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Thus the agarose can act as a sieve treatment yeast in urine purchase baycip with paypal, to separate molecules on the basis of the size medicine information quality baycip 500mg. The uncharged nature of agarose allows a current to be passed through it medicine 029 discount baycip 500 mg free shipping, which can drive the move- ment of samples such as pieces of deoxyribonucleic acid (DNA) from one end of an agarose slab to the other treatment ind cheap 500mg baycip with amex. The speed of the molecule movement treatment tracker best buy for baycip, is also related to molecular size (largest molecules moving the least). In the non-microbiological world, agar and agarose have also found a use as stabilizers in ice cream, instant cream whips, and dessert gelatins. See also Bacterial growth and division; Laboratory techniques in microbiology quently diffuse out of the disk into the agar. This version of agar diffusion is known as the Kirby-Bauer disk-diffusion assay. The agar diffusion assay allows bacteria to be screened Agar diffusionAGAR DIFFUSION in a routine, economical and easy way for the detection of Agar diffusion refers to the movement of molecules through resistance. More detailed analysis to ascertain the nature of the the matrix that is formed by the gelling of agar. This phenomenon forms the basis of the agar diffu- in microbiology sion assay that is used to determine the susceptibility or resist- ance of a bacterial strain to an antibacterial agent, (e. AGGLUTINATION • see ANTIBODY-ANTIGEN, BIOCHEM- When the seaweed extract known as agar is allowed to ICAL AND MOLECULAR REACTIONS harden, the resulting material is not impermeable. Rather, there are spaces present between the myriad of strands of agar that comprise the hardened polymer. Small molecules such as AIDSAIDS antibiotics are able to diffuse through the agar. Typically, an antibiotic is applied to a well that is cut The advent of AIDS (acquired immunity deficiency syndrome) into the agar. Thus, the antibiotic will tend to move from this in early 1981 surprised the scientific community, as many region of high concentration to the surrounding regions of researchers at that time viewed the world to be on the brink of lower antibiotic concentration. AIDS, an infectious disease the well, then the zone of diffusion can be larger. A bacterial suspension is spread onto the sur- viruses known as retroviruses. There can be different concentrations of a infections that take hold of the body because the immune sys- single antibiotic or a number of different antibiotics present. Following a time to allow for growth of the bacteria then agar tem is severely impaired. If bacterial growth is right up to the antibiotic Following the discovery of AIDS, scientists attempted containing well, then the bacterial strain is deemed to be to identify the virus that causes the disease. If there is a clearing around the two scientists and their teams reported isolating HIV, the virus antibiotic well, then the bacteria have been adversely affected that causes AIDS. The size of the inhibition zone can be meas- Montagnier (1932– ), working at the Pasteur Institute in Paris, ured and related to standards, in order to determine whether and the other was American immunologist Robert Gallo the bacterial strain is sensitive to the antibiotic. Both identified HIV as the cause of AIDS and absorbent material that have been soaked with the antibiotic of showed the pathogen to be a retrovirus, meaning that its interest directly onto the agar surface. Following the discov- 7 AIDS WORLD OF MICROBIOLOGY AND IMMUNOLOGY ery, a dispute ensued over who made the initial discovery, but sion is that a person who has had another sexually transmitted today Gallo and Montagnier are credited as co-discoverers. Inside its host cell, the HIV retrovirus uses an enzyme Laboratories use a test for HIV-1 that is called Enzyme- called reverse transcriptase to make a DNA copy of its genetic linked immunosorbant assay (ELISA). The viral even though the disease attacks the immune system, B cells RNA in turn directs the synthesis protein capsids and both are begin to produce antibodies to fight the invasion within weeks assembled into HIV viruses. HIV destroys the immune sys- HIV-1 type antibodies and reacts with a color change. In addition, ELISA sub-Saharan Africa and subsequently spread to Europe and the may give a false positive result to persons suffering from a dis- United States by way of the Caribbean. Patients that test positive with ELISA are that suppress the immune system in monkeys, scientists given a second more specialized test to confirm the presence of hypothesize that these viruses mutated to HIV in the bodies of AIDS. Developed in 1996, this test detects HIV antigens, pro- humans who ate the meat of monkeys, and subsequently teins produced by the virus, and can therefore identify HIV caused AIDS. A fifteen-year-old male with skin lesions who before the patient’s body produces antibodies. During the 1960s, doctors often listed phase the infected individual may experience general flu-like leukemia as the cause of death in many AIDS patients. After symptoms such as fever and headache within one to three several decades however, the incidence of AIDS was suffi- weeks after exposure; then he or she remains relatively ciently widespread to recognize it as a specific disease. This stage continues for as long as the and distribution of diseases, turned their attention to AIDS. Progression of American scientist James Curran, working with the Centers the disease is monitored by the declining number of particular for Disease Control and Prevention (CDC), sparked an effort antibodies called CD4-T lymphocytes. First spread in the United immune cells by attaching to their CD4 receptor site. The States through the homosexual community by male-to-male virus also attacks macrophages, the cells that pass the antigen contact, HIV rapidly expanded through all populations. The progress of HIV can also be Presently new HIV infections are increasing more rapidly determined by the amount of HIV in the patient’s blood. After among heterosexuals, with women accounting for approxi- several months to several years, the disease progresses to the mately twenty percent of the AIDS cases. The worldwide next stage in which the CD4-T cell count declines, and non- AIDS epidemic is estimated to have killed more than 6. The CDC has established a definition for occurs about every fifteen seconds. HIV is not distributed the diagnosis of AIDS in which the CD4 T-cell count is below equally throughout the world; most afflicted people live in 200 cells per cubic mm of blood, or an opportunistic disease developing countries. In 1995 scientists developed the disease was concentrated in large cities, it has spread to a potent cocktail of drugs that help stop the progress of HIV. Once the leading cause of death among Among other substances, the cocktail combines zidovudine people between the ages of 25 and 44 in the Unites States, (AZT), didanosine (ddi), and a protease inhibitor. Its main means of reverse transcriptase, mistakenly incorporates the drugs into transmission from an infected person is through sexual con- the viral chain, thereby stopping DNA synthesis. Used alone, tact, specifically vaginal and anal intercourse, and oral to gen- AZT works temporarily until HIV develops immunity to the ital contact. Proteases are enzymes that are needed by HIV to high risk of contracting AIDS. An infected mother has a 15 to reproduce, and when protease inhibitors are administered, 25% chance of passing HIV to her unborn child before and HIV replicates are no longer able to infect cells. In 1995 the during birth, and an increased risk of transmitting HIV Federal Drug Administration approved saquinaviras, the first through breast-feeding. Although rare in countries such as the protease inhibitor to be used in combination with nucleoside United States where blood is screened for HIV, the virus can drugs such as AZT; this was followed in 1996 by approval for be transmitted by transfusions of infected blood or blood-clot- the protease inhibitors ritonavir and indinavir to be used alone ting factors. Another consideration regarding HIV transmis- or in combination with nucleosides. The combination of drugs 8 WORLD OF MICROBIOLOGY AND IMMUNOLOGY AIDS, recent advances in research and treatment brings about a greater increase of antibodies and a greater per microliter of blood, the number of infective virus particles decrease of fulminant HIV than either type of drug alone. This Although patients improve on a regimen of mixed drugs, they loss of the ability to fight off foreign organisms leaves the are not cured due to the persistence of inactive virus left in the patient open to life-threatening illnesses that normally would body. Researchers are looking for ways to flush out the be routinely defeated by an unimpaired immune system. In the battle against AIDS, researchers are also Until 2001, the prevailing view was that the decline in attempting to develop a vaccine. As an adjunct to the classic the number of CDC4 cells was due to a blockage of new T cell method of preparing a vaccine from weakened virus, scientists production by the infecting virus. However, the conclusions are attempting to create a vaccine from a single virus protein. Even though the result is viduals pass HIV-laden macrophages and T lymphocytes in the same, namely the increased loss of the specialized AIDS- their bodily fluids to others. Sexual behaviors and drug-related fighting T cells, the nature of the decline is crucial to deter- activities are the most common means of transmission. Commonly, the virus gains entry into the bloodstream by way If the reasons for the accelerated loss of the T cells can be of small abrasions during sexual intercourse or direct injection determined, perhaps the loss can be prevented. In attempting to prevent HIV trans- better equip patients to fight the infection. Highly Active Anti-Retroviral Therapy programs; it is vitally important to increase public under- (HAART) consists of administering a “cocktail” of drugs tar- standing of both the nature of AIDS and the behaviors that put geted to the AIDS virus to a patient, even when the patient individuals at risk of spreading or contracting the disease. The drug mixture typically con- tains a so-called nucleoside analog, which blocks genetic See also AIDS, recent advances in research and treatment; replication, and inhibitors of two enzymes that are critical Antibody and antigen; Blood borne infections; Centers for enzyme in the making of new virus (protease and reverse tran- Disease Control (CDC); Epidemics, viral; Human immunode- scriptase). Immunodeficiency diseases; Immunological analysis tech- But, this benefit has come at the expense of side effects that can niques; Infection and resistance; Infection control; Latent often be severe. But now, viruses and diseases; Sexually transmitted diseases; T cells or research published toward the end of 2001 indicates that the use T lymphocytes; Viral genetics; Viral vectors in gene therapy; of HAART in a “7-day-on, 7-day-off” cycle does not diminish Virology; Virus replication; Viruses and responses to viral treatment benefits, but does diminish treatment side effects. Another advancement in AIDS treatment may come from the finding that the inner core of the AIDS virus, which AIDS, RECENT ADVANCES IN RESEARCH is called the nucleocapsid, is held together by structures AND TREATMENT known as “zinc fingers. Acquired Immune Deficiency Syndrome (AIDS) has only been Furthermore, evidence supports the view that the nucleocapsid known since the early years of the 1980s. Thus, a drug that effectively number of people infected with the causative virus of the syn- targeted the nucleocapsid could be an effective drug for a long drome and of those who die from the various consequences of time. The drawback to this approach at the present time is that the infection, has grown considerably. So, an anti- In the 1980s and 1990s, researchers were able to estab- AIDS zinc finger strategy will have to be made very specific. Since then, much research has cine for the AIDS virus would be developed within two years. In late 2001, how- immune system due to infection, seeking ways of reversing ever, preliminary clinical trials began on a candidate vaccine. The candidate vaccine implicated in the progression of AIDS is a type of T cell called works by targeting what is called cell-mediated immunity. This cell, which is activated following This type of immunity does not prevent infection, but rather recognition of the virus by the immune system, functions in clears the virus-infected cells out of the body. Such a vaccine the destruction of the cells that have been infected by the would be intended to prolong and enhance the quality of the virus. Over time, however, the number of CDC4 cells lives of AIDS-infected people. However, studies must still rule out the possibil- 9 Alexander, Hattie Elizabeth WORLD OF MICROBIOLOGY AND IMMUNOLOGY ity that vaccination would create “carriers,” individuals who In the 1950s Alexander began studies on the genetic are not sick but who are capable of spreading the disease. During the next two decades she There are various vaccine treatment strategies. One made fundamental observations concerning bacterial and viral involves the injection of so-called “naked” DNA. She demonstrated that the ability of Hemophilus contains genes that code for gag, a viral component thought to influenzae to cause disease rested with its genetic material. The DNA can be Additionally she demonstrated that the genetic material of attached to inert particles that stimulate the response of the poliovirus could infect human cells. In another strategy, the viral gene is bundled mechanisms of inheritance of traits in microorganisms could into the DNA of another virus that is injected into the patient. Time has As of 2002, more than two dozen experimental vaccines borne out her suggestion. For her research and other Treatment strategies, vaccine-based or otherwise, will professional accomplishments Alexander received many need to address the different isolates of the AIDS virus that are awards, honorary degrees, and other honors. These different isolates became the first woman president of the American Pediatric tend to be separated into different geographical regions. Thus, it has become clear that a universal See also Bacterial adaptation; Microbial genetics treatment strategy is unlikely. See also Human immunodeficiency virus (HIV); Immune ALGAE, ECONOMIC USES AND BENEFITS • stimulation, as a vaccine; Vaccination see ECONOMIC USES AND BENEFITS OF MICROORGANISMS ALEXANDER, HATTIE ELIZABETH AAllergies LLERGIES (1901-1968)Alexander, Hattie Elizabeth An allergy is an excessive or hypersensitive response of the American physician and microbiologist immune system to harmless substances in the environment. Hattie Elizabeth Alexander was a pediatrician and microbiol- Instead of fighting off a disease-causing foreign substance, the ogist who made fundamental contributions in the early studies immune system launches a complex series of actions against of the genetic basis of bacterial antibiotic resistance, specifi- an irritating substance, referred to as an allergen. The immune cally the resistance displayed by Hemophilus influenzae, the response may be accompanied by a number of stressful symp- cause of influenzal meningitis (swelling of the nerves in the toms, ranging from mild to severe to life threatening. Her pioneering studies paved the way cases, an allergic reaction leads to anaphylactic shock—a con- for advances in treatment that have saved countless lives. After The immune system may produce several chemical working as a public health bacteriologist from 1923 to 1926, agents that cause allergic reactions. Some of the main immune she entered the Johns Hopkins School of Medicine. She system substances responsible for the symptoms of allergy are received her M. Alexander assumed a residency at the histamines that are produced after an exposure to an aller- New York City Babies Hospital in 1930. Along with other treatments and medicines, the use of for the remainder of her career, attaining the rank of Professor antihistamines helps to relieve some of the symptoms of in 1957. The study of Alexander pioneered studies of the antibiotic resistance allergy medicine includes the identification of the different and susceptibility of Hemophilus influenzae. In 1939 she suc- types of allergy, immunology, and the diagnosis and treatment cessfully utilized an anti-pneumonia serum that had been of allergy. Until then, infection with Hemophilus influen- responsible for seasonal or allergic rhinitis. Her antiserum for rhinitis, hay fever, a term used since the 1830s, is inaccu- reduced the death rate by almost 80%. Further research led to rate because the condition is not caused by fever and its symp- the use of sulfa drugs and other antibiotics in the treatment of toms do not include fever. Her discovery prompted 46 million allergy sufferers in the United States, about 25 mil- research that has led to effective treatments for croup. While the mite itself is too large to be inhaled, its feces are about the size of pollen grains and can lead to allergic rhinitis.


