and date of death G date of and reason for admission to hospital G mode of admission, for example GP referral, via the A&E department or elective admission G in-patient diagnoses and treatment G background medical history G what you think the cause of death was that you are intending to write on the death certificate, that is Ia, Ib, Ic and II G name and telephone number of the next of kin There are certain times when it is mandatory to report the death of a patient to the coroner, for example death due to an accident or violence. These are changing with time and the patient affairs or bereavement affairs office in your hospital can provide you with an up-to-date list. Dress Code and Personal Hygiene Clothes All professionals should dress appropriately, particularly doctors. Men should wear clean, ironed shirts and trousers (not combats) and a tie. Men should shave daily 28 What They Didn’t Teach You at Medical School Surviving the Pre-registration House Officer Post 29 30 What They Didn’t Teach You at Medical School Give the ward and hospital This means you will gain financially from the death of the patient. The answer should be “No” The ordinary medical attendant is the GP As the hospital doctor, you should write “No” Your examination should be external only Has a post mortem been performed? Answer “Yes” or “No” This should read the same as the Death Certificate Figure 4. It is inadvisable to state that the patient died alone “No” “No” “No” “No” “No” e. BSc, MBBS It is mandatory to circle YES or NO on (a) and (b) to allow cremation. NB: radioactive implants, pacemakers and inflatable orthopaedic nails explode and are potentially harmful and must be removed prior to cremation by the undertakers or morticians Figure 4. It is not acceptable to turn up to ward rounds or meetings with relatives looking like you have not left the hospital for three days. If you are prone to body odour and your shirt smells,then bring a spare when on-call or wear theatre blues and change them in the morning. Women should wear trousers or skirt with an appropriate top (not exposing too much cleavage) as it draws the attention of not only your male colleagues but also the patients!

Common causes include: ● Diabetes mellitus: edema and hard exudates at the macula are a common cause of visual impairment generic keftab 500 mg overnight delivery treatment for dogs ear mites, especially in noninsulin dependent diabetes mellitus 250mg keftab overnight delivery bacteria 02 micron. Cross References Cherry red spot at the macula; Retinopathy; Scotoma; Visual field defects Magnetic Movements Movements may be described as magnetic in varying contexts: ● the following or tracking movements of an alien hand in corti- cobasal degeneration, reaching out to touch or grasp the exam- iner’s hand or clothing, as in forced groping; ● in a hesitant gait (ignition failure), with seeming inability to lift the feet (“stuck to the floor”) in gait apraxia. Cross References Alien hand, Alien limb; Forced groping; Gait apraxia; Grasp reflex Main d’Accoucheur Main d’accoucheur, or carpopedal spasm, is a posture of the hand with wrist flexion in which the muscles are rigid and painful. Main d’ac- coucheur is so called because of its resemblance to the posture of the hand adopted for the manual delivery of a baby (“obstetrical hand”). This tetanic posture may develop in acute hypocalcemia (induced by hyperventilation, for instance) or hypomagnesemia, and reflects muscle hyperexcitability. Development of main d’accoucheur within 4 minutes of inflation of a sphygmomanometer cuff above arterial pres- sure (Trousseau’s sign) indicates latent tetany. Mechanosensitivity of nerves may also be present elsewhere (Chvostek’s sign). Cross References Chvostek’s sign; Trousseau’s sign Main en Griffe - see CLAW HAND Main Étranger - see ALIEN HAND, ALIEN LIMB Main Succulente Main succulente refers to a swollen hand with thickened subcutaneous tissues, hyperkeratosis and cyanosis, trophic changes which may be observed in an analgesic hand, e. Cross References Charcot joint “Man-in-a-Barrel” “Man-in-a-barrel” is a clinical syndrome of brachial diplegia with preserved muscle strength in the legs. Acute central cervical cord lesions may also produce a “man-in-a-barrel” syndrome, for example after severe hyperextension injury, or after unilateral vertebral artery dissec- tion causing anterior cervical spinal cord infarction. This may follow a transient quadriplegia, and considerable recovery is possible. A neuro- genic main-in-a-barrel syndrome has been reported (“flail arm syn- drome”), which is a variant of motor neurone disease. Neurology 1969; 19: 279 (abstract GS7) Cross References Flail arm; Quadriparesis, Quadriplegia Marche à Petit Pas Marche à petit pas is a disorder of gait characterized by impairments of balance, gait ignition, and locomotion. Particularly there is short- ened stride (literally marche à petit pas) and a variably wide base. This gait disorder is often associated with dementia, frontal release signs, and urinary incontinence, and sometimes with apraxia, parkinsonism, and pyramidal signs. This constellation of clinical signs reflects under- lying pathology in the frontal lobe and subjacent white matter, most usually of vascular origin. Modern clinical classifications of gait dis- orders have subsumed marche à petit pas into the category of frontal gait disorder. Human walking and higher- level gait disorders, particularly in the elderly. Neurology 1993; 43: 268-279 Cross References Apraxia; Dementia; Frontal release signs; Parkinsonism Marcus Gunn Phenomenon - see JAW WINKING Marcus Gunn Pupil, Marcus Gunn Sign The Marcus Gunn pupil or sign, first described in 1902, is the adapta- tion of the pupillary light reflex to persistent light stimulation, that is, a dilatation of the pupil is observed with continuing stimulation with incident light (“dynamic anisocoria”). This is indicative of an afferent pathway defect, such as retrobulbar neuritis. Normally the responses are equal but in the presence of an afferent conduction defect an inequality is manifest as pupillary dilatation. Cross References Pupillary reflexes; Relative afferent pupillary defect (RAPD); Swinging flashlight sign Mask-like Facies The poverty of spontaneous facial expression, hypomimia, seen in extrapyramidal disorders, such as idiopathic Parkinson’s disease, is sometimes described as mask-like. Cross References Hypomimia; Parkinsonism Masseter Hypertrophy Masseter hypertrophy, either unilateral or bilateral, may occur in indi- viduals prone to bruxism. A familial syndrome of hypertrophy of the masseter muscles has been described. Journal of Neurology 1987; 234: 251-253 Cross References Bruxism Masseter Reflex - see JAW JERK Masticatory Claudication Pain in the muscles of mastication with chewing may be a sign, along with headache, of giant cell (temporal) arteritis. McArdle’s Sign McArdle’s sign is the combination of reduced lower limb strength, increased lower limb stiffness and impaired mobility following neck flexion. The sign was initially described in multiple sclerosis but may occur in other myelopathies affecting the cord at any point between the fora- men magnum and the lower thoracic region. The mechanism is pre- sumed to be stretch-induced conduction block, due to demyelinated plaques or other pathologies, in the corticospinal tracts. McArdle’s sign may be envisaged as the motor equivalent of Lhermitte’s sign. Journal of Neurology, Neurosurgery and Psychiatry 1988; 51: 1110 O’Neill JH, Mills KR, Murray NMF. Journal of Neurology, Neurosurgery and Psychiatry 1987; 50: 1691-1693 - 193 - M Medial Medullary Syndrome Cross References Lhermitte’s sign; Myelopathy Medial Medullary Syndrome The medial medullary syndrome, or Dejerine’s anterior bulbar syn- drome, results from damage to the medial medulla, most usually infarction as a consequence of anterior spinal artery or vertebral artery occlusion. The clinical picture is of: ● Ipsilateral tongue paresis and atrophy, fasciculations (hypoglossal nerve involvement) ● Contralateral hemiplegia with sparing of the face (pyramid) ● Contralateral loss of position and vibration sense (medial lemnis- cus) with pain and temperature sensation spared ● +/− upbeat nystagmus (?