What is paralysis?

Nervous System Functions

To understand the causes of paralysis—weakness or the inability to move a part of the body—it is necessary to review briefly the motor nervous system and muscles. Following an action from initiation to completion through the motor nervous system may clarify this process. One may begin, for example, with a voluntary movement. An alarm clock rings early one morning. A sleeper hears the noise and decides to hit the snooze button. This decision is made in the cerebral cortex, which sends impulses to the nerves in the arm via the spinal cord.

The actual microscopic actions that result in a nerve impulse traveling from the motor cortex all the way to individual muscles will be briefly reviewed. An individual nerve cell, or neuron, comprises three parts: the dendrites, the cell body, and the axon. The cell body conducts the metabolism for the cell and otherwise keeps things in running order, but it has little direct involvement with the transmission of nerve impulses.

Dendrites are similar in appearance to the roots of plants. They are numerous and relatively short. Their function is to pick up impulses received either from sensory organs or from other cells. They do this when the receptors on their surface become activated by certain chemical signals released by neighboring nerve cells. Once these receptors are activated, they initiate a process known as depolarization.

In the most basic description, depolarization refers to the generation of a minute electrical charge on nerve cell membranes. It occurs through the motion of charged molecules, or ions, across the cell membrane. The specific ions involved include potassium, sodium, and calcium. Depolarization progresses down the length of the nerve cell. It passes through the dendrite to the cell body of the nerve cell and then to the axon. The axon is long and thin, some axons reaching lengths of three or more feet. Depending on its type and function, the axon may split into small filaments that go to several nerve or muscle cells, or it may remain single.

The sending axons do not touch the receiving cells when passing an impulse. Instead, they come close to the receiving cell’s dendrites but leave a small gap (the synapse). Once a nerve impulse reaches the end of an axon, the axon releases chemical compounds called neurotransmitters.

Synthesized by the nerve cell, the neurotransmitter is collected and stored in small packets resting at the end of the axon. In response to depolarization, the small packets of neurotransmitter are released into the synapse, and the original electrical nerve impulse is converted into a chemical impulse. When the neurotransmitter is released, it diffuses across the gap and contacts specific receptors on the dendrite of the receiving nerve cell. The receiving nerve cell’s receptors then depolarize the receiving nerve cell, converting the chemical impulse back into an electrical one.

The receiving nerve cell is forced to continue depolarizing until the neurotransmitter is no longer in contact with the receptor, or until the nerve cell itself becomes exhausted and cannot depolarize again. To allow the receiving nerve cell to stop firing and to prepare itself for another signal, the neurotransmitter must be removed rather quickly from the receptor. This can be done by the axon of the sending cell, which takes it back in, or by enzymes located within the synapse that actually destroy the neurotransmitter. The most common neurotransmitter is acetylcholine, and the most frequently encountered form of enzyme that destroys neurotransmitters is called acetylcholinesterase.

The transmission of the nerve impulses signaling the hand to press the alarm clock’s snooze button involves passing the impulses through several nerves. The impulses form synapses on nerve cells in the spinal cord before those cells pass the impulse down the spinal cord toward the arm to cause the desired action.

The spinal cord is protected inside the vertebral column, a hollow column of bone. This column is made up of a stack of vertebrae supported by solid bone in the front and a hollow ring of thinner bone in the back through which the spinal cord runs. The vertebrae are anchored to one another by bony connections; the facets and vertebral spines; fibrous ligaments to the front, back, and side; and the intervertebral disks. Disks are made up of soft, gelatinous material surrounded by fibrous tissue. The disks and joints in the vertebral column allow the spine to flex and turn, while the bony column surrounding the spinal cord provides protection.

When the nerve leaves the spinal cord, it travels in what is called the motor ramus, or “root.” The ramus passes through an opening in the vertebral column called a foramen. While passing through the foramen, the ramus passes near the intervertebral disk. The motor nerve fibers (and consequently the nerve impulses sent out to turn off the alarm clock) in the motor ramus join with the sensory nerve fibers in the sensory ramus just outside the vertebral column, and together they form the spinal nerves. These spinal nerves regroup to form peripheral nerves.

A peripheral nerve is the part of the nervous system that finally contacts the muscles that turn off the alarm clock. Peripheral nerves carry both sensory and motor information in the same nerve. They are the only locations in which sensory and motor nerve fibers are so completely joined. Peripheral nerves must sometimes pass through relatively tight or exposed locations. An example of an exposed nerve is the “funny bone,” the ulnar nerve, which causes an unpleasant sensation when struck. Nerves that pass through tight spaces may suffer entrapment syndromes. A common nerve entrapment syndrome is carpal tunnel syndrome, in which the median nerve is squeezed in the fibrous band around the wrist.

Finally, the arm muscles themselves become involved in the process of turning off the alarm. The muscles are made up of numerous muscle fibers, and each muscle fiber is made up of numerous muscle cells. Inside each muscle cell are two active protein filaments, actin and myosin, which pull together when activated, causing the muscle cell to shorten. When the majority of muscle cells “fire” at once, the whole muscle contracts. The signal from nerve to muscle cell is transmitted across a synapse. The snooze button is pushed, and the alarm ends. Finally, the signals to the arm end, and the filaments slide back to their initial positions, relaxing the muscle cells.

For actin and myosin to move well, there must be adequate blood flow and adequate concentrations of substances such as oxygen, glucose, potassium, sodium, and calcium. Many other substances are needed indirectly to keep muscle cells functioning optimally, including thyroid hormone and cortisone.

Types of Paralysis

True paralysis is the inability to produce movement of a part of the body. Paralysis may result from problems at many locations in the body, such as the motor cortex of the brain, the spinal cord, the nerves in the arms or legs, the blood, or the muscle cells themselves. Doctors must determine the specific cause of paralysis or weakness since the treatment of each disease is different. The first task is to determine whether the weakness or paralysis is caused by a disease of the nervous system, the muscle cells, or one of the substances that interferes with nerve conduction or muscular contraction. Some characteristics of specific problems are helpful in this diagnosis.

Disease of the nervous system is most often associated with complete paralysis. Diseases affecting the muscle cells or the factors controlling them are usually associated with a partial rather than complete paralysis—there is weakness rather than a lack of movement. When weakness is severe, however, it may be mistaken for complete paralysis. The fact that diseases of the nervous system cause paralysis of one side of the body (hemiplegia) or one part of the body is helpful in diagnosis. Paralyzing conditions that affect muscle cells tend to result in whole-body weakness, although some muscles may be more severely affected than others. Another aid in differentiation is that neurologic diseases are almost always associated with some degree of impairment in sensation, while muscular causes are never associated with sensory loss.

Damage to the central nervous system and to the peripheral nervous system can be differentiated by features of the dysfunction. Central nervous system problems affect either half of the body or one region of the body, while peripheral damage affects only the muscles controlled by the damaged nerve or nerves. Central nervous system damage leaves pronounced reflexes, while damage to peripheral nerves results in an affected area without any reflexes. There is some muscle wasting with either type of paralysis, but the wasting seen after a peripheral nerve disease appears more quickly and more severely. When central nervous system damage occurs, the muscles involved are generally tight (spastic paralysis). Conversely, in patients with peripheral nervous system damage, muscles are usually loose. Through attention to these differentiating features, the source of paralysis can usually be discovered.

In adults, the most common cause of paralysis is stroke. A stroke results from interruption of the blood supply to a part of the brain. After being cut off from blood flow, the affected area dies. Brain tumors may also cause paralysis. Unlike strokes, however, which cause most of their damage as soon as the blood supply is interrupted, the damage produced by tumors tends to increase slowly as the tumor grows. An interesting feature of brain tumors is that they are surrounded by an area of swelling called edema. The edema, not the tumor itself, causes most of the neurologic changes. This distinction is important because edema is usually responsive to medical treatment.

Subdural hematomas are collections of blood that are outside the brain but inside the skull. They are seen most frequently in older people and alcoholics. To form a subdural hematoma, a small blood vessel becomes injured in such a way that blood slowly oozes from it, accumulates, and clots. Interestingly, the trauma may be so slight as to not be remembered by the patient. This clot may cause pressure on the motor cortex that results in paralysis. Generally, subdural hematomas are slow in onset.

Multiple sclerosis, a disease affecting the nervous system, causes scattered, multiple small areas of destruction virtually anywhere in the brain or spinal cord. The extent of paralysis depends on the sites and extent of the damaged areas. Patients often have impairments in vision, speaking, sensation, and coordination.