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Some of the authority of some of Andry’s critics medicine 94 cheap 500mg baycip overnight delivery, wrote these medications in spanish baycip 500mg purchase otc, such as the one on animal parasites treatment of lyme disease order 500mg baycip, were that with “un peu de merite et une grande talent not received very well schedule 9 medications generic baycip 500mg otc. He added to his unpopu- d’intrigue” he obtained his various positions of larity by leading the movement to require all importance and responsibility in the medical written contributions on medicine symptoms 0f diabetes baycip 500mg buy visa, surgery and affairs of Paris. Also, he was among those who per- student days onward suggests that Andry lacked suaded the Cardinal to issue the proclamation neither ideas nor courage, and his industry in that, “desormais les Chirugiens, au moment de numerous directions (making due allowance for faire quelque grande operation se feraient assister the opposition he encountered) indicated a keen d’un docteur. These are fair qualifica- In the list of Andry’s writings are papers on tions for a medical man in any age. Comments and Observations But whatever Finger it is, you ought to con- sider whether it is only Flesh, or Flesh and Bones like That Andry was entirely aware of the skeletal the rest. If it is only Flesh, it may easily be taken off, factor in some deformities is indicated by one of by the means of a Ligature of Silk tied about the Root his earliest statements about curvature of the of it. The Ligature must not be tight at first, but some spine: days after it may be tied a little tighter,... References Andry had plenty of precedent for his use of bandages and splints for the prevention and the 1. Andry N (1741) L’orthopédie, ou, L’art de prevenir correction of deformity. Such excellent works as et de corriger dans les enfans les difformites du that of Guido Guidi (Vidius), published in Paris corps, 2 vols, Paris, Alix 2. McMurtrie D (1914) Am J Care for Cripples 1:27 in 1544, provided him with illustrations from the 19 3. Orr HW (1952) History and biography of orthope- surgery of Hippocrates, Galen and Oribasius. Am Acad Orthop Surgeons Instruct Many of these illustrations, so well done by Pri- Course Lectures 9:423 maticcio, were primarily for wounds and frac- 4. Andry N (1843) Orthopaedia, or, The Art of Pre- tures, but all of the fundamental ideas for the venting and Correcting Deformities in Children, 2 control of position, and even for immobilization, vols, London, Millar were inherent in these earlier publications. Bick EM (1948) Source Book of Orthopedics, ed 2, Baltimore, Williams & Wilkins Andry discussed club foot quite thoroughly in 6. Hunter J (1837) Collected Works, Palmer JF (ed) a short paragraph: 4 vols, London 7. Delpech JM (1829) L’orthomorphie That Tendon which goes from the Calf of the leg to the 8. Pott P (1783) Collected Works, 3 vols, London Heel, is sometimes so short, that the Person is obliged 9. Keith A Menders of the Maimed, London, Oxford, to walk upon the fore part of his Foot, without being 1919; Philadelphia, Lippincott, 1951 able to set the Heel to the Ground... Garrison FH (1921) An Introduction to the History sometimes born with this Defect, and sometimes they of Medicine, ed 3, Philadelphia, Saunders come by it afterwards. Andry N (1741) De la generation des vers dans le provided this Shortness does not proceed from any corps de l’homme, 2 vols, ed 3, Paris, Alix violent Cause, which has absolutely maimed the 12. Paré A (1634) Johnson T (ed), London Tendon, such as a Burning after Birth, for example, or 13. Caulfield E (1928) A full view of all the diseases incident to children, Ann M Hist 10:409 any other Accident that is capable of rendering this 14. Biological Research, Dedicated to Sir William Osler, vol 1, p 189, New York, Hoeber Under “parathesis” there is an apparent refer- 15. William Brown of Melrosee (brother to the author 1852 of Rab and His Friends), and then in 1860 became 17. Dezeimeris JE (1828) Ollivier and Raige-Delorme: House-Surgeon to Professor Syme. After filling his Dictionnaire historique de la medecine, vol 1, term of office with much zeal, he became one of the p 138, Paris, Bechet junior demonstrators of Anatomy in the University, and 18. Stuck WG (1935) Historical backgrounds of ortho- was appointed by Professor Syme as his private assis- pedic surgery. Guidi G (1544) Commentaries upon the Surgery determination to be steadfast to Surgery. He then of Hippocrates, Galen, and Oribasius, with the became a lecturer in the Extra-Mural School, first on Drawings of Primaticcio, Paris Systematic and afterwards on Clinical Surgery. He was appointed Assistant-Surgeon to the Edinburgh Royal Infirmary, and in his turn became full Surgeon, which post he held when elected in 1877 to the Clinical Chair. Professor Annandale has been a diligent writer on Surgical subjects, having in 1864 published his Jacksonian Prize Essay on the “Malformations, Dis- eases, and Injuries of the Fingers and Toes, and their Surgical Treatment. So numerous were his minor papers, that between 1860 and 1877 no fewer than seventy-four separate contributions are recorded. Since 1877, and the respon- sible duties of a University Chair, only fifteen more can be discovered. Among so many, there must be great variety in value and importance, but all Professor Annandale’s papers are practical in character, describ- ing successful cases or modes of treatment, chiefly operative, indicating or originating advances in method. His style has all the simplicity of a personal Thomas ANNANDALE narrative, though it cannot be said to reach the marvel- lous terseness and quaint Hebraic force of his great 1838–1908 master. There is no doubt that the author has kept in step with surgical progress. As a teacher, he is thor- Thomas Annandale, since October 1877, has filled the oughly sound, and as an operator he is skilful, careful, Chair of Clinical Surgery, which was for so long a time quiet, and unobtrusive, without dash or show: the thing, held by the greatest surgeon of the nineteenth century, however difficult, gets done in an excellent way. He was born early in 1838, in When assistant to Professor Syme, he was as good Newcastle-on-Tyne, where his father practiced for an assistant as could be imagined—always ready, for- many years. He was educated at local schools and after getting nothing, perfectly quiet, never discouraged, and an apprenticeship of two years in connection with the never discouraging. To such qualities as these many Newcastle Infirmary, he began his professional studies serious and brilliant operations in the later days of his in the University of Edinburgh in 1856. He was soon distinguished among his to lend a helping hand to a set of Health Lectures, or fellow-dressers for his diligence, his constant work on any other popular fancy of the time. Pleasant and cour- the wards, his neat-handedness, and the zeal with which teous to all, he is an excellent example of success fairly he collected, dissected, and preserved any morbid spec- earned by single-eyed devotion to one line of work and to one great teacher. He was soon known to the House-Surgeon as a safe man to have ready on the nights when on duty, and, still better, as a good man to This biographic note by an unknown contem- take to private operations with the “Professor”. Annandale 12 Who’s Who in Orthopedics does not give any information regarding the type He then served during the Second World War as of anesthesia employed or the type of antisep- an Army medical officer in India. A junior staff man during the period pedic training and in 1947 was appointed as a in which Lister was perfecting his sterile tech- consultant to the Rowley Bristow Orthopedic niques at the Royal Infirmary, he was thoroughly Hospital at Pyrford on the south-western outskirts familiar with Lister’s methods. This was one of a number of tuber- work of Lister that permitted Annandale to be an culosis hospitals, which had been developed into aggressive, innovative surgeon. Thomas’ Hospital and with George Perkins, the inspirational Professor of Surgery. References From him, Alan Apley absorbed an understanding of the pathology and the healing of orthopedic and traumatic lesions, which was to be the sheet 1. Quasi Cursores: Portraits of High Officers and Professors of the University of Edinburgh at H’s anchor of his own clinical work. Edinburgh, University Press, His talent for teaching soon became apparent, 1884, pp 255–256 and lectures at Pyrford developed into a special course for the Final FRCS, starting