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For many of my patients order baclofen 25mg with visa, the prospect of prolonging their stay in a world that has little time or respect for them has little appeal cheap baclofen 25mg free shipping. The controversy over euthanasia and the romanticisation of suicide among young men (such as rock stars Kurt Cobain and Michael Hutchence) reflect a deeply pessimistic current in contemporary society purchase baclofen 10 mg without a prescription. The desire simply to live longer by taking health precautions may be interpreted as another way of responding to the perception that life in modern society lacks meaning and purpose buy generic baclofen 10mg. The promoters of health awareness will object that their emphasis is not so much on ensuring that people live longer as on preventing premature deaths. They will point out that, even though there is an average life expectancy of 75– 80, more than 90,000 people die every year in the UK before the age of 65. Furthermore, some 32,000 of these deaths are from cancer and 25,000 from heart disease and strokes, many of which could have been prevented. In this context, the concept of prevention is abused: death cannot be prevented, only postponed. Unfortunately, given the current state of medical science, death can generally be postponed only for a relatively short time by relatively intensive preventive measures. In the nineteenth century, public health measures to improve sanitation and housing played a decisive role in curtailing the epidemics of infectious diseases that devastated the urban poor. Over the past two decades, proponents of the ‘new public health’ have emphasised the promotion of a healthy lifestyle as the key strategy to combat the modern epidemics of heart disease and cancer. The central weakness of the new public health is the fact that the scope for significant postponement of death from the major causes of premature mortality by preventive measures is limited, though the costs are often substantial. Thus, for example, the increase in average life expectancy to be gained from a 10 per cent reduction in the level of serum cholesterol in the population at large (a much vaunted target of the 1992 Health of the Nation White Paper, though dropped in the 1999 document) is between 2. However, even to achieve this degree of reduction in cholesterol would require either drastic dietary modification or long-term drug treatment (with its attendant side- effects). Now it is true that the fact that old people live longer does not necessarily mean that they suffer worse health. However, it is also true that there is a tendency for the prevalence of common chronic degenerative conditions— heart disease, stroke, cancer, osteoarthritis, diabetes, dementia—to increase with age. What is by no means clear is the contribution of the various preventive measures favoured by the government to improving the quality—as distinct from the duration—of people’s lives. Indeed it may well be the case that an old person’s enjoyment of a cigarette, a cream bun and a bottle of Guinness is more important to them than the extra few weeks they might spend in a life of miserable abstinence. A further aim of government public health policy is to ‘narrow the health gap’ between rich and poor by concentrating its efforts on improving the health of the ‘worst off in society’. Here is another paradox: the government and the medical profession have become more preoccupied with the relationship between inequality and health at a time when social differentials in health are less significant in real terms than ever before. No doubt it is true that people who are better off are healthier and that the poor are sicker. A vast edifice of epidemiological data has been erected in recent years substantiating these differentials in great detail in relation to every disease and health indicator. Yet the simple contrasts between the health gap that exists in Britain today and that between rich and poor in Victorian England, or that which still prevails between Western and Third World countries today, is enough to expose the lack of historical or social perspective of contemporary public health. Take infant mortality, one of the most intensively studied indices of population health. The persistent gap between the rate of infant deaths among rich and poor has been a particular focus of the new public health since the publication of the Black Report in 1980 (Black 1980; Townsend, Davidson 1992). The 1990 figures reveal that the number of babies whose fathers are classified as ‘unskilled workers’ (social class V) who die in the first year of life is 11. In other words, the infant mortality rate for the poor is nearly twice that among the rich. While there can be little doubt that the persistence of this differential is a pernicious effect of Britain’s class divided society, it is important to place it in a 4 INTRODUCTION wider context. The overall rate of infant deaths in 1990 was slightly less than 8, by 1996 it had fallen below 6. At the turn of the century the figure was around 150, by the Second World War it was still above 50; it did not fall below 20 until the 1960s (Halsey 1988) In some Third World countries today, the infant mortality rate remains comparable with that of Britain in the early decades of this century: for example, India—94, Bangladesh—114, Egypt—61, Mali—164 (Gray 1993:11). Infant mortality has fallen dramatically among all social classes in Britain in the course of the twentieth century.