If the spinal cord is the cause, the extent and location of the paralysis and numbness depend on the size, location, and level of the lesion. Spinal cord paralysis may result from trauma, tumors, interruption of blood flow, blood clots, or infections such as abscesses. These disorders are similar, except for location, in most respects to the previously described conditions in the brain. One of the conditions, however—trauma of the spinal cord—is very different from trauma of the brain.

Significant trauma may result in fracture of the vertebral column. Spinal fractures may be classified as stable or unstable. Unstable fractures, unlike stable ones, are often associated with paralysis because unstable fractures allow subluxation to occur. Subluxation is a dislocation of the vertebral column that compresses the spinal cord. If it occurs in the neck, quadriplegia (paralysis of all four limbs) results. If it occurs lower down the spine, paraplegia (paralysis of both lower limbs) is seen. On occasion, through inadvertent or excessive movement, overenthusiastic rescuers cause permanent paralysis by converting a nonsubluxated fracture to a subluxated one during rescue attempts.

Another unique type of spinal cord trauma is the rupture of an intervertebral disk, which allows the gelatinous material to press on the spinal cord or on the rami leaving the spinal cord. In addition to causing severe pain, an intervertebral disk rupture may cause weakness or paralysis. It usually affects only one or two rami and spares the spinal cord itself. Trauma to the spinal cord is particularly dangerous to individuals with conditions that weaken the bony spine. These conditions include osteoporosis of all types and rheumatoid arthritis.

Peripheral nerve damage can occur through a number of conditions that may result in nerve degeneration, including diabetes mellitus, vitamin deficiencies, use or abuse of certain medications, and poisoning by toxins such as alcohol and lead. Sometimes, a temporary nerve degeneration called Guillain-Barré syndrome follows upper respiratory tract infections and may be quite serious if the respiratory muscles are affected. A peripheral nerves may also be damaged by direct trauma, or by pressure as it passes through a narrow compartment, as happens in carpal tunnel syndrome. Peripheral nerve conditions are accompanied by numbness, tingling, and weakness or paralysis of only the area served by the affected nerve.

Paralysis may complicate diseases affecting muscles, although in these cases the patients usually demonstrate weakness rather than paralysis. In muscular diseases, the paralysis (or weakness) tends to affect all the muscles of the body, although some may be more affected than others. The most frequent causes of paralysis in children are inherited diseases such as muscular dystrophy. In adults, muscular diseases are mainly attributable to hormonal imbalances caused by problems such as an underactive thyroid gland or an overactive adrenal gland.

Paralysis may result if the concentration of certain substances in the body is significantly altered, although weakness is a much more common occurrence. The concentration of potassium, sodium, calcium, glucose, and specific hormones may dramatically affect muscle strength. A specific, though uncommon, disease of this type is periodic hypokalemic paralysis, a condition that runs in families. In this disorder, the amount of potassium in the blood can be dramatically reduced for short periods of time, resulting in brief periods of severe weakness or paralysis. These episodes rarely have serious consequences.

Weakness or paralysis may result if the body is unable to produce adequate amounts of acetylcholine, or if this neurotransmitter is destroyed in the synapse before it can pass on its message. Myasthenia gravis is the most common example of this type of disorder. Affected patients initially have adequate strength, but they develop weakness and paralysis in muscles during periods of use because acetylcholine stores become depleted. The weakness in this condition tends to become more prominent as the day wears on. The most frequently used muscles are the most affected. This type of paralysis temporarily improves after rest or medication.

Another unique type of paralysis, called Todd’s paralysis, may follow a generalized epileptic seizure. It happens only when the seizure has been so extensive and prolonged that the nerve cells in the brain are literally exhausted and no longer able to initiate the nerve impulses needed to generate movements. This paralysis is temporary.

Paralysis may be caused by a variety of psychiatric disorders, including hysteria, catatonic psychosis, conversion disorder, factitious disorder, and somatization disorder. In psychological paralysis, the patient’s inability to move parts of the body is psychological. This paralysis is particularly common during periods of high stress such as combat. Psychological paralysis should be differentiated from malingering. In a psychological paralysis, the patients genuinely believe that they are paralyzed, whereas malingerers, though they deny it, know that they are not paralyzed. Malingering is usually seen when some benefit resulting from the paralysis is anticipated.

Perspective and Prospects

Once a nerve cell has been destroyed, it cannot be repaired. This is the main reason that the outlook is quite poor when most types of paralysis occur. The only thing that doctors can do is to try to limit the extent of the paralysis. Improvements can be made only by training the neighboring cells to take over the functions of the lost cells.

After suffering a paralyzing event, a patient begins rehabilitation using a number of exercises. These activities are usually carried out with the help of physical therapists, occupational therapists, or kinesiotherapists. Unfortunately, progress is rather limited, and most patients are not able to resume their old lifestyle after suffering extensive paralysis.

It is very important to take seriously paralysis or weakness that is localized to a single muscle or single group of muscles. Doctors need to find out the cause of this weakness as soon as possible and take steps to minimize or reverse the damage prior to complete destruction of the nerve cells. Initial and subsequent stroke prevention, tumor treatments, hematoma evacuation, spinal alignment and stabilization, intervertebral disk surgery, toxin removal, hormonal manipulation, and ion correction are all currently available methods of dealing with paralysis.

Because of the poor prognosis for overcoming paralysis, research has focused on understanding how nerve cells grow. Some lower animals possess an ability to regenerate nerve cells when they are damaged. It is well known that a lobster which has lost one of its claws can regenerate that claw, as well as the nerves that control the claw’s functioning. A lower animal nerve growth factor has been identified and is being examined by a number of researchers. It is likely that drugs which could aid regeneration of damaged nerve cells in higher animals will be discovered. Once available, these drugs will improve the outlook for recovery of patients with paralysis. These medications may also help with other conditions associated with nerve cell damage, such as Alzheimer’s disease and Parkinson’s disease.

Progress in medical treatment and an increased health awareness by the public will reduce the incidence of diseases such as diabetes mellitus and the intake of toxins, such as alcohol, that may cause paralysis. Seat belt laws and motorcycle helmet laws may reduce the incidence of paralysis by reducing the severity of injuries in motor vehicle accidents.

Progress in neurosurgery should also improve a patient’s hope for recovery in trauma cases. Although dead nerve cells cannot regenerate, cut nerve filaments may be able to regenerate and reattach, which is why surgeons have been able to reattach severed limbs. With progressively finer techniques and equipment, the success rate should improve further. Future progress in neurosurgery may also benefit patients whose paralysis is attributable to causes other than trauma. Progress in genetic research may allow scientists to isolate the genes responsible for diseases causing paralysis. Diseases such as myasthenia gravis and muscular dystrophy could respond to treatment if genetic therapies are found.

Bibliography

Bear, Mark F., Barry W. Connors, and Michael A. Paradiso. Neuroscience: Exploring the Brain. 3rd ed. Philadelphia: Lippincott, 2009. Print.

Christopher and Dana Reeve Foundation, Paralysis Resource Center. http://www.christopherreeve.org.

Cure Paralysis Now. http://www.cureparalysisnow.org.

Goroll, Allan H., and Albert G. Mulley, eds. Primary Care Medicine. 5th ed. Philadelphia: Lippincott, 2006. Print.

Kandel, Eric R., James H. Schwartz, and Thomas M. Jessell. Principles of Neural Science. 5th ed. New York: McGraw, 2013. Print.

Lukas, Rimas. "Quadriplegia and Paraplegia." Health Library, 15 Mar. 2013. Web.

MedlinePlus. "Paralysis." MedlinePlus, 9 Aug. 2013. Web.

Nicholls, John G., A. Robert Martin, and Bruce G. Wallace. From Neuron to Brain. 5th ed. Sunderland: Sinauer, 2012. Print.

"Progress for the Paralyzed." MedlinePlus Magazine 8.1 (2013): 10. Print.

Tortora, Gerard J. Principles of Anatomy and Physiology. 14th ed. [S.I.]: Wiley, 2013. Print.

What is sneezing?

Causes and Symptoms

During the breathing process, the lung part of the chest cavity is expanded and air is allowed to flow in. When impulses that cause excitation reach a threshold level in the nasal lining, a message is transferred to the sneeze reflex center of the brain via the sensory nerves. At that point, the stimulus provides the chest muscles with the signal to convulse and therefore squeeze the lungs. The contracted muscles in the pharynx block the exit of the air from the mouth and instead detour it through the nasal cavity and out into the atmosphere. The phenomenon of genuine sneezing cannot be performed voluntarily and, at the same time, cannot be easily suppressed. In fact, suppression may create an increase in pressure in the acoustic part of the body, with occasional serious results.