in 1948. This was then the basic selection examination for all branches of surgery. Would-be surgeons, espe- cially those with little orthopedic experience, found the two long weekends at the Rowley Bristow an essential if somewhat frightening preparation for Finals. The orthopedic knowledge was so well organized that typed notes were requested, copied and passed around. These were seen by Ian Aird, the fiery Professor of Surgery at the Royal Postgraduate Hospital in Hammer- smith, who sent for the author and instructed him to turn them into a book. The first edition appeared as an unillustrated softback in 1959, interleaved with blank pages for personal notes. When the publishers offered to print a limited number of pictures for the second edition, Alan Apley’s typical response, involving much labor was to produce that number of composites, each containing a large number of postage-stamp, but perfectly adequate, images. Keeping this book up to date would have daunted many, but not until Alan Graham APLEY the sixth edition did he recruit Louis Solomon as 1914–1996 coauthor. It is now in its seventh edition as Apley’s System and a concise version is in its second Alan Apley was born in London, the youngest edition. It is so popular throughout the world that son of Polish parents; his father had served in the pirated editions have appeared, which Alan found Russian Army. His latest work with Professor brothers and one sister all showed the intelligence Solomon on clinical examination will now be and energy often seen in second-generation published posthumously, although he saw an immigrants. Many other books had Council schools in Battersea and at the Regent the very considerable benefit of his coauthorship, Street Polytechnic led him to medical studies at editing or other assistance. He qual- The FRCS courses continued, becoming ified MB BS in 1938 and became a Fellow of the known as the “Apley” course. He 13 Who’s Who in Orthopedics always responded, using to advantage his won- improved, and rememorized for the next fortun- derful collection of slides. In his patient manner he enjoyed the administrative and intellectual chal- insisted, sometimes quite firmly, on the continu- lenges and was a vice president from 1983 to ing value of many “old-fashioned” virtues: lis- 1985, delighting in the ceremonial. He was tening to the patient, careful clinical examination, appointed Director of Orthopedics at St. Thomas’ and an understanding of the biological processes Hospital in 1972, and was Honorary Treasurer of of disease and repair. Many of his interests, the British Orthopedic Association from 1972 to however, were wider. He skied and was an 1977 receiving the rare distinction of Honorary accomplished pianist, continuing to play in small Fellowship in 1985, having delivered the Robert chamber groups to the time of his last illness. Jones lecture in 1978 and the Watson–Jones His final and richly deserved honor was the lecture in 1984, appropriately enough on “Sur- award of the Honorary Medal of the Royal geons and Writers. This was Alan Apley became the editor of The Journal established in 1802 for “liberal acts or distin- of Bone and Joint Surgery in 1984, at the age of guished labours, researches and discoveries emi- 70 years, with undiminished energy and firm nently conducive to the improvement of natural views on standards and presentation. They Jones, Lord Webb Johnson, Lord Brock, and Sir were always encouraging, never unkind; some Stanford Cade. In his own quiet way, Alan Apley authors, delighted with his response, discovered fully deserved to be added to this distinguished only at their second read that their work had not list. His other great skill was the ability With the death of Alan Apley on 20 December to edit a muddled or ugly sentence into clear 1996, the orthopedic world lost one of its best- prose. Under his kindly editorship, authors felt known and best-loved teachers and writers. For happy to submit their work; there was a steady over 50 years, in an unassuming and often self- increase in the number of submissions and the effacing way, he used his skills in communication beginning of the now firmly international content to help and to guide the expansion of orthopedic of the Journal. He maintained a clear After retiring again, at 75 years of age, he view of the essentials, viewed each advance in the increased his teaching and writing activities. In light of his experience, and always emphasized 1990, for example, he gave instructional courses a hands-on, clinical and caring approach to or major lectures in 11 countries. Throughout his life he engaged in dis- became ill in autumn 1996, his aim was to be fit tilling the important facts from the mass of new for a teaching visit to Australia planned for spring information and then presented them in clear and 1997. He knew that he had unique gifts of expression His eldest brother John, a distinguished pedia- and presentation, but rarely explained and never trician, died before him. A second brother, Martin, mentioned the hours of hard work, the patience lives in London. His son Richard and his daugh- and the dogged persistence that had produced ter Mary, from his first marriage to Janie, have such results. His insistence on the “drawer” both inherited his interest and skill in music. His method of writing papers and lectures was not second wife, Violet, brought great joy into his theoretical; his own work was always put away later years, supported him in his travels and cared for later review and polishing, many times. Pencil for him with amazing optimism and energy and paper were his tools; a lecture or a chapter of during his final illness. The “spontaneity” and the “readability,” the clarity, the memorable phrases, and even Alan Apley devoted most of his indefatigable the jokes, were carefully orchestrated and timed. How fortu- 14 Who’s Who in Orthopedics nate it was that he lived long enough to dedicate five full decades to this. Alan’s internationally famous “Pyrford Post- graduate Course,” held twice each year, was attended by well over 5,000 orthopedic trainees and surgeons from the UK and countless other countries. It may be less well known that he organized and lectured at annual satellite courses for 18 years in New York and for 15 years in Toronto. Having yearned to be an actor, he did have some theatrical training, and his presenta- tions at home and abroad reflected this flair. His dramatic delivery gave clarity and impact, which was seasoned with a delightful sense of humor. He served in this capacity in seven universities in the United States, four in Christopher George Canada, four in Australia and 22 in other coun- tries throughout the world. His internationally acclaimed textbooks have 1922–1979 been used by hundreds of thousands of students and orthopedic surgeons worldwide. It is under- Born in 1922 into a medical family, Christopher standable that he became a legend in his own Attenborough was first educated at Marlborough time, and is entirely appropriate that the sixth and College and then went to Trinity College, Cam- seventh editions have been coauthored by Louis bridge, followed by King’s College Hospital, Solomon as Apley’s System of Orthopedics and qualifying in 1944. He has been facile soon posted to the East Indies fleet, where he princeps, easily the first, and his magnificent con- served as a surgeon lieutenant in destroyers, tributions as a teacher will live on through his including HMS Vigilant when it went into inspiring books. Singapore at the end of the war, and he was in the detachment that released the prisoners of war from Changi Prison. His exceptional hospital for 6 months before returning to England ability with written and spoken words displayed in 1947, continuing his training at King’s College a clear and well-ordered mind, which enabled him Hospital under Sir Cecil Wakeley and others. Anyone year at the Metropolitan Hospital as orthopedic who worked closely with him in any of his many registrar preceded his appointment in January distinguished roles soon became aware of these 1952 as first assistant to the orthopedic and acci- remarkable qualities. He could extract the essence dent department of the London Hospital under from a paper or a discussion, pick out the salient Sir Reginald Watson-Jones and Sir Henry points, and give a fair and unbiased opinion, Osmond-Clarke. When Christopher published an article it was He will also be remembered for his innate an event. He never wrote “pot boilers” but con- sense of humor, which made him a wonderful fined his publications to important contributions companion.