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Hydrocephalus secondary to craniopharyngiomas usually resolves after surgical resection of the tumor generic 10mg baclofen with mastercard. Hydrocephalus secondary to third ventricular region gliomas usually does not resolve after surgical resection baclofen 10mg free shipping, and ventricular shunt placement is often necessary discount baclofen 10 mg on-line. Cerebral Aqueduct The normal aqueduct of a neonate is 12–13 mm in length and only 0 purchase baclofen 10mg. Thus, it is prone to obstruction from a variety of lesions, including congenital aqueductal malformations, pineal region neoplasms, arteriovenous malformations, and periaqueductal neoplasms. Hydrocephalus secondary to aqueductal occlusion is generally severe and causes distension of the third ventricle and separation of the thalami, thinning of the septum pellucidum and corpus callosum, and compression of the cerebral hemi- spheres. Less than 2% of cases of congenital aqueductal stenosis are the result of the recessively inherited X-linked Bickers–Adams–Edwards syndrome, which is asso- ciated with flexion–adduction of the thumbs (‘‘cortical thumbs’’). Many pineal region tumors, especially germinomas, are highly radiosensitive; and success- ful tumor irradiation as well as surgical resection may adequately treat the obstruc- tive hydrocephalus. Low-grade astrocytomas are the most common periaqueductal pediatric neo- plasms that cause hydrocephalus. Historically, children with neurofibromatosis have often been diagnosed with ‘‘late-onset aqueductal stenosis. Fourth Ventricle In infants, the fourth ventricle is the location for obstruction secondary to Dandy– Walker cysts or obliteration of the basal foramina. Such occlusions result in the dilation of the lateral, third, and fourth ventricles above the obstruction. Dandy–Walker cysts are developmental abnormal- ities characterized by a large cyst in the fourth ventricle lined with pia-arachnoid and ependyma, hypoplasia of the cerebellar vermis, and atrophy of the cerebellar hemi- spheres. Arachnoiditis secondary to either meningitis or subarachnoid hemorrhage can also occlude the basal foramina and cause obstructive hydrocepha- lus. In addition, infants with Chiari II malformations and myelomeningoceles have hydrocephalus secondary to blockage of CSF flow from basilar obstruction. Arachnoid Granulations Sclerosis or scarring of the arachnoid granulations can occur after meningitis, sub- arachnoid hemorrhage, or trauma. The subarachnoid spaces over the convexities enlarge, thus forming a condition often referred to as ‘‘external hydrocephalus. Symptomatic external hydrocephalus is treated with a subdural= subarachnoid to peritoneal shunt. CLINICAL FEATURES Premature Infants Hydrocephalus in premature infants is predominantly caused by posthemorrhagic hydrocephalus (PHH). Because the poorly myelinated premature brain is so easily compressed and the skull is so distensible, premature infants can develop consider- able ventriculomegaly before their head circumference increases. Infants with PHH may have no symptoms or may exhibit increasing spells of apnea and bradycardia. Poor feeding and vomiting are uncommon signs of hydrocephalus in premature infants. If ventriculomegaly progresses and ICP increases, the anterior fontanelle becomes convex, tense, and nonpulsatile; and the cranial sutures splay and the scalp veins distend. As ventriculomegaly persists, the head develops a globoid shape, and the head circumference increases at a rapid rate. Table 2 Signs and Symptoms of Hydrocephalus in Children Premature infants Infants Toddlers and older Apnea Irritability Headache Bradycardia Vomiting Vomiting Tense fontanelle Drowsiness Lethargy Distended scalp veins Macrocephaly Diplopia Globoid head shape Distended scalp veins Papilledema Rapid head growth Frontal bossing Lateral rectus palsy Macewen’s sign Hyper-reflexia-clonus Poor head control Lateral rectus palsy ‘‘Setting-sun’’ sign (From Elsevier from: P. Signs include macrocephaly, a convex and full anterior fontanelle, distended scalp veins, cranial suture splaying, frontal bossing, ‘‘cracked pot’’ sound on skull percussion over dilated ventricles (Macewen’s sign), poor head control, lat- eral rectus palsies, and the ‘‘setting-sun’’ sign, in which the eyes are inferiorly deviated. Paralysis of upgaze and Parinaud’s sign herald dilation of the suprapineal recess (Table 2). Head cir- cumference increases by 2 cm=month during the first 3 months, by 1 cm=month from 4 to 6 months, and by 0.