During inhalation, air is inserted through the nostrils, heated to the body temperature, humidified, and finally filtered of foreign contaminants (such as bacteria and dust particles) before it enters the lungs. When the air contains a large quantity of particles, such as dust or pollen during windy conditions, or is drier or colder than expected, sneezing takes place. The main reason for this reaction is irritation of the nerve endings, which is temporarily relieved by the explosive blowing of air during sneezing. The process is intensified in both children and adults by several nasal disorders, such as congestion attributed to bacterial infection, cold, allergy created by foreign particles, pressure, or a growth inside the nostril. In addition, up to one-third of the population tends to sneeze when exposed to a sudden bright light, a reaction termed photic sneeze reflex (also known as photoptarmosis) that may be genetic.

Treatment and Therapy

In a way similar to coughing, in which air is expelled through the mouth, sneezing has a protective role in breathing. The hairs inside the nostrils, known as cilia, serve as the filtering device and, when they cannot trap the contaminants, as the instigators for the irritation of the nerve endings. Their presence is therefore instrumental in protecting the windpipe from the solid particles that are suspended in air. Parents may have a young child blow his or her nose in order to remove the trapped particles in the nasal mucus. This action should be performed with the minimum damage of the capillaries, which may collapse and lead to a nosebleed, possibly followed by an infection.

Perspective and Prospects

Sneezing is very important because it serves as the first weapon of the respiratory system’s defense against invading foreign particles. The search goes on for inhalers and other medications to relieve the effects of sneezing, as well as for various means to release the pressure created by the common cold and rhinoviruses. The traditional methods of soothing nerve endings with steam and other vaporizers are still dependable and help in avoiding the subsequent spread of the more serious viral infections such as pneumonia and bronchiolitis.

Bibliography

Adler, Tina. “The Radical Theory of Sneezing.” Environmental Health Perspectives 113, no. 11 (November 1, 2005): A736.

Can, Ilknur, et al. "Sneezing and Runny Nose: Should Allergy Testing be Routinely Performed." Indian Journal of Otalaryngology and Head and Neck Surgery 65 (August, 2013): 267–270.

Fowler, Michael A., and Nancy McKemie. "What's the Reason for All That Sneezing and Wheezing?" Tuscon: Fireship Press, 2012.

Karpa, Kelly Dowhower. “The Assault on Allergies: From Diagnostics to Treatments.” Drug Topics (June, 2000): 12S–16S.

Knight, Allan. Asthma and Hay Fever: How to Relieve Wheezing and Sneezing. New York: Arco, 1981.

McCarthy, Robert. “New Approaches to Allergic Rhinitis and Asthma.” Patient Care 34, no. 19 (October 15, 2000): 108–118.

Miller, Kathryn E., and Ian M. Mackay. "From Sneeze to Wheeze: What We Know About Rhinovirus Cs." Journal of Clinical Virology 57, no 4 (August, 2013): 291–299.

Ross-Flanigan, Nancy. “Nothing to Sneeze At.” Health 14, no. 3 (April, 2000): 102–104.

Voelker, Rebecca. “Allergies: More than Just Sniffles and Sneezes.” Business and Health 18, no. 4 (April, 2000): 19–25.

Let F(x)=f(x^9) and G(x)=(f(x))^9 and suppose that a^8=6, f(a)=2, f′(a)=12, f′(a^9)=4 find F'(a) and G'(a)

We begin by stating the given information: 

`F (x) = f(x^9)` ... Eq. 1.1

`G(x) = (f(x))^9` ... Eq. 1.2

Additionally we are given :

`a^8 = 6`  ... Eq. 2.1

`f(a) = 2` ... Eq. 2.2 

`f'(a) = 12` ... Eq. 2.3

`f'(a^9) = 4` ... Eq. 2.4

We are required to find: 

`F'(a) = ?`

And 

We have to use to above equation to solve what is required. Let's begin by solving F'(a): 

If `F(x) = f(x^9)`

` `

 Then using the chain rule :

`F'(x) = f'(x^9) * 9x^8`

Therefore applying ourselves, by substituting 'a' for 'x': 

`F' (a) = f'(a^9) * 9a^8`

We can now substitute Eq. 2.4 and Eq. 2.1

`F'(a) = 4 * 9(6) = 216` 

We have solved the first part, now let's solve the last part: 

If `G(x) = (f(x))^9`

Then using the chain rule: 

`G'(x) = 9[f(x)}^8 * f'(x)`

Now we can apply ourselves by substituting 'a' for 'x':

`G'(a) = 9 [f(a)]^8 * f'(a)`  

Now substitute eq. 2.2 and eq. 2.3 in the above equation: 

`G'(a) = 9* (2)^8 * 12 = 27648`

SUMMARY: 

F'(a) = 216

G'(a) = 27648

What is the significance of the Great Purge?

The Great Purge took place in the Soviet Union between 1936 and 1938.  In the Great Purge, Josef Stalin targeted rich peasants, entrepreneurs, clergy, military commanders and political rivals.  During the Purge, Stalin collectivized more of the farms in Ukraine and Kazakhstan and ordered show trails and executions for anyone who was not willing to give up everything and move to a collective.  Moscow exported food while the people who lived in these areas was starving--through collectivization, Stalin targeted any nationalists who were not loyal to Stalinism.  Entrepreneurs were seen as opportunists because they were not willing to give everything they had to the state.  This did not strengthen Stalin's Five Year Plan, but rather pushed the black market for goods further underground and it would remain a staple of Soviet life well after Stalin's death.  Stalin demolished any outward signs of religion in the Soviet Union and replaced them with monuments to himself and Communism.  After the purge Stalin bragged that the Soviet Union was the world's first atheistic state, but churches continued to meet in secret.  The most dramatic part of the Purge, however, was Stalin's willingness to kill his top generals and innovative military thinkers.  Stalin was a paranoid man who feared being replaced by a strong military leader.  He targeted these generals on the grounds that they were Western sympathizers.  Stalin's decision to kill his top military brass put his armed forces behind in terms of leadership and technology and early Soviet failures against Hitler would prove that this was a grave mistake.  

What is sudden infant death syndrome (SIDS)?

Causes and Symptoms

The distribution of sudden infant death syndrome (SIDS) is worldwide. According to the Centers for Disease Control and Prevention (CDC), 1,500 infants died of SIDS in the United States in 2013.

Cultural practices may make the incidence rate vary. In England, a Birmingham study found that 22 percent of Asian babies were put to sleep on their backs, compared with 3 percent of European babies. Sleeping prone is significantly more common in infants dying of SIDS than in controls. In the same study, 98 percent of Asian babies slept in the same room as their parents for the first year, 34 percent in the same bed. Only 65 percent of European infants slept in the same room as their parents. Perhaps the risk of sudden infant death increases in proportion to the amount of time an infant spends asleep out of parental earshot. In Zimbabwe, SIDS practically does not exist. According to English pediatrician Duncan Keeley, who served in that country for two years, Zimbabwean infants almost invariably sleep with their mothers, at least until they are six months old and often until they are a year old.

The cause of sudden infant death syndrome is unknown, but a variety of genetic, environmental, and social factors have been associated with an increased risk of SIDS. Besides sleeping in the prone position, other associations include cold weather, overheating, the hours of the day from midnight to 9:00 a.m., and poor socioeconomic conditions, including overcrowding. The young, unmarried mother, especially if she has had no prenatal care, is more likely to have an infant with SIDS; so is the mother who smokes (either before or after the birth), is anemic, or ingests narcotics. Prematurity, especially with a history of apnea or damage to the immature lungs from elevated levels of inspired oxygen while on a respirator, also increases the risk.

Males are at a higher risk for SIDS than are females; so are the brothers and sisters of infants with SIDS. Likewise, a previously aborted episode of SIDS (that is, a “near miss”) increases risk. On average, Apgar scores (a measure of infant health immediately after birth) are lower in infants with SIDS than they are in surviving peers. In a family that has lost an infant to SIDS, the risk for the next or subsequent child is about five times the usual risk. Most risk factors, however, are associated with only a twofold or threefold elevation of incidence. Therefore, predicting which infants will die unexpectedly is extremely difficult. Recent immunization is not a risk factor. Breast-feeding is not associated with a decreased risk, as was originally thought. Although the peak incidence of SIDS is around three months of age and coincides with normally low levels of circulating immunoglobulins, the syndrome is not associated with any known pathogen.

Pathologists report a wide variety of findings in their postmortem reports—especially changes in the brain and other parts of the body that suggest chronic or intermittent hypoxemia. Yet pathologists also fail to find an increase in the number of cells in tissue of the carotid bodies, a chemoreceptor that responds to decreases in blood oxygen tension; such a finding weighs against the presence of chronic hypoxia.