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For example symptoms for pink eye baycip 500mg purchase without prescription, motor (“expressive”) aphasias are characterized by nonfluent verbal output treatment uterine cancer discount baycip 500mg mastercard, with intact or largely unim- paired comprehension medicine you can take during pregnancy generic baycip 500mg line, whereas sensory (“receptive”) aphasias demon- strate fluent verbal output symptoms 0f kidney stones 500 mg baycip buy free shipping, often with paraphasias treatment eating disorders best baycip 500 mg, sometimes jargon, - 32 - Aphemia A with impaired comprehension. Conduction aphasia is marked by rela- tively normal spontaneous speech (perhaps with some paraphasic errors) but a profound deficit of repetition. In transcortical motor aphasia spontaneous output is impaired but repetition is intact. Aphasias most commonly follow a cerebrovascular event: the specific type of aphasia may change with time following the event, and discrepancies may be observed between classically defined clini- coanatomical syndromes and the findings of everyday practice. Aphasia may also occur with space-occupying lesions and in neu- rodegenerative disorders, often with other cognitive impairments (e. Summary of findings in aphasia syndromes Transcortical: Broca Wernicke Conduction Motor/Sensory Fluency ↓↓ ↓/N Comprehension N ↓↓ ↓ Repetition N/N Naming N? Philadelphia: Lippincott Williams & Wilkins, 2002: 27-39 Spreen O, Risser AH. Brain 1993; 116: 1527-1540 Cross References Agrammatism; Agraphia; Alexia; Anomia; Aprosodia, Aprosody; Broca’s aphasia; Circumlocution; Conduction aphasia; Conduit D’approche; Crossed aphasia; Dysarthria; Jargon aphasia; Neologism; Optic aphasia; Paraphasia; Transcortical aphasias; Wernicke’s aphasia Aphemia Aphemia was the name originally given by Broca to the language dis- order subsequently named “Broca’s aphasia. Aphemia probably encompasses at least some cases of the “foreign accent syndrome,” in which altered speech pro- duction and/or prosody makes speech output sound foreign. They usually reflect damage in the left frontal operculum, but sparing Broca’s area. The “pure” form of the phonetic disinte- gration syndrome (pure anarthria): anatomo-clinical report of a single case. London: Imperial College Press, 2003: 69 Schiff HB, Alexander MP, Naeser MA, Galaburda AM. Archives of Neurology 1983; 40: 720-727 Cross References Anarthria; Aphasia; Aprosodia, Aprosody; Dysarthria; Phonemic disin- tegration; Speech apraxia Aphonia Aphonia is loss of the sound of the voice, necessitating mouthing or whispering of words. As for dysphonia, this most frequently follows laryngeal inflammation, although it may follow bilateral recurrent laryngeal nerve palsy. Dystonia of the abductor muscles of the larynx can result in aphonic segments of speech (spasmodic aphonia, or abduc- tor laryngeal dystonia); this may be diagnosed by hearing the voice fade away to nothing when asking the patient to keep talking; patients may comment that they cannot hold any prolonged conversation. Aphonia should be differentiated from mutism, in which patients make no effort to speak, and anarthria in which there is a failure of articulation. Cross References Anarthria; Dysphonia; Mutism Apraxia Apraxia or dyspraxia is a disorder of movement characterized by the inability to perform a voluntary motor act despite an intact motor system (i. Automatic/reflex actions are preserved, hence there is a voluntary-automatic dissociation; some authors see this as critical to the definition of apraxia. Different types of apraxia have been delineated, the standard clas- sification being that of Liepmann (1900): - 34 - Apraxia A ● Ideational apraxia, conceptual apraxia: A deficit in the conception of a movement; this frequently interferes with daily motor activities and is not facilitated by the use of objects. Apraxia may also be defined anatomically: ● Parietal (posterior): Ideational and ideomotor apraxia are seen with unilateral lesions of the inferior parietal lobule (most usually of the left hemisphere), or premotor area of the frontal lobe (Brodmann areas 6 and 8) ● Frontal (anterior): Unilateral lesions of the supplementary motor area are associated with impairment in tasks requiring bimanual coordination, leading to difficulties with alternating hand movements, drawing alternating patterns (e. This may be associated with the presence of a grasp reflex and alien limb phenomena (limb-kinetic type of apraxia). Difficulties with the clinical definition of apraxia persist, as for the agnosias. For example, “dressing apraxia” and “constructional apraxia” are now considered visuospatial problems rather than true apraxias. Likewise, some cases labeled as eyelid apraxia or gait apraxia are not true ideational apraxias. The exact nosological status of speech apraxia also remains tendentious. Advances in Clinical Neuroscience & Rehabilitation 2005; 5(1): 16,18 Freund H-J. Cambridge: MIT Press, 2003: 239-258 - 35 - A Aprosexia Heilman KM, Gonzalez Rothi LG. Brain 1996; 119: 319-340 Cross References Alien hand, Alien limb; Body part as object; Crossed apraxia; Eyelid apraxia; Forced groping; Frontal lobe syndromes; Gait apraxia; Grasp reflex; Optic ataxia; Speech apraxia Aprosexia Aprosexia is a syndrome of psychomotor inefficiency, characterized by complaints of easy forgetting, for example of conversations as soon as they are finished, material just read, or instructions just given. There is difficulty keeping the mind on a specific task, which is forgotten if the patient happens to be distracted by another task. These difficulties, into which the patient has insight and often bitterly complains of, are commonly encountered in the memory clinic. They probably represent a disturbance of attention or concentration, rather than being a har- binger of dementia. These patients generally achieve normal scores on formal psychometric tests (and indeed may complain that these assess- ments do not test the function they are having difficulty with). Concurrent sleep disturbance, irritability, and low mood are common and may reflect an underlying affective disorder (anxiety, depression) which may merit specific treatment. Cross References Attention; Dementia Aprosodia, Aprosody Aprosodia or aprosody (dysprosodia, dysprosody) is a defect in or absence of the ability to produce or comprehend speech melody, intonation, cadence, rhythm, and accentuations, the nonlinguistic aspects of language which convey or imply emotion and attitude. Aprosodia may be classified, in a manner analogous to the aphasias, as: ● Sensory (posterior): Impaired comprehension of the emotional overtones of spo- ken language or emotional gesturing, also known as affective agnosia; this may be associated with visual extinction and anosognosia, reflecting right posterior temporoparietal region pathology. The aprosodias: functional-anatomic organization of the affective components of language in the right hemisphere. Archives of Neurology 1981; 38: 561-569 Cross References Agnosia: Anosognosia; Aphasia; Aphemia; Broca’s aphasia; Fisher’s sign; Visual extinction Arc de Cercle - see OPISTHOTONOS Arcuate Scotoma An arcuate scotoma suggests retinal or optic nerve disease, such as glaucoma, acute ischemic optic neuropathy, or the presence of drusen. Cross References Retinopathy; Scotoma Areflexia Areflexia is an absence or a loss of tendon reflexes. This may be physi- ological, in that some individuals never demonstrate tendon reflexes, or pathological, reflecting an anatomical interruption or physiological dysfunction at any point along the monosynaptic reflex pathway, which is the neuroanatomical substrate of phasic stretch reflexes. Sudden ten- don stretch, as produced by a sharp blow from a tendon hammer, acti- vates muscle spindle Ia afferents which pass to the ventral horn of the spinal cord, there activating α-motor neurones, the efferent limb of the reflex, so completing the monosynaptic arc. Hence, although reflexes are typically regarded as part of the examination of the motor system, reflex loss may also occur in “sensory” disorders, affecting the Ia affer- ents from the muscle spindle. It is often possible to “hear” that reflexes are absent from the thud of tendon hammer on tendon. Areflexia is most often encountered in disorders of lower motor neu- rones, specifically radiculopathies, plexopathies and neuropathies (axonal and demyelinating). Areflexia may also occur in neuromuscular junction disorders, such as the Lambert-Eaton myasthenic syndrome, in which condition the reflexes may be “restored” following forced muscular con- traction (facilitation). Transient areflexia may be seen in central nervous system disorders, such as cataplexy, and in acute spinal cord syndromes (“spinal shock,”e. Cross References Cataplexy; Facilitation; Hyporeflexia; Lower motor neurone (LMN) syndrome; Plexopathy; Radiculopathy; Reflexes Argyll Robertson Pupil (ARP) The Argyll Robertson pupil is small (miosis) and irregular. It fails to react to light (reflex iridoplegia), but does constrict to accommodation - 37 - A Arm Drop (when the eyes converge). In other words, there is light-near pupillary dissociation (ARP = accommodation reaction preserved). Since the light reflex is lost, testing for the accommodation reaction may be per- formed with the pupil directly illuminated: this can make it easier to see the response to accommodation, which is often difficult to observe when the pupil is small or in individuals with a dark iris. Although pupil involve- ment is usually bilateral, it is often asymmetric, causing anisocoria. The Argyll Robertson pupil was originally described in the context of neurosyphilis, especially tabes dorsalis. If this pathological diagno- sis is suspected, a helpful clinical concomitant is the associated loss of deep pain sensation, as assessed, for example, by vigorously squeezing the Achilles tendon (Abadie’s sign). There are, however, a number of recognized causes of ARP besides neurosyphilis, including: Multiple sclerosis Encephalitis Diabetes mellitus Syringobulbia Sarcoidosis Lyme disease Pinealoma Herpes zoster Hereditary motor and sensory neuropathies (Charcot-Marie