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Luke’s Hospital order 10mg baclofen, and election to the Born in New York City on January 23 quality baclofen 10mg, 1897 baclofen 25mg otc, the Alpha Omega Alpha fraternity buy baclofen 10mg with visa. Bosworth was son of a minister, David Bosworth attended City the only foreign recipient of the Japanese award, College of New York and graduated from the the Second Order of the Sacred Treasure, which 31 Who’s Who in Orthopedics was awarded to him in April 1968 for his contri- Perhaps best known for his work in the surgi- butions to orthopedic surgery. Because of his many publications, it was only With his wife, Dorothy, Dr. Bosworth be appointed to the edi- made his home a welcome place for his many res- torial board of The Journal of Bone and Joint idents away from home. He held annual New Surgery, and he served for a time as assistant to Year’s Eve parties attended by his residents and the editor. He was also appointed to the Board of many a Sunday night was spent in his basement, Trustees of the Journal and served as treasurer for in a cloud of cigar smoke, with his staff, ironing his entire term as trustee. Many of his residents in Orthopedics at New York Polyclinic Medical can recall him quoting from memory during School, at Flower Fifth Avenue Medical School, long operations in the late afternoon—lengthy and as a lecturer in orthopedic surgery at passages from Hamlet or “Elegy in a Country Bellevue Medical College and the University Churchyard. Bosworth left New York His staff appointments included: Assistant City to return to his birthplace, Vermont, where Surgeon, Attending Surgeon, and Director of he was in active practice almost until his 82nd Orthopedic Surgery at St. David Marsh Bosworth died in Vermont on Seaview Hospital, the House of St. His 94 original Cripple, and Richmond Borough Hospital, all of orthopedic publications alone (from 1930 to New York City. He was also consultant to 22 1967) could fill a volume or two, and indicate the hospitals in New York and surrounding areas. Bosworth’s many community service efforts David Marsh Bosworth was affectionately included working as consultant surgeon of the known as “Uncle David” by all his ex-residents, New York City Police Department, beginning in although he was seldom called anything but Dr. His great surgical State Supreme Court, Department of Labor, and wisdom and experience have passed from him to the United States Department of Labor. When, as it must served as an examiner for the American Board of sometime happen to all of us, we encounter a dif- Orthopedic Surgery from 1940 to 1966. Bosworth, in order to cover more the most natural thing in the world to ask, “What ground faster, he early obtained his own airplane would Uncle David do here? In his earlier years, he would work all week in New York City, then fly to Vermont to teach and operate over the weekend, and return home to Harold Hamlyn BOUCHER begin again early Monday morning. Residents and coworkers learned that his work schedule 1899– stopped only for sleep. Evenings and Sundays, after hospital rounds, were reserved for photog- Harold “Hammy” Boucher was born in raphy (he did his own) or writing. He attended to waste any time when travelling between the McGill University and the McGill Medical many hospitals, he used to read journals or correct School, graduating in 1926. Bosworth’s hobbies the University of Iowa where he was a student of included boating, flying, and photography. His Arthur Steindler, and where he received a Masters skill with his Leica cameras was such that he did Degree in orthopedics. His orthopedic career was his own photography for all of his publications. He was a member of the faculty of the of the Year, 1954 University of British Columbia. Boucher was —Internship—Los Angeles County Hospital, a member and past president of the Canadian 1932 Orthopedic Association, the International Society —Surgical residency—Kern County Hospital, of Orthopedic Surgery and Traumatology, and the Bakersfield, California, 1932–1934; surgical American Academy of Orthopedic Surgeons. He coached Canadian football for —Orthopedic residency—Campbell Clinic, several years and wrote several books for the use Memphis, Tennessee, 1934–1936 of trainers and coaches. He was an avid hunter —Orthopedic practice—White Memorial Hospi- who enjoyed training his own hunting dogs. Farm work and car- Section, National Institutes of Health, pentry added much to the strength, endurance, 1957–1961; Orthopedic Research and Educa- and manual dexterity that were later to enhance tion Foundation, Trustee, 1964, President, his surgical skills. After attending Emmanual 1966; Campbell Foundation, President, Missionary College in Berrien Springs, Michigan, 1970–1974 he entered the College of Medical Evangelists, —Military—orthopedic consultant to the army in now Loma Linda University.