Like many other aspects of this disease, the mechanism or mechanisms of death in SIDS are unknown. Does the infant stop breathing, or does some cardiac irregularity occur? An immature cardiorespiratory control mechanism involving the nervous system is the most common hypothesis.

D. P. Davies and Madeleine Gantley of the University of Wales College of Medicine have stated that an important mechanism underlying SIDS is failure of respiratory control at a vulnerable stage of development—more a physiological syndrome than a disease in the accepted sense. These doctors hypothesized that the disturbance to this delicate equilibrium might upset the regulation of breathing, sometimes leading to death. Epidemiological risk factors, such as an upper respiratory infection (which is not uncommon), are somehow linked with destabilizing influences to breathing. By avoiding or modulating these factors, the risk of death can be reduced.

Although the pathogenesis of SIDS remains unclear, Anne-Louise Ponsonby and her colleagues at the University of Tasmania in Australia proposed that SIDS be considered as a biphasic event, with the first set of factors operating to predispose the infant and the second set of factors acting as loading factors that operate at a critical stage of the infant’s development. According to the Australian doctors, a warm environment could lead to sudden infant death through direct hyperthermia; a thermolabile, sudden fall in blood pressure leading to a diminished oxygen supply to the brain; impaired respiratory control; altered sleep state; or depressed arousal. An asphyxial mode of death would also be more likely, particularly in heavily dressed infants found prone (face down).

Additionally, there is increasing evidence to suggest that those infants who succumb to SIDS are born with brain abnormalities that make them vulnerable to the syndrome. Studies of SIDS children have found these abnormalities in a network of nerve cells that use serotonin to transmit signals from one nerve cell to another. This network is located in the arcuate nucleus part of the brain, which controls major bodily functions—breathing, heart rate, temperature, and waking up from sleep. An infant with these abnormalities is thus less able to cope with environmental challenges, including overheating, inhalation of cigarette smoke, and sleeping in a prone position. However, medical experts do not believe that brain abnormalities are the only cause of SIDS, as the discussion of risk factors above suggests.

Concern for the confusion of SIDS with child abuse should not be ignored, nor should the efforts of the National Sudden Infant Death Syndrome Foundation to provide information about psychosocial support groups and counseling for families of SIDS victims.

Treatment and Therapy

Since the causes and mechanisms of death from SIDS may continue to be unknown, strategies that might reduce the incidence of this syndrome seem imperative. Cold weather and the hours of midnight to 9:00 a.m. bring increased risks for SIDS. A closer look explains that other risk factors are involved. Overheating as a response to cold weather and leaving the infant alone at night (particularly in Western countries) may be more important. Babies sleeping alone might lose external sensory stimulation that may help stabilize breathing patterns. Davies and Gantley, citing experimental work with mothers and infants co-sleeping in sleep laboratories, have shown how patterns of breathing may interact. They say that the alertness of the babies’ caregivers to early symptoms of illness might also be important.

French doctors studied the seasonal variation of death from SIDS in their country for a two-year period in the early 1980s. They concluded that for babies born in the spring, the third month of age was not necessarily associated with the highest SIDS risk. Babies born during other seasons, however, exhibited a normal pattern of increasing risk between the first and third months. Age was an especially critical factor among babies who reached three months of age during the winter months. If they reach this age in July or August, they are less susceptible to SIDS.

This finding, then, leads to a consideration of the risk of overheating. Explanations for the association between cold weather and SIDS include hypothermia, increased viral illness, and indirect hyperthermia. New Zealand doctors looked at the role of thermal balance in SIDS by investigating the death scene. They found that infants who died of SIDS were significantly more likely to be overdressed for the room temperature at the death scene and in the prone position, when compared to control infants. They also suggest that parents may have responded to infections in their babies by increasing the amount of clothing and bedding or by otherwise warming the infant.

The government of New Zealand initiated a program of education for parents recommending that the prone sleeping position be avoided, that mothers not smoke, and that breast-feeding be encouraged. (Most experts believe that breast-feeding itself does not reduce risks for SIDS. Rather, closer and more frequent contact with mothers is the operative factor.)

A similar education program for parents in Avon, England, was initiated, but it omitted advice on breast-feeding and included suggestions to avoid overheating after a retrospective case-control study that suggested a nearly ninefold relative risk for SIDS from infants sleeping prone. New Zealand and Avon both reported fewer deaths from SIDS after their parental education programs were introduced. The Department of Health extended Avon’s campaign nationally.

In an editorial note in 1986, the US National Center for Health Statistics acknowledged that “the rapid decline of infant mortality rates in the 1970s has been attributed largely to the advent of medical technology in the area of premature and other clinically ill newborns.” Yet, “in the 1980s, this decline has slowed considerably—partly because of a lack of progress in primary prevention of conditions which lead to infant death.” Undoubtedly, the United States would benefit from a massive, national program of education for parents. For example, cigarette packages carry a warning of the harmful effects of smoking on the fetus; perhaps they should also include a warning about the dangers to infants of maternal smoking. Another possibility for intervention exists in the area of infections: pertussis (whooping cough) could be prevented by the immunization of infants under six months of age. In the long term, all nations should work toward improving the socioeconomic status and health care of the poor.

Finally, improved medical technology will be less important over the long haul than will efforts to educate parents in infant care practices. The ability of parents and other members of the household to monitor infants and respond appropriately to both true and false alarms is crucial, as is appropriate training in infant CPR (cardiopulmonary resuscitation) and the proper use of monitory equipment. Even if all SIDS is eliminated in at-risk children, there will continue to be cases among children not known to have been at risk.

Perspective and Prospects

The term “sudden infant death syndrome” was popularized by Abraham Berman’s book on SIDS in 1969, which grew out of a conference on that subject. Since then, recognition of the syndrome has led to the creation of organizations dealing with it. The Sudden Infant Death Foundation merged, on January 1, 1991, with the National Center for the Prevention of SIDS to form one organization, the SIDS Alliance. In 2002, as the organization's goals and efforts continued to expand, it changed its name to First Candle.

In dealing with SIDS, one factor looms most important: education of parents makes all the difference. In 1991, for example, England’s Scarborough district reported a 50 percent fall in the SIDS death rate after parents were advised not to overwarm their small infants. That same year, four other districts in England reported a similar reduction after parents were advised not to let their infants sleep in a prone position. The Foundation for the Study of Infant Deaths and the US Department of Health recommend both procedures: a supine sleeping position and prevention of overwarming.

These successes raise two issues: the overall decline in rates of SIDS worldwide in industrial countries and parental guilt. For a number of years, the incidence of SIDS was generally falling. This decline slowed considerably in the 1980s. How much, then, did the parental education programs actually lower the incidence rate in these English districts? No one can say with certainty, but one thing is clear: if doctors make recommendations regarding sleeping positions and warming, they run the risk of inducing guilt in parents who have not followed their recommendations—or, alternatively, who have followed the recommendations but have still lost an infant to SIDS. Parents who have lost a child to SIDS are grief-stricken. They are not prepared for such a tragedy, and their grief is compounded by guilt, because no definitive cause for SIDS has been identified and, as a result, parental behavior seems to be implicated. Investigations conducted by police, social workers, or others who become involved only add to this guilt. Parents may be confronted by questions of whether they positioned their infant correctly or overdressed the child. Regardless of these behaviors, however, the factors causing the death may not have been under the parents’ control.

SIDS will continue to occur until the exact etiologies of the syndrome, its mechanisms, and its correct treatment—based on fact, not simply risks alone—are identified. Until that time, it is expected that incidence rates will continue to go down, based on what is now known of the risk factors and recommendations against prone sleeping positions and overwarming.

In 2015, a study published in the journal Pediatrics continued to emphasize that while sleeping position does play a significant role in causing SIDS, other factors also influence its occurrence. Specifically, the researchers leading the study reported that there are three major factors that impact the risk of SIDS: an infant's intrinsic predisposition, an infant's period of development, and the sleeping position. Decreased numbers of women smoking or drinking while pregnant, an increase in mothers choosing to breastfeed, and increased access to prenatal care have also contributed to the declining instances of SIDS in conjunction with the change in sleeping position, the researchers suggested. Therefore, public health education needs to focus on maintaining these behaviors as well.

Bibliography

Beers, Mark H., et al., eds. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station: Merck Research Laboratories, 2006. Print.

Blaszczak-Boxe, Agata. "Safe Sleeping Is Just 1 Part of Preventing SIDS." LiveScience. Purch, 2 Dec. 2015. Web. 6 Jan. 2016.

Behrman, Richard E., Robert M. Kliegman, and Hal B. Jenson, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Saunders, 2011. Print.

Byard, R. W., and H. F. Krous. “Sudden Infant Death Syndrome: Overview and Update.” Pediatric and Developmental Pathology 6.2 (2003): 112–27. Print.