Tooth disease; Dejerine-Sottas hypertrophic neuropathy) Miosis and pupil irregularity are inconstant findings in some of these situations, in which case the term “pseudo-Argyll Robertson pupil” may be preferred. The neuroanatomical substrate of the Argyll Robertson pupil is uncertain. A lesion in the tectum of the (rostral) midbrain proximal to the oculomotor nuclei has been claimed. In multiple sclerosis and sarcoidosis, magnetic resonance imaging has shown lesions in the periaqueductal gray matter at the level of the Edinger-Westphal nucleus, but these cases lacked miosis and may be classified as pseudo- Argyll Robertson pupil. Some authorities think a partial oculomotor (III) nerve palsy or a lesion of the ciliary ganglion is more likely. Four cases of spinal myosis [sic]: with remarks on the action of light on the pupil. American Journal of Medicine 1989; 86: 199-202 Cross References Abadie’s sign; Anisocoria; Light-near pupillary dissociation; Miosis; Pseudo-argyll Robertson pupil “Arm Drop” “Arm drop,” or the “face-hand test,” has been suggested as a useful diag- nostic test if hemiparesis or upper limb monoparesis is suspected to be psychogenic: the examiner lifts the paretic hand directly over the patient’s - 38 - Astasia-Abasia A face and drops it. It is said that in organic weakness the hand will hit the face, whereas patients with functional weakness avoid this consequence. However, the validity and reliability of this “avoidance testing maneuver” has never been examined; its clinical value is therefore doubtful. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 241-245 Cross References Babinski’s trunk-thigh test; Functional weakness and sensory distur- bance; Hoover’s sign “Around the Clock” Paralysis - see SEQUENTIAL PARESIS Arthrogryposis - see CONTRACTURE Asomatognosia Asomatognosia is a lack of regard for a part, or parts, of the body, most typically failure to acknowledge the existence of a hemiplegic left arm. Asomatognosia may be verbal (denial of limb ownership) or nonverbal (failure to dress or wash limb). All patients with asomatognosia have hemispatial neglect (usually left), hence this would seem to be a precon- dition for the development of asomatognosia; indeed, for some author- ities asomatognosia is synonymous with personal neglect. Attribution of the neglected limb to another person is known as somatoparaphrenia. The anatomical correlate of asomatognosia is damage to the right supramarginal gyrus and posterior corona radiata, most commonly due to a cerebrovascular event. The predilection of asomatognosia for the left side of the body may simply be a reflection of the aphasic problems asso- ciated with left-sided lesions that might be expected to produce aso- matognosia for the right side. Asomatognosia is related to anosognosia (unawareness or denial of illness) but the two are dissociable on clini- cal and experimental grounds. Neurology 1990; 40: 1391-1394 Cross References Anosognosia; Confabulation; Neglect; Somatoparaphrenia Astasia - see CATAPLEXY Astasia-Abasia Astasia-abasia is the name that has sometimes been given to a dis- order of gait characterized by impaired balance (disequilibrium), - 39 - A Astereognosis wide base, shortened stride, start/turn hesitation, and freezing. The term has no standardized definition and hence may mean different things to different observers. It has also been used to describe a disorder characterized by inability to stand or walk despite normal leg strength when lying or sitting, believed to be psychogenic (although gait apraxia may have similar features). Modern clinical classifications of gait disorders subsume astasia-abasia under the categories of subcortical disequilibrium and frontal disequilibrium (i. A transient inability to sit or stand despite normal limb strength may be seen after an acute thalamic lesion (thalamic astasia). Human walking and higher- level gait disorders, particularly in the elderly. Neurology 1993; 43: 268-279 Cross References Gait apraxia Astereognosis Astereognosis is the failure to recognize a familiar object, such as a key or a coin, palpated in the hand with the eyes closed, despite intact pri- mary sensory modalities. Description of qualities, such as the size, shape and texture of the object may be possible. There may be associated impairments of two-point discrimination and graphesthesia (cortical sensory syndrome). Astereognosis was said to be invariably present in the original description of the thalamic syn- drome by Dejerine and Roussy. Some authorities recommend the terms stereoanesthesia or stereo- hypesthesia as more appropriate terms for this phenomenon, to empha- size that this may be a disorder of perception rather than a true agnosia (for a similar debate in the visual domain, see Dysmorphopsia). Cross References Agnosia; Dysmorphopsia; Graphesthesia; Two-point discrimination Asterixis Asterixis is a sudden, brief, arrhythmic lapse of sustained posture due to involuntary interruption in muscle contraction. It is most eas- ily demonstrated by observing the dorsiflexed hands with arms out- stretched (i. Movement is associated with EMG silence in antigravity muscles for 35-200 ms. These features distinguish asterixis from tremor and myoclonus; the phenomenon has previously been described as negative myoclonus or negative tremor. Recognized causes of asterixis include: - 40 - Ataxia A Hepatic encephalopathy Hypercapnia Uremia Drug-induced, for example, anticonvulsants, levodopa Structural brain lesions: thalamic lesions (hemorrhage, thalamo- tomy) Unilateral asterixis has been described in the context of stroke, contralateral to lesions of the midbrain (involving corticospinal fibers, medial lemniscus), thalamus (ventroposterolateral nucleus), primary motor cortex and parietal lobe; and ipsilateral to lesions of the pons or medulla. Unilateral asterixis and stroke in 13 patients: localization of the lesions matching the CT scan images to an atlas. European Journal of Neurology 2004; 11(suppl2):56 (abstract P1071) Cross References Encephalopathy; Myoclonus; Tremor Asynergia Asynergia or dyssynergia is lack or impairment of synergy of sequen- tial muscular contraction in the performance of complex movements, such that they seem to become broken up into their constituent parts, so called decomposition of movement. Dyssynergy of speech may also occur, a phenomenon sometimes termed scanning speech (q. This is typically seen in cerebellar syndromes, most often those affecting the cerebellar hemispheres, and may coexist with other signs of cerebellar disease, such as ataxia, dysmetria, and dysdiadochokinesia. Cross References Ataxia; Cerebellar syndromes; Dysarthria; Dysdiadochokinesia; Dysmetria; Scanning speech Ataxia Ataxia or dystaxia refers to a lack of coordination of voluntary motor acts, impairing their smooth performance. The rate, range, timing, direction, and force of movement may be affected. Ataxia is used most frequently to refer to a cerebellar problem, but sensory ataxia, optic ataxia, and frontal ataxia are also described, so it is probably best to qualify ataxia rather than to use the word in isolation. Cerebellar hemisphere lesions cause ipsilateral limb ataxia (hemiataxia; ataxia on finger-nose and/or heel-shin testing) whereas midline cere- bellar lesions involving the vermis produce selective truncal and gait ataxia. These fibers run in the corticopontocerebellar tract, synapsing in the pons before passing through the middle cerebellar peduncle to the con- tralateral cerebellar hemisphere. Triple ataxia, the rare concurrence of cerebellar, sensory and optic types of ataxia, may be associated with an alien limb phenomenon (sensory type). There are many causes of cerebellar ataxia, including: ● Inherited: Autosomal recessive: Friedreich’s ataxia Autosomal dominant: clinically ADCA types I, II, and III, now reclassified genetically as spinocerebellar ataxias, types 1-25 now described Episodic ataxias: channelopathies involving potassium (type 1) and calcium (type 2) channels Mitochondrial disorders Huntington’s disease Dentatorubropallidoluysian atrophy (DRPLA) Inherited prion diseases, especially Gerstmann-Straussler- Scheinker (GSS) syndrome ● Acquired: Cerebrovascular events (infarct, hemorrhage): usually cause hemiataxia; postanoxic cerebellar ataxia Inflammatory: demyelination: multiple sclerosis, Miller Fisher variant of Guillain-Barré syndrome, central pontine myelinolysis - 42 - Ataxic Hemiparesis A Inflammatory: infection: cerebellitis with Epstein-Barr virus; encephalitis with Mycoplasma; HIV Neoplasia: tumors, paraneoplastic syndromes Neurodegeneration: one variant of multiple system atrophy (MSA-C); prion diseases (Brownell-Oppenheimer variant of sporadic Creutzfeldt-Jakob disease, kuru); idiopathic late- onset cerebellar ataxia Drugs/toxins: for example, alcohol, phenytoin Metabolic: vitamin E deficiency, thiamine deficiency (Wernicke’s encephalopathy), gluten ataxia, hypothyroidism (debatable) References Klockgether T (ed. Neurology in clinical practice: principles of diagnosis and management (3rd edition). Boston: Butterworth-Heinemann, 2000 309-317 Cross References Alien hand, Alien limb; Asynergia; Balint’s syndrome; Cerebellar syndromes; Dysarthria; Dysdiadochokinesia; Dysmetria; Head tremor; Hemiataxia; Hypotonia, Hypotonus; Macrographia; Nystagmus; Optic ataxia; Proprioception; Pseudoathetosis; Rebound phenomenon; Rombergism, Romberg’s sign; Saccadic intrusion, Saccadic pursuit; Scanning speech; Square-wave jerks; Tandem walk- ing; Tremor Ataxic Hemiparesis Ataxic hemiparesis is a syndrome of ipsilateral hemiataxia and hemi- paresis, the latter affecting the leg more severely than the arm (crural pare- sis). This syndrome is caused by lacunar (small deep) infarction in the contralateral basis pons at the junction of the upper third and lower two-thirds. It may also be seen with infarcts in the contralateral thala- mocapsular region, posterior limb of the internal capsule (anterior choroidal artery syndrome), red nucleus, and the paracentral region (anterior cerebral artery territory). Sensory loss is an indicator of cap- sular involvement; pain in the absence of other sensory features of thalamic involvement.