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His appearance at sci- entific meetings in foreign countries had been greeted with triumphal acclaim buy 25 mg baclofen fast delivery. He was made a baronet in 1883 order 25 mg baclofen otc, a peer in 1897 buy baclofen 25mg without prescription, and was one of the original 12 members of the Order of Merit instituted in 1902 cheap 10 mg baclofen amex. The universal and abiding value of Lister’s work for the physical ills of mankind has made him one of the outstanding benefactors of humanity. In our own day we have wit- Oxford, Clarendon Press, 2 vols nessed the growth of special branches of surgery 2. It started at the beginning of the Victorian era and, like many another movement, owed its inspiration to the leadership of one man, in this instance William John Little. He was afflicted with a deformity of the foot due to infan- tile paralysis and, being compelled to contemplate his own disability and seep its cure in vain, he was aroused to the misery of thousands of cripples here in England. He came from Norfolk farming stock who had lived for many generations in and about the village of Carbrooke near Kimberley. His father, John Little, migrated to London and eventually became proprietor and host of “The Red Lion” in Aldgate, a famous hostelry, which was haunted by the memories of Dick Turpin who had often called there. William John Little, the third child of his parents, was born on August 7, 1810. His earliest recollection recalls a fragment of social history that can be read with appreciation today: The year 1814–15 was remarkable in my child history. The long war of over twenty years with France was ter- minated, but it left a heavy burden of debt upon our nation. Scarcity of food was experienced by the poorer classes on and off during the war. Bread riots occurred 201 Who’s Who in Orthopedics during the Autumn and Winter of 1814. Afterwards, during the winter Aldersgate School of Medicine, where Robert of 1814–15, the 10th Hussars were lodged in the dis- Grant of University College lectured on anatomy trict, their headquarters being at my father’s house, the Red Lion Inn. In 1831, he qualified by obtaining the a highly privileged little person, often admitted into the Licence of the Apothecaries Company and the drawing room which was occupied as the day-room of next year received the diploma of Membership of the officers, some ten or a dozen in number. The Colonel (Clinton) kindly took me on his coach, in wintry weather, for Newcastle. I expect he was a family man, and was thinking Little sought a means of curing, or at least mini- of his own family as he was again about to set out on mizing, the disability for which he had been Foreign Service. The year 1814–15 was in raised by reading in Cruveilhier’s Anatomic many ways a remarkable one and forcibly impressed Pathologique of Delpech’s improved method of itself on my mind and memory.... My father took me to the fair and I believe diffuse suppuration and sloughing. Since Delpech that I remember the gingerbread stalls and the prepara- tions for, if not the roasting of, an ox. Little’s hopes were, When he was 4 years old Little suffered from however, revived by reading in the Archives Gen- infantile paralysis. Louis Stromeyer of muscles of the left leg were completely paralysed, Hanover had proposed important modifications of leading to contracture and talipes equinovarus. Delpech’s plan and treated two patients success- His young school companions in England gave fully. Little decided to go to Germany and learn him the nickname “lame duck” and in France for himself, taking with him a letter of introduc- “canard boitu. In Goodman’s Fields and acquired knowledge of 1835 and 1836, he visited Leyden, Leipzig, French, as well as of English grammar and arith- Dresden, and Berlin, and made contact with metic. About this time he and his father went to several distinguished surgeons and anatomists. Both He found that there was no more enthusiasm for arrived at Dieppe, prostrate with sea sickness. After 2 years at the day school, he spent some However, Professor Muller and Professor Froriep years at a school at St. Margaret’s, near Dover, of Berlin considered that Stromeyer’s operation and at the age of 13 entered the celebrated Jesuit was based on sound anatomical and surgical prin- College of St. Thus encouraged, Little went to Hanover guished himself by winning, against native com- and placed himself under the care of Stromeyer, petitors, the prize for French composition. He who divided his tendo Achillis, gradually cor- afterwards spoke highly of the management of rected the deformity of the foot, and gained a the College, and of the instruction and kindness successful result.

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