Samuels, M. “Viruses and Sudden Infant Death.” Pediatric Respiratory Reviews 4.3 (2003): 178–83. Print.

Southall, D. P., and M. P. Samuels. “Reducing Risks in the Sudden Infant Death Syndrome.” British Medical Journal 304 (1992): 265–66. Print.

"Sudden Infant Death Syndrome." MedlinePlus. US Natl. Library of Medicine, 23 Dec. 2015. Web. 6 Jan. 2016.

"Sudden Infant Death Syndrome (SIDS)." National Institute of Child Health and Human Development. Natl. Inst. of Health, 12 Apr. 2013. Web. 6 Jan. 2016.

"Sudden Infant Death Syndrome and Other Infant Death (SIDS/OID)." SIDS Network. SIDS Network, 1 Jan. 2016. Web. 6 Jan. 2016.

In The Bronze Bow by Elizabeth George Speare, how does Daniel describe Jesus?

In Chapter 4, when Daniel sees Jesus for the first time, he mentions that his figure was "not in any way arresting" and that he could see from Jesus' arms and shoulders that he had worked hard labor as a child. Daniel says, "He was not regal or commanding" (Speare 46). When Jesus turns and faces the crowd, Daniel is startled. Daniel mentions that his face was vital and radiant. Daniel notices that Jesus' face burned with the intensity of the spirit. When he hears Jesus speak, Daniel feels a certain gentleness and promise in Jesus' voice. When Daniel sees Jesus preaching to the fishermen at the shore, he mentions that Jesus looks vigorous, confident, and happy. Although Jesus is not physically imposing, Daniel says, "The impression of strength came from an extraordinary vitality that seemed to pulse in the very air around him" (Speare 57). In Chapter 8, Daniel speaks to Jesus and notices that Jesus' eyes are filled with light and warmth. Jesus clearly has a mystical, commanding presence that attracts so many followers, including Daniel. Although he appears to look like a typical carpenter, his confidence and passion are evident in his gaze and speech.

What is an obstruction?

Causes and Symptoms

The
gastrointestinal (GI) tract runs from the mouth to the anus and includes the throat, esophagus, stomach, small intestine, large intestine, and rectum. Accessory glands whose secretions drain into the GI tract include the liver, gallbladder, and pancreas. Because the GI tract is essentially a hollow tube, its inner channel being called its lumen, it is susceptible to being closed off. The same holds true for the biliary tree, which is a series of ducts draining bile from the liver and gallbladder into the duodenum, and the pancreatic duct, which drains secretions from the pancreas into the duodenum.

Obstruction of the gastrointestinal tract is a blockage severe enough to impair the transit of materials through the lumen. Although often caused by narrowing, that term differs from obstruction in that a narrowing may be without consequences. A partial obstruction is one in which there is still some flow through the narrowing; in complete obstruction, there is no flow.

Obstruction of these organs or ducts may be mechanical or functional. Mechanical obstructions result when a problem arises from within the bowel lumen (intraluminal), from within the wall of the organ (mural), or from something outside the organ causing its lumen to be narrowed (extrinsic). Functional obstructions are caused by some motor abnormality, such as spasm or lack of peristalsis, causing impaired transit of materials.

An example of an intraluminal obstruction is a gallstone occluding the cystic duct. The liver produces bile, a fluid that has various functions including excretion of bilirubin, which is a breakdown product of hemoglobin, the protein inside red blood cells that carries oxygen. Bile also contains bile salts and cholesterol, substances that help break down large fat globules in the duodenum into smaller droplets, initiating fat digestion. Bile from the liver flows through tiny ducts that eventually unite to form the common hepatic duct. The gallbladder, a hollow sac that stores bile, joins the common hepatic duct via the cystic duct; these two ducts unite to form the common bile duct, which drains bile into the duodenum.

If there is excess cholesterol in bile, it tends to form gallstones. These stones most often form in the gallbladder, but they may form in other areas of the biliary tree such as in the common bile duct. If the stones are formed in the gallbladder but do not occlude the cystic duct, bile may still flow in and out of the organ. If the stones become impacted in the cystic duct, however, they cause obstruction to the flow of bile, leading to inflammation of the gallbladder, called acute cholecystitis.

With cystic duct obstruction, the impacted stone and some of the components of bile cause the gallbladder to become inflamed. The inflamed lining secretes fluid into the gallbladder; this fluid cannot escape because the cystic duct is occluded by the gallstone. The accumulating fluid causes the gallbladder to become distended.

This inflamed gallbladder causes abdominal pain that often lasts several hours. It is also associated with nausea, vomiting, and a fever. The fever may be attributable to a bacterial infection of the bile: When not flowing well, bile tends to be a good place for bacteria to multiply. The stones may pass through the cystic duct and occlude the common bile duct. In this situation, there is no route for bile to flow into the duodenum. Therefore it backs up, dilating the common bile duct, and is reabsorbed into the bloodstream. This causes jaundice, or a yellowish pigmentation of the skin; it may be associated with dark-colored urine.

There are ways to distinguish between acute
cholecystitis caused by cystic duct obstruction and biliary tract infection (cholangitis) caused by obstruction of the common bile duct. Ultrasonography is excellent for detecting stones in the gallbladder and dilated bile ducts, but it is not as good at detecting stones in the common duct. To detect such stones, endoscopic retrograde cholangiopancreatography (ERCP) may be performed. In this study, an endoscope is passed through the mouth, esophagus, and stomach and into the duodenum. A catheter is inserted into the opening of the common bile duct, and dye is injected. The dye outlines stones in the common bile duct.

An example of a mechanical obstruction caused by a mural process is an esophageal obstruction caused by a cancer which grows from the walls of the
esophagus into its lumen. The most common symptom of esophageal obstruction is dysphagia, or a sensation of food sticking in the throat after being swallowed. If food becomes impacted in the narrowed region, it may cause an aching sensation in the chest wall.

The obstruction is evaluated with a barium esophagram, in which barium is swallowed and an x-ray of the esophagus is taken. It may show findings such as severe narrowing of the lumen of the esophagus. Endoscopy is then performed, which can be used to visualize the area, looking for evidence of cancer, and to take a piece of the lining of the esophagus for evaluation under the microscope.

An example of an extrinsic mechanical obstruction is one caused by scar tissue, or adhesions, compressing a portion of the small intestine. Adhesions may be caused by previous abdominal surgery. If they cause obstruction, the bowel proximal to the obstruction dilates to a diameter that is larger than normal. Its function changes: normally the small intestine absorbs fluid, whereas in obstruction it secretes fluid. Since intestinal contents cannot pass through the narrowing, vomiting occurs.

Normally, the bacterial content of the small intestinal lumen is kept low because of the continuous flow of contents through it. During small bowel obstruction, this flow is partially or completely diminished, enabling bacteria to overgrow in the small intestine. These bacteria may pass through the wall of the small intestine into the bloodstream, causing a systemic infection or even death.

An example of a functional obstruction is a disorder called chronic intestinal pseudo-obstruction (CIP). The prefix “pseudo” means “false”: A pseudo-obstruction is a disorder in gastrointestinal motility that results in diminished peristalsis through the diseased segment of gut, creating an illness similar to a mechanical obstruction but without any occlusion of the lumen. There are a variety of causes of CIP, which can involve the different regions of the gastrointestinal tract. It may occur as part of the spectrum of some systemic diseases, or it may be of unknown cause (idiopathic).

If the esophagus is involved, dysphagia and
heartburn are predominant symptoms, resulting from decreased esophageal peristalsis. Everyone experiences occasional reflux, or the backward flow of stomach acid into the esophagus. Normal esophageal peristalsis keeps this acid in the stomach; if peristalsis is diminished, then the acid may cause heartburn. If the stomach and small intestine are involved, symptoms include nausea, vomiting, bloating, and abdominal discomfort. The abdomen may become extremely distended. Since the flow of small intestinal contents is slowed, overgrowth of bacteria that are normally present only in the colon occurs. These bacteria may take up so much vitamin B12 in the gut that a deficiency results. Bacterial overgrowth may also cause diarrhea. If the colon is extensively involved and exhibits markedly diminished peristalsis, abdominal distension and constipation result. An abdominal x-ray may show that the colon has become very dilated, a condition called megacolon.