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He never received salary for his whose interest many of the contacts of the work medicine 7253 buy baycip 500 mg amex, and at the time the Association made the Journal with Soviet publications had been made first attempt to show their appreciation of his possible medicine effects discount baycip express. This sum was set up by over the standard of the papers presented at the the Association as the Elliott G treatment advocacy center purchase baycip american express. Brackett Endow- annual meetings treatment yeast infection 500mg baycip purchase with mastercard, and the creation of a Board of ment Fund treatment 2nd degree burn baycip 500 mg buy mastercard. Since the appointment of the a second attempt was made by the Association to latter, all papers have been submitted to this body, show their esteem, and a large number of letters and gradually the editor impressed upon them his were written to him, and a gift was made with the ideals and standards for a journal. No one not intimately associated with and to the Association, he found time to serve his him has any idea how much time and thought he community in its hospitals and in promoting gave to it. To him it was not merely a rostrum many movements to aid the physically handi- from which an author might exploit his ideas. He was identified with various Boston must present something that was new, or at least, hospitals, in his early years at the House of the if not wholly new, it must be presented in a better Good Samaritan, later as orthopedic surgeon at form than ever before. In 1911 he became chief the writers that brevity should be an accompani- of the orthopedic service at the Massachusetts ment of clarity in expression, and that it was a General Hospital and continued in that position mistake to rush into print before sufficient time until 1918, when he resigned to go into war had elapsed for a definite opinion to be formed as service. At the time of his death he was orthope- to the soundness of any position taken. His study of club feet July, 1898, he was sent to Cuba as representative published 60 years ago might well be used today of the Massachusetts Volunteer Aid Association. Besides his His assignment was to receive supplies sent on great technical contributions, particularly to the hospital ships and to determine the needs of the treatment of tuberculous coxitis and of congeni- men. His first concern was for the sick among our tal hip disease, he introduced the “social point of troops ready to be evacuated to the United States view” into orthopedic surgery by helping found and he made provision for their care on transports. His amazing Answering the call of his country in World War industry is attested by the publication between I, he was largely responsible for the training of 1887 and 1902 of 105 original papers, a textbook, the orthopedic personnel and for the determina- and numerous articles on orthopedic progress in tion of where they should be located after their the Boston Medical and Surgical Journal. He himself, eventually, was sent overseas, returning with the rank of Colonel. At the invitation of the China Medical Board of the Rockefeller Foundation, who learned that he contemplated a trip to China in 1922, he gave a series of lectures at the Peking Union Medical College and in one or two other medical centers. BRECK 1909–1993 The son of a pioneer dentist, Louis Breck was born in El Paso, Texas, in 1909. He was educated in local schools and attended Northwestern Uni- versity, from which he received his medical degree in 1933. He returned to El Paso to of the “founding fathers,” the third president of continue his practice and remained active until his the American Orthopedic Association (1889) and retirement in 1979. Professor of Orthopedic Surgery at the Harvard To his patients and friends, Dr. He had many innovative 38 Who’s Who in Orthopedics ideas, among which was a McBee card system, widening circle of friends in many different walks enabling him to keep track of the conditions that of life—was conspicuous for his athletic skill. He he was treating and to obtain long-term follow-up represented the hospital at lawn tennis, soccer, and studies on his patients. Breck was active in his water polo; and quickly became a scratch golfer. He was a member of the an ample allowance by a generous father, was able closely knit group of friends who were founders to indulge his hobby in a series of sporting cars. One year later he of 47 patients with hip disease using a cementless graduated as MB BS in the University of London, system consisting of a Urist acetabular cup and within 2 more years had successfully negoti- machined to fit precisely a hip prosthesis was ated the formidable hurdles of the primary and important, because it demonstrated that the use of final examinations for the FRCS (Eng). His first cement was not always necessary in total hip resident appointment at St. The quality of his technique can be house surgeon to Sir George Makins; this was fol- assessed by the fact that no case was complicated lowed by a term as senior house surgeon on the by infection. Bristow’s practical acquain- He died in El Paso on 24 September 1993 and tance with many forms of athletics and sport was barried in Evergreen Cemetery. He had already entered into military commitments as medical officer to the Middlesex Yeomanry and served with this unit in Gallipoli, being mentioned in dispatches for his conduct at the Suvla Bay landing. He returned to England in 1916 to convalesce from an attack of the prevailing dysentery and by a happy conspiracy of events came under the notice of Sir Robert Jones, who was then engaged in forming the staff of the Military Orthopedic Centre at Shepherd’s Bush, London. Bristow’s primary appointment was to organize and take charge of the electro-therapeutic department, but he was soon added to the surgical staff, and then joined the small band of younger orthopedic sur- geons who were to become the devoted disciples of Robert Jones in the post-war years. At Walter Rowley BRISTOW Shepherd’s Bush, Bristow devoted much time and 1882–1947 patience to the study of peripheral nerve injuries, and he made full use of the wealth of clinical and Walter Rowley Bristow was born at Bexley, operative material that came his way. He received his early his appointment on the Committee on Peripheral medical education at St. Thomas’ Hospital Nerve Injuries set up by the Medical Research Medical School, where among his contemporaries Council. Ostensibly he was selected as an expert and close friends were Charles Max Page, in after-treatment, for it brought him into contact Gathorne R. Girdlestone, and Godfrey Martin with the minds of such men as Henry Head and Huggins (later Prime Minister of Southern Wilfred Trotter. During his undergraduate years, disclaim any status as an academic, it became “Rowley”—as he became known to an ever- evident that his mental processes were as 39 Who’s Who in Orthopedics acute as those of the intellectuals, and his keen grace by “Rowley” and his devoted wife. George intelligence pierced through a mass of facts to the Perkins has given a vivid account of a typical day essential principles of a problem. Thomas’ Hospital set up an ortho- evening, with a break for lunch, at which there was never less than one guest, he worked at top pressure, pedic department. It was the end of an epoch and expending his own depthless energy and exhausting a breakaway from old tradition. There followed champagne was invited to become Director of Orthopedics at cocktail and a change for dinner. Dinner was an the hospital, and Bristow was formally appointed occasion. He had one of the best cooks in London, and to the staff as Orthopedic Surgeon. Sir Robert, could talk intelligently to any chef de cuisine on his then at the height of his powers and deeply subject. This was Bristow’s great Bristow was an original member of the British chance. He had already learned many things Orthopedic Association and served on the Exec- from his association and growing friendship with utive Committee for many years. One thing above all he saw dent during the years 1936–1937 and infused the clearly—that the head of a surgical clinic must society with his dynamic leadership. In this ambition before his death he was accorded the rare dis- he achieved an outstanding success, as witnessed tinction of emeritus membership. He was in due by the quality of the men he attracted in turn as course elected as a corresponding or honorary his chief pupils—George Perkins, E. Furlong; and by the influence he among them the American Orthopedic Associa- exerted on many more who came to sit at his feet tion and the French, German, Scandinavian, for shorter spells. Thomas’, he next looked out beyond the horizon In 1937, he delivered the Hugh Owen Thomas of the orthopedic department of a general hospi- Memorial Lecture in Liverpool, and in 1946, tal to discover a long-stay hospital, without which the Robert Jones Memorial Lecture at the Royal no orthopedic service was complete. By adapta- Regional Orthopedic Consultant, Bristow was tions and new buildings, St. Nicholas’ Orthopedic appointed Consulting Orthopedic Surgeon to the Hospital was gradually transformed into an active army and attained the rank of Brigadier. This was country orthopedic hospital, at first limited to his heart’s desire—to recreate the orthopedic children, and later providing adult wards. In the service in the army that Robert Jones had formed Second World War, this hospital became an ortho- during 1914–1918. He was eager to don uniform pedic center under the Emergency Medical again, and, in actual fact, his uniform from the Service, and it is to be known in future as the First World War still fitted him. He gave most Rowley Bristow Orthopedic devoted and distinguished service to the army, Hospital, a fitting tribute to the life and work of organizing the orthopedic sections of the military its first surgeon-in-chief. In 1946, the French Government appointed was conducted in and from 102 Harley Street, a him Chevalier of the Legion of Honour and house that contained some beautiful examples of awarded him a Croix de Guerre with palm. Number 102 was the scene steady output of contributions to surgical litera- of bounteous hospitality, dispensed with taste and ture. Two subjects held his interest throughout— 40 Who’s Who in Orthopedics disabilities of the knee joint, and injuries of Morayshire; an Alexander Brodie of Brodie was peripheral nerves. His Robert Jones Memorial Lord of Session in 1649 and his Jacobite descen- Lecture on the latter topic was a masterly exposi- dant, also named Alexander, migrated to London tion of the subject. As a teacher of undergraduates in the earlier part of the eighteenth century. Two of the to the heart of his subject and picking on the grandchildren, Lord Denman and Sir Benjamin essentials with clarity and emphasis. His out- Brodie, rose to eminence in law and medicine, patient clinics at St. Thomas’ were stimulating, one became Lord Chief Justice and the other memorable, and crowded. Thomas’ students will still recall such apho- tainly received a thorough grounding in the clas- risms as “We treat patients, not disease. Part of parental tutoring Rowley Bristow married in 1910, Florence, was the inculcation of industrious habits; the son only daughter of James White, LLD, and they had who became surgeon of St. But it was not all work, there was play-acting, in which young Denman joined, and the pastimes of the countryside. In that year, Napoleon had an army at Boulogne watching out for a favorable moment for the invasion of Britain. There was considerable alarm in England, of which the still standing defensive Martello Towers of the south coast are a symbol. Brodie and his brothers raised a company of volunteers under a commission signed by George III whereby William was appointed Captain and “Our trusty and well- beloved Benjamin Collins Brodie, gent, Ensign in the company. He joined Abernethy’s school of anatomy; here he met William Lawrence, after- wards surgeon to St. Bartholomew’s Hospital, Sir Benjamin Collins BRODIE with whom he formed a lifelong friendship. The 1783–1862 following year he attended the lectures of James Wilson at the Hunterian School of Anatomy in Benjamin Collins Brodie increased our knowl- Great Windmill Street and worked hard at edge of diseases of joints by his prolonged studies dissection. After spending nearly 2 years at of their clinical and pathological manifestations. George’s Hospital as He was born in 1783, the fourth of six children a pupil of Everard Home in 1803. Early the fol- of the Rector of Winterslow in Wiltshire, the lowing year his father died, leaving Mrs. Brodie Reverend Peter Bellinger Brodie, MA, who was in strained circumstances, dependent on a fixed educated at Charterhouse and Worcester College, income in days of high prices, war taxation and Oxford, and of Sarah, daughter of Benjamin depreciation of paper currency; an economy Collins, banker and printer of Milford near strangely descriptive of England 150 years on. The Brodies derived from a clan of But with austere living, saving and some sacrifice 41 Who’s Who in Orthopedics of capital she just managed to keep up supplies to first at 22 Sackville Street, but 3 years later moved her sons in mid-career. There were In May 1805, Brodie became house surgeon, a two sons and a daughter of the marriage; the elder post that he held for 6 months, when he resigned son became a Fellow of the Royal Society and on appointment as lecturer in anatomy at the Wayneflete Professor of Chemistry at Oxford, Windmill Street School. The he accepted a proposal from Everard Home to younger son became Vicar of East Meon. He lectured were of supreme importance to Brodie for, as he on the functions of the organs of respiration, remarked, “ These occupations afforded me the circulation and digestion, and on the nervous means of learning much as to my profession system. In practical surgery he was interested which cannot be learnt in a hospital; and further above everything else in diseases of joints, to by initiating me in the study of anatomy and which his attention was first directed when as physiology generally, without limiting my views house surgeon he dissected a specimen consisting merely to that which is required for surgical of a pathological dislocation of the hip. The the help and guidance of Clift, the Conservator of pathology of joint disease had been neglected; the Museum, who in his youth had lived in John there was great need of investigation, particularly Hunter’s home and was trained by him. With this in mind he an intimate knowledge of every specimen and wrote: “I availed myself of every opportunity manuscript such as no one else had. In In 1808, Brodie was appointed assistant particular I was anxious to do this when the surgeon to St. George’s Hospital, being attached morbid changes were still in an early stage, and to Everard Home; owing to the absence of where I had the opportunity of noting the symp- Gunning, another surgeon, in the Peninsular War, toms by which the incipient disease was indi- Brodie and Robert Keate shared his duties. Brodie cated, and the knowledge thus acquired became was at the hospital every day; he introduced clin- the basis of my future observations. Brodie’s joined James Wilson in lecturing on surgery at the researches on joint disease occupied the greater Windmill Street School. In 1818, he published His researches at the Royal College of Sur- his great treatise on Pathological and Surgical geons and his association with Sir Everard Home Observations on the Diseases of the Joints; it and Clift brought him into intimate contact with went through five editions, the last in 1850. In 1810, he was elected a rapid and it secured him an international reputa- Fellow of the Royal Society and the same year tion. It was the first serious attempt to separate the delivered the Croonian Lecture “On the Influence various conditions grouped together as “white of the Brain on the action of the Heart, and the swelling. He had consid- Copley Medal of the Society for his physiologi- erable success with spinal caries by his enforced cal researches. He was against any attempt at correction of Sellon who had been a barrister of a good deal of the kyphos, for he believed that the collapsed repute and the author of Sellon’s Practice, a work vertebrae provided for a more certain ankylosis. They lived He wrote: 42 Who’s Who in Orthopedics Without such undue interference of the part of the baronet in 1953; it was the work of Wyon of the surgeon, the carious surface of the vertebra above will Royal Mint. George’s without a sense of regret that by bony matter, and to this alone, that we are to his work there was over. Whatever disturbs this process (and any attempt to straighten the spine cannot delivered a short course of lectures to the students fail to do so) must therefore be carefully avoided. Yet in many instances after being for some time in the recumbent posture, the power of the will over the Brodie’s Abscess muscles begins to be restored; and I have known children, in whom the muscles of the lower limbs had been completely useless, after the lapse of three or four The lecture on abscess of the tibia was delivered years, to be able to walk and run and jump as well as in the theater of St. George’s Hospital on Novem- if they had never laboured under any kind of disease. George’s Hospital; for the next 18 years he was In the year 1824 I was consulted by a young man, 24 heavily engaged in his hospital and private prac- years of age, under the following circumstances: There was a considerable enlargement of the lower end of the tice; he lectured a great deal and continued with tibia, but the ankle joint admitted of every motion his physiological researches.