Treatment and Therapy

Obstructions caused by
gallstones can be treated in several ways. If the stones are in the gallbladder and are obstructing the cystic duct, surgery is often performed within a day or two. One technique for removing the gallbladder is laparoscopic cholecystectomy, which involves making a small incision in the abdominal wall and inserting an instrument called a laparoscope. The structures of the biliary tree are identified, and dye is injected into the cystic duct to obtain a cholangiogram, an x-ray that helps identify where the stones are located. After cholangiography, clips are placed along the cystic duct, and the duct is cut between the clips (similar to cutting the umbilical cord between the ties). Bile and stones are evacuated from the gallbladder, which is then removed. The advantages of laparoscopic cholecystectomy over other surgical approaches are that the laparoscopic approach is less invasive, causes less scarring and less pain, and allows a more rapid recovery.

If the stones are in the common bile duct, one way to remove them is endoscopically. The endoscope is advanced into the duodenum, and the opening of the common bile duct is visualized. An instrument is passed through the endoscope into the opening of the common bile duct. Electrical current is applied, creating a small incision in the opening of the common bile duct. This enlarges the opening, and sometimes bile and stones come gushing out into the duodenum. If the stone is still in the common duct, a balloon-tipped catheter is passed into the common bile duct and advanced up above the stone. The balloon is inflated, and the catheter is pulled out of the common duct, bringing the stone with it. If this procedure fails, other options include surgery or extracorporeal shock-wave lithotripsy. This involves generating shock waves and focusing them onto the stone, causing it to break into tiny fragments.

Despite progress made in the care of esophageal cancer patients, the overall five-year cure rate did not change from the 1950s to the 1990s. A main treatment goal is to relieve the symptom of dysphagia. This can be done by passing dilators down through the narrowed area, stretching it so that food, saliva, and liquids can pass. Because the tumor is undoubtedly growing, repeated dilations are necessary. This treatment obviously does nothing to reduce the mass of the tumor, but it helps relieve the symptom of dysphagia.

Two treatments aimed at reducing the tumor mass are surgical removal of the tumor and radiation therapy. Before deciding that surgery is a viable option, several factors need to be taken into consideration, including the potential risks of surgery. For example, surgery performed on patients with advanced heart or lung disease has a very high mortality risk. If the tumor involves the lower esophagus, that area can be removed and the stomach can be sewn to the remaining end of the esophagus. This surgery can be dangerous: mortality rates from the operation range from 2.8 to 17 percent.

Another treatment, which is effective if the tumor is of a specific cell type called a squamous cell carcinoma, is to irradiate the tumor, attempting to kill tumor cells by focusing beams of radiation onto the mass. This procedure produces survival rates that are roughly equal to surgical survival rates and avoids the risk of surgery. The most common way to apply radiation is to focus it onto the chest wall using an external source. The radiation energy penetrates into the area on which it is focused—the esophageal tumor. One complication of
radiation therapy is that the radiation, which kills rapidly dividing cells, cannot distinguish between cancer cells and those lining the wall of the esophagus. Therefore the lining of the esophagus may become very inflamed, a condition called radiation esophagitis. Another approach for applying radiation is with a delivery system such as a specialized radioactive device which fits inside the lumen of the esophagus and delivers radiation locally.

Small bowel obstructions can be fatal. Their treatment first consists of generalized care, such as correcting fluid deficits. All oral intake is stopped, and a nasogastric tube, which is a tube inserted into the nose and passed into the stomach, is hooked up to suction to try to decompress the dilated loops of bowel. Since surgery may be imminent, it is important to optimize the functions of various organ systems so that the mortality risk of surgery is minimized. The likelihood of needing surgery depends on whether the obstruction is partial or complete: About 81 percent of partial small bowel obstructions and about 16 percent of complete obstructions resolve without surgery. This likelihood also depends on the cause of obstruction. For example, many partial obstructions resulting from adhesions resolve with conservative treatment, whereas obstructions caused by a loop of intestine twisting at its base, called a volvulus, carry a high probability of needing surgery.

The treatment of CIP is difficult: Nothing is curative, and nothing slows the progression of the diseases causing pseudo-obstruction. The most effective drug for increasing intestinal motility is probably cisapride. Some studies show that it improves symptoms and hastens the transit of material through the gut. Antibiotics to treat bacterial overgrowth in the small intestine are sometimes used in CIP, especially in cases where diarrhea is present. Dietary measures may be somewhat helpful, including lowering fat, lactose, and fiber. Vitamin supplementation may be necessary, especially with injectable vitamin B12.

Occasionally, surgery is helpful in CIP, especially for a localized problem. Because the disease often causes widespread gut involvement, however, surgery will not cure the problem. Nevertheless, when the problem is caused by the lower esophageal sphincter (LES) failing to open properly, creating a distal esophageal obstruction, a myotomy (or cutting of the circular smooth muscle in the LES) may improve dysphagia symptoms. If the stomach or colon is massively dilated, it may need to be removed. Sometimes removal of portions of the small intestine may be helpful. Once abdominal surgery has been performed, it may be difficult to distinguish future attacks of CIP from mechanical bowel obstruction caused by adhesions.

Alternative forms of nutrition may need to be considered. For example, if the disease mainly affects the esophagus and stomach, a feeding tube could be placed into the small intestine. If the gut has such widespread involvement that jejunal feeding would be fruitless, parenteral nutrition, which is the administration of nutrition intravenously, may be necessary.

Perspective and Prospects

Since obstructions of various areas in the gastrointestinal tract can be life-threatening, they served as the sources of some of the most exciting diagnostic and therapeutic advances in medicine during the twentieth century.

The earliest way to diagnose mechanical obstruction, such as small bowel obstruction, was by exploratory surgery. Then came x-ray studies, which were initially able to outline the gastrointestinal tract first by plain-film studies that showed various findings such as loops of small intestine dilated with air that suggested obstruction. Later, the addition of contrast dyes, given either by mouth or by rectum, increased the ability to outline the anatomy of the GI tract and to diagnose obstructions.

Endoscopy has revolutionized the ability to diagnose mechanical obstructions that are attributable to various causes. Developed initially using a rigid endoscope, which was difficult to position and required that the patient be put under general anesthesia, endoscopes now are flexible, only about one centimeter in diameter, and easily passed well into the duodenum. The instruments passed through the endoscope have also been greatly improved. There are instruments for removing coins lodged in the esophagus, inserting feeding tubes through the stomach wall, injecting drugs to stop the bleeding in ulcers, and cutting the opening of the common bile duct for removing stones impacted in it.

Surgical techniques have improved.
Crohn’s disease can cause inflammation and segments of narrowing of the intestine called strictures; these strictures can cause problems such as mechanical small bowel obstructions. Surgeons used to remove the strictured areas, plus a significant margin of small intestine on either side of the stricture, in the belief that such removal would eliminate the diseased segments of the small intestine. The disease tends to recur, however, and a patient needing repeated operations to remove strictures might end up with a small intestine so short that it would be unable to absorb fluids and nutrients. Therefore, the individual could have massive diarrhea and malabsorption of nutrients and need to be fed intravenously. By the 1990s, surgical treatment for Crohn’s disease sought to relieve the stricture but preserve as much small intestine as possible.

In the 1970s, therapy for biliary stones began to move away from traditional surgery and toward the use of stone-dissolving medications, endoscopic techniques, lithotripsy, and laparoscopy.

Manometry, which involves the measurement of pressure inside the GI tract, has been especially useful in helping scientists understand the physiology of functional obstruction and its relationship to emotions. For example, in 1987, L. D. Young and coworkers published an article describing how exposing research subjects to experimental noise and complicated thinking problems would increase the pressure inside the esophagus, in effect concluding that it increased the strength and speed of esophageal muscle contractions.

Bibliography

Classen, Meinhard, G. N. J. Tytgat, and C. J. Lightdale, eds. Gastroenterological Endoscopy. 2d ed. New York: Thieme Medical, 2010.

Dugdale, David C., III. " Bile Duct Obstruction." MedlinePlus, May 1, 2012.

Dugdale, David C., III. "Intestinal Pseudo-Obstruction." MedlinePlus, July 25, 2012.

Feldman, Mark, Lawrence S. Friedman, and Lawrence J. Brandt, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. New ed. 2 vols. Philadelphia: Saunders/Elsevier, 2010.

Ganong, William F. Review of Medical Physiology. 23d ed. New York: Lange Medical Books/McGraw-Hill Medical, 2009.

Health Library. "Mechanical Bowel Obstruction." Health Library, March 21, 2013.

Heller, Jacob L. "Intestinal Obstruction." MedlinePlus, July 25, 2012.

Kapadia, Cyrus R., James M. Crawford, and Caroline Taylor. An Atlas of Gastroenterology: A Guide to Diagnosis and Differential Diagnosis. Boca Raton, Fla.: Pantheon, 2003.

Kumar, Vinay, Abul K. Abbas, and Nelson Fausto, eds. Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia: Saunders/Elsevier, 2010.

Lucey, Julie Rackliffe. "Small Bowel Obstruction." Health Library, September 26, 2012.