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Jared, 22 years: Once this has been done, alter the ques- tions accordingly, then send out a number of question- naires to the type of people who will be taking part in the main survey. A similar dis- The history of agar and agarose extends back centuries crimination of one bacterial species from another is not possi- and the utility of the compounds closely follow the emergence ble in liquid growth media. From being sedentary, people can develop life- threatening conditions such as pressure ulcers or pulmonary emboli (clots generally formed in leg veins that lodge in the lungs, blocking blood flow).

Renwik, 40 years: These musculos- keletal tissues all have a composite structure of cells embedded in a matrix produced by the cells themselves. The phenomenon known as the jogger’s high—a sense of extraordinary well-being—results from the flood of endorphins released postexercise. In particular, he was largely instrumental in the setting up of Professor Lipmann Kessel was born in South the spinal injuries unit and a specialist shoulder Africa, educated at the University of Witwater- unit, his own particular lifelong interest.

Mannig, 37 years: They were developed initially for ● Drager Medical training anaesthetists and they are now used for a wide variety The Willows of different scenarios. He subsequently developed an academic large man, but he was one of the giants of program that had ten full-time faculty members orthopedics. Pugh is best remembered for his “traction by suspension” and for his “Carshalton carriages,” which were the tools he used to diminish the destructive changes so manifest in tuberculous joints treated without traction.