McCoy, Krisha. "Intestinal Pseudo-Obstruction." Health Library, September 12, 2012.

MedlinePlus. "Intestinal Obstruction." MedlinePlus, August 15, 2013.

Peikin, Steven R. Gastrointestinal Health. Rev. ed. New York: Quill, 2001.

Why was Elizabeth's visit to Derbyshire important?

Elizabeth Bennet visits the county of Derbyshire with her aunt and uncle Gardiner.  While there, her aunt tells her that the county is home to Pemberley, Mr. Darcy's grand estate.  Because they learn that the family is away from home, the trio decide to go and tour the home (a relatively common practice with large estates like this one).  Here, Elizabeth hears from Mrs. Reynolds, a servant who has known Mr. Darcy since he was a child, that she's "never had a cross word from him in [her] life" and that she doesn't view him as proud at all.  This clashes very strongly with Elizabeth's earlier impressions of the man, and begins to confirm the goodness she glimpsed in his post-proposal letter to her from when she was in Hunsford.  

Further, when Darcy returns early and bumps into Elizabeth and her family, he addresses her with such "civility"; she'd never seen "his manners so little dignified, never had he spoken with such gentleness as on this unexpected meeting."  He is kind and cordial to her aunt and uncle, and he expresses a wish of introducing Elizabeth to his sister.  It becomes obvious fairly quickly that he still loves Elizabeth, and she later says that it was around this time that she began to love him.

Finally, the fact that Elizabeth is staying at Lambton and that Darcy can call so easily means that he can be the first person she sees after news of Lydia's elopement reaches her.  Thus, he is able to step in and resolve the situation before it becomes a really big scandal for the Bennet family.  It is, later, Elizabeth's wish to thank Darcy for his involvement that once again prompts him to share his unaltered feelings for her.  And, by this point, she returns them.

After looking at her new surroundings, Hannah feels as if she is in what kind of place in The Devil's Arithmetic?

Hannah feels as if she is in a “dream or an elaborate game” caused by the wine she sipped at the Seder meal.  The actual “place” is a field and then a small cottage.  Hannah has just been participating (and complaining) about all of the customs of the Passover supper.  The most recent one she was asked to perform was opening the door for the prophet Elijah.  She opens the door of the Bronx apartment and, instead of seeing the hall, sees a strange sight:  “a greening field and a lowering sky.” A strange figure comes closer carrying a hoe.  He sings the following song:

Who asked you to be buried alive? / ... no one forced you / ... you took this madness on yourself.

At this point, Hannah is quite frightened.  She whirls around hoping to see the apartment, but instead she is standing in a cottage with one plain table and a black stove.  At this point, a woman asks her if Shmuel is approaching.  It takes Hannah a moment to understand the Yiddish, but she finally notices a man coming to the door.  It is at this point that she decides what “kind of place” she is in for the moment:  a daydream or game.

What is virology?

Definition

Virology is the study of viruses and their role in disease. The science includes human, animal, insect, plant, fungal, and bacterial virology. Researchers may work in clinical, ecological, biological, or biochemical fields.

History

The first studies of viruses and their role in causing disease began thousands
of years ago in China, when an early form of vaccination against smallpox was
developed. This early process involved applying tiny amounts of secretions from a
person who had smallpox to those who had not yet been infected to keep them from
becoming infected. Viruses received closer study in 1892, when Russian
bacteriologist Dmitri Ivanovsky noticed in an experiment that the agent that carried
tobacco mosaic disease could pass through filters that kept out bacteria. Though
the question still existed as to what exactly this agent was, it was soon
discovered by Dutch microbiologist Martinus Beijerinck that the agent grew in the host and, therefore,
was not a toxin. However, the agent had other characteristics not found in
bacteria. Louis
Pasteur then experimented with immunizations using viruses,
and others continued these studies throughout the nineteenth century and into the
twentieth century.

The modern study of virology began early in the twentieth century with the
discovery of bacteriophages, viruses that infect bacteria. Plant viruses
and bacteriophages are fairly easy to grow in a laboratory environment, so it
became easier to experiment with and observe these viruses. Animal viruses
normally require a living host, which impeded study in virology until 1931, when
it was demonstrated that the influenza virus could be grown in fertilized chicken
eggs. This method is still used to develop flu vaccines.

Already in 1903, discussions had begun about how viruses caused cancer by
transduction (by transferring genetic material from one bacterium to another using
a bacteriophage). Peyton Rous described this type of oncovirus in chickens in 1911, and
it was later determined to be a retrovirus, a type that includes the
human
immunodeficiency virus.

By 1937, the yellow fever virus was being grown in chicken eggs, and
vaccines were being developed with many different viruses. With the introduction
of the electron microscope in the 1940’s came the ability to see viruses.

Viruses have been the cause of many of the epidemics and
pandemics that have occurred worldwide. These epidemics
include the yellow fever epidemics of 1793 and 1878 and the Spanish flu pandemic
of 1918. Late twentieth and twenty-first century viruses have caused epidemics and
pandemics of human immunodeficiency virus (HIV) infection, severe acute respiratory
syndrome (SARS), and H1N1
influenza.

Virologists

As undergraduates, virologists generally studied biology or chemistry, with a
focus on biochemistry and cell biology. (The biology of viruses
is closely tied to cell biology.) Other common areas of study are epidemiology,
behavioral and social sciences, and the humanities because of the impact of
viruses on human health. Virologists have extensive science backgrounds and also
may take courses in physics, mathematics, molecular biology, immunology, and
structural biology.

Most virologists continue their education to earn a medical degree (M.D.). They attend medical school for four years, complete a residency of three years, and train in postdoctoral research for three to five years. Others earn a doctoral degree (Ph.D.) by attending graduate school for four to six years and then training in postdoctoral research for three to five years. Graduates may then pursue research in a variety of areas, including human health, infectious diseases, and epidemiology. Virologists who intend to teach often substitute formal teacher-training for postdoctoral research.

Impact

Each year, public health officials, including virologists, attempt to determine, for example, what types of influenza viruses are likely to cause the most infections during the yearly flu season. Virologists help to craft a vaccine to keep these viruses from spreading.

Virology also is studying how a bundle of proteins called interferon, which are
produced during a viral infection of a cell, triggers an immune response. These
proteins somehow inhibit the replication of the virus in the cell. Virology also
is looking at how viruses may cause some types of cancers and at how viruses cause
the body’s immune response to occasionally malfunction and develop
autoimmune
disorders.

Viruses have an interesting role in genetics too because of their ability to carry extra genetic material into host cells. This ability has been studied by virologists through transferring material specifying a particular enzyme into the nucleus of host cells that lack the ability to synthesize that enzyme. This method has particular interest for those studying hereditary enzyme-deficiency diseases, such as diabetes, because these gene transfers may help to cure such diseases.

Bibliography

Carter, John, and Venetia Saunders. Virology: Principles and Applications. Hoboken, N.J.: John Wiley & Sons, 2007. Basic virology textbook with an “at-a-glance” feature for each chapter, a list of abbreviations, and a glossary.

Dimmock, N. J., A. J. Easton, and K. N. Leppard. Introduction to Modern Virology. 6th ed. Hoboken, N.J.: Wiley-Blackwell, 2007. Includes the definition of viruses and discusses laboratory techniques and the evolution of viruses. Chapters focus on specific groups of viruses.

Norkin, Leonard. Virology: Molecular Biology and Pathogenesis. Washington, D.C.: ASM Press, 2010. A detailed account of virus structure and replication and the basis for disease pathology.

Shors, Teri. Understanding Viruses. Sudbury, Mass.: Jones and Bartlett, 2008. Includes historical perspectives on viruses and treatment and prevention information.

In Elie Wiesel's Night, how do many of the prisoners continue to practice their religion even while being persecuted for it?

In Elie Wiesel’s memoir Night, the Jewish prisoners of Auschwitz continue practicing their religion despite the fact the Nazis persecute them based on their faith. For many prisoners, keeping their faith is a source of strength they use to endure the camp’s horrific conditions. Though Wiesel lost his faith due to his experiences in the Holocaust, he dutifully reports the experiences of his fellow inmates.

The memoir’s largest example of how prisoners continue to practice their faith is during Rosh Hashanah, the Jewish New Year. 10,000 prisoners gather after a day of hard labor to offer prayers to God. Wiesel doesn’t reveal why the Nazi guards allow the prisoners to practice their religion. One possible reason is that they did not see it as a threat, that prisoners who were allowed to pray were less likely to rebel. Another possibility is that the Nazis simply did not care, as the prisoners would soon die from the combination of overwork and poor living conditions.   

How is Atticus different compared to Bob Ewell and Aunt Alexandra in the novel To Kill a Mockingbird?

Atticus is the novel's morally upright character who defends Tom Robinson in front of a prejudiced jury and town. Atticus believes in justice, tolerance, and equality. He is a compassionate individual who displays integrity and courage throughout the novel. Atticus loves his children and tries his best to impress certain positive values on them. Unlike her brother, Aunt Alexandra is prejudiced towards African-Americans and people of lower social classes. She displays contempt for the Finches' cook, Calpurnia, and refuses to let Scout play with Walter Cunningham Jr. because he is poor. Alexandra argues with Atticus throughout the novel and opposes his decision to defend Tom Robinson. Alexandra means well, but holds traditional Southern views regarding race and social class. Bob Ewell is Atticus' foil throughout the novel. He is the polar opposite of everything Atticus believes in. Bob Ewell is a racist alcoholic who lies while he is on the witness stand. Bob Ewell sexually abuses his daughter and neglects his children. Bob is a selfish, mean-spirited individual who seeks revenge on Atticus and his family.

What is the difference between natural and moral liberty, according to John Winthrop?

John Winthrop was a Puritan minister from England who became the deputy-governor of the Massachusetts Colony. In 1645, while serving as a magistrate, he was accused of overstepping his boundaries when he intervened in the election of a militia officer. Called to account for his behaviour, Winthrop made a famous speech in which he identified and defined two types of liberty. 

The first, according to Winthrop, is natural liberty which he described in the following way:

The first is common to man with beasts and other creatures. By this, man, as he stands in relation to man simply, hath liberty to do what he lists; it is a liberty to evil as well as to good.

In other words, natural liberty is inherent in all living creatures. It is the freedom to do as one desires and it is not limited by any type of power or authority, and, as such, results in evil or immoral behaviour. 

In contrast, moral liberty relates to "that only which is good, just, and honest." This type of liberty is enforced by various social institutions, like the government and the Church, and encourages individuals to do good things. Winthrop likens it to the authority between a man and wife: when a woman consents to marriage, she consents to be ruled by her husband. But this does not force her into "bondage," as  Winthrop points out. A man rules over his wife with love and affection, like Christ over his believers. 

As a result, Winthrop believed that moral liberty was far more important than natural liberty. For him, moral liberty ought to be asserted and protected because of its positive effects on people and society. In contrast, natural liberty, which fosters self-interest and corruption, ought to be discouraged and rebuked. 

How did Gatsby behave prior to meeting with Daisy? What did his choice of clothing indicate about his feelings for her?

Gatsby goes to extreme lengths to manage his reunion with Daisy at Nick's bungalow in West Egg.  Without considering the potential offensiveness of his actions, Gatsby arranges to have Nick's grass cut, sends over "a greenhouse" of flowers for a simple tea party, and even offers Nick a lucrative job for agreeing to provide a place for him to see Daisy again.  That afternoon, Gatsby hovers nervously in Nick's kitchen and parlor, miserably predicting that Daisy won't show up. When she arrives, he slips out the back door.

Once Daisy has settled in, Gatsby knocks at the front door of the bungalow and pretends he is just arriving.  The clothing he has selected for the day of the reunion he has waited five years for is deeply symbolic.  His stylish flannel suit is white, Daisy's signature color.  His shirt is gold and his tie is silver, both emblematic of the precious metals that back American currency.  Gatsby wants Daisy to recognize that he intends to please her and that he has the means to give her all the things that he imagines she wants. 

Fitzgerald, F. Scott.  The Great Gatsby.  Charles Scribner's Sons, 1925.

How does society shape and influence Scout in the novel To Kill a Mockingbird?

Scout's character develops extensively throughout the novel To Kill a Mockingbird, and she is greatly influenced by Maycomb's society. Scout encounters prejudice, traditional ideologies about gender, various religious beliefs, delicate social relationships, the inefficient justice system, and standardized education throughout Maycomb's society. Scout's initial beliefs and views about various social issues are influenced by her neighbors and their way of life in the small town of Maycomb. Many of those initial beliefs are challenged and corrected by her father, brother, Calpurnia, and Miss Maudie. Scout's views regarding her neighbors, and other citizens, are shaped by those around her. She tells Calpurnia that Walter is just a Cunningham, which she more than likely heard from her classmates. She believes the rumors about Boo Radley, which is information she indirectly receives from Miss Stephanie. Scout learns about Boo's true identity from her neighbor, Miss Maudie. Miss Maudie also explains the negatives attached to religious fanaticism. Scout hears racial slurs from prejudiced community members throughout the novel, and asks Atticus the meaning behind the terms she hears, such as "nigger-lover." Her experience in the community introduces her to explicit subjects such as rape and mob mentality. In school, her teacher, Mrs. Gates, hypocritically condemns Hitler, while she supports segregation and prejudice at home. Scout becomes skeptical of what she witnesses outside in the community and compares what she sees and hears to what her father teaches her. Topics related to equal treatment regardless of race and social class become illuminated as Scout matures. She witnesses racial injustice during Tom's trial, but is not jaded about Maycomb's community like her brother, Jem. Scout learns the complexities attached to human nature from Calpurnia, Walter Cunningham Sr., Mrs. Dubose, and Boo Radley. She learns that people have both positive and negative qualities, and that traditional views are hard to change. Many of the ideas that Atticus teaches Scout are juxtaposed against a prejudiced, backward society. Scout learns that no matter how imperfect society is, individuals with integrity and courage can change it.

What steps did the Catholic Church take in Europe during medieval times to make ordinary people remain loyal?

The Catholic Church in the middle ages benefitted from being the only institution with money and infrastructure left standing after the fall of the Roman Empire. Ordinary people lived short, brutal lives during these times. Mortality rates were shockingly high, the cause of disease was still unknown, and the vast most majority of Europeans were illiterate and suffering from severe malnutrition.

The Church offered the promise of a happy afterlife, as well as an explanation and justification for the pain and suffering that was the daily routine of Europeans in medieval times. Not only did the Catholic Church offer faith and a safe place for people to gather together every week to comfort themselves and each other, but its services, which were filled with pageantry and even small amounts of wine and bread (the sacraments) were often the only source of free entertainment and distraction from the daily grind of life.

If one was not won over by the sense of hope and promise that the church offered, or the food and shelter it gave, the Church also had a very strong enforcement plan. Not only could the clergy choose to help clothe and feed the needy, but they could also order executions of the unfaithful or banish villagers who misbehaved in any way from the relative safety of their village. During that time, when each feudal village was a world into itself, and outsiders were routinely killed or left for dead, being cast out or banished from one's village was tantamount to execution.

If those threats and benefits were not enough to command an individual's loyalty to the Church, then the Inquisition usually was. The Inquisition was the enforcement mechanism for the Church, and it went around the continent looking for disbelievers or anyone who asked too many questions, or interpreted the bible differently than the Church did. The Inquisition labelled these non-conformists "heretics" and "apostates," and then burned at the stake, stoned them to death or had them drawn and quartered. The barbarism of the Inquisition knew no bounds.

During a time in which strong governments did not exist, rule of law was arbitrary or absent, the Catholic Church offered answers to life's great questions, and gave the hope of a better future (in the afterlife) to anyone who played by the rules. Additionally, the Church often helped those who were faithful to avoid starvation, and sometimes housed refugees and beggars in the relative safety of the church.

In fact, the best way for an ordinary person in the middle ages to have sufficient food and shelter (a major luxury) was to join a holy order and become a man or woman of God. The second best thing one could do was to show unerring obedience to the Church, and hope for its charity in times of need. The very last thing most people wanted to do was provoke the only entity that stood between themselves and starvation, public execution and eternal damnation. 

What is hospice?

Introduction

Hospice is a philosophy of care directed toward persons who are dying. Hospice care uses a family-oriented holistic approach to assist these individuals in making the transition from life to death in a manner that preserves their dignity and comfort. Hospice care encourages patients to participate fully in determining the type of care that is most appropriate for their comfort. By creating a secure and caring community sensitive to the needs of the dying and their families and by providing palliative care that relieves patients of the distressing symptoms of their disease, hospice care can aid the dying in preparing mentally as well as spiritually for their impending death.

Unlike traditional health care, where the patient is viewed as the client, hospice care, with its holistic emphasis, treats the family unit as the client. There are usually specific areas of stress for the families of the dying. In addition to the stress of caring for the physical needs of the dying, family members often feel tremendous pressure in maintaining their own roles and responsibilities within the family itself. The conflict of caring for their own nuclear families while caring for dying relatives places a huge strain on everyone involved and can be a source of anxiety and guilt for the patient as well. Another area of stress experienced by family members involves concern