Brenton, 62 years: Fred Daigle Early sixties; white; married to Martha, with several grown children; seventh- grade education; retired from job as painter and handyman; low income; severe chronic lung disease related to asbestos exposure and smoking, heart disease; required supplemental oxygen; walked slowly short distances in home without assistance. Style Various characteristics can be applied to lettering like italic or bold. He was of Office, which the British Orthopaedic Associa- always willing to do more if it was related to his tion presented to the president of each English- beloved orthopedics.

Gelford, 57 years: Considered to Hydrocephalus 27 be congenital lesions, they can become symptomatic at any age. The other nitrogen-fixing The representative species is Azotobacter vinelandii. Institute in Bethesda, Maryland, announced his own discovery of the HIV virus in April 1984 and received the patent on the AIDS, recent advances in research and treatment; test.

Pedar, 33 years: Karp finds that, “Although you may have to assert yourself to get the right wheelchair, it’s possible that approval from your insurance company will go smoothly” (1998, 25). The gold standard for results can be identified by a series that uses second-look arthroscopy as an outcome measure. Although the majority of records are pa­ per based (manual records), there are an increasing number of computer-based notes (electronic records).

Ben, 30 years: The following year he became a Fellow of greatest strain, lent some support for this of the Royal College of Surgeons and in 1883 pro- view—what Lane called “crystallisation of the ceeded to the degree of Master of Surgery. For example, common side effects of baclofen (frequently used to treat spasticity) include fatigue, increased drooling, and fatigue. Since many people with mobility difficulties cannot do sustained weight-bearing exercise, they are especially prone to osteoporosis or thin- ning bones, increasing their chances of fractures.

Grok, 43 years: You will be taught in the out-patients department as well as on the ward. The operator, however, still has the responsibility for delivering the shock and for ensuring that everyone else is clear of the patient and safe before the charge is delivered. They can get into the bathroom, that there’s a clear path, there’s no obstacles, no cords, no scatter rugs, especially if they use a mobility device.

Esiel, 39 years: Available directed history of the seizure episode and the child’s previous medical history should be obtained and the child examined. Reflecting on this experience, I recognised two fundamental problems with the substitute medication approach, one relating to motivation, the other to addiction. These studies also have demonstrated that daily treatment is more effective than alternate-day therapy.

Hatlod, 28 years: In summary, because patient numbers are so small, firm conclusions cannot be drawn regarding the efficacy of immunomodulatory therapies. Advisory Committee to the Surgeon-General of the Public Health Service (1964) Smoking and Health, Atlanta: US Department of Health, Education and Welfare. His in the Ottawa Civic Hospital he moved to New advanced ideas in orthopedic surgery led him to York for further training.

Tippler, 46 years: In 1993, he received the Lifetime Achievement Award from the Joint Implant Surgery and Research Foundation, in commemoration of 60 years of surgery. This must then be reassessed (audited) to check that care has improved (Figure 18. Multiple factors probably contribute, including differences in access to care and personal preferences.

Falk, 42 years: As well, Costerton discovered the Other species of the genus Corynebacterium cause mas- so-called bioelectric effect, in which an application of current titis in cows (an infection and inflammation of the udder), makes a biofilm much more susceptible to antibiotic killing. The Bicontact Hip System fulfills all these aspects and thus justifies the catalogue of requirements we initially have laid down. The tunnels are drilled centrally through the epiphysis and fixed with a button on the periosteal surface.

Jaffar, 29 years: But then the doctor said they couldn’t guarantee me more than fifteen years, and fifty-five is kind of young to get something like that done. The only way to sleuth out your solutions is by being fully aware of your con- dition and working through the Eight Steps. How bad memories can sometimes lead to fan- tastic beliefs and strange visions.

Jorn, 26 years: The precise neuroanatomical substrate is unknown but the associ- ation with basal ganglia disorders points to involvement of this region. A checklist for a five minute Marks station that is testing history taking may have up to 25 items if a ❑ Drapes patient appropriately 2 faculty observer is doing the scoring. Terayama K (1982) Natural process and waiting strategy for treatment of osteoarthri- tis of the hip (in Japanese).

Rhobar, 60 years: Paraldehyde (no longer available in the United States) has been used as an IV bolus of 400 mg, followed by a further bolus of 200 mg. They will do this in a number of ways, from laughing to getting up and walking around. Magnuson was called to Washington, DC, to staffed by medical school faculties, residency pro- serve as an assistant to Dr.

Snorre, 45 years: This is a synkinesis of central origin involving superior rectus and inferior oblique muscles. The basic details are not difficult, but most newly qualified doctors get stuck on the cause of death (Ia, Ib, Ic and II). Social Encounters in the Last Two Weeks Social Encounter (%) Mobility Visited Ate Attended Church Difficulty Friends Out or Temple Mild 70 60 46 Moderate 62 52 39 Major 55 44 30 terviews illustrate these diverse dynamics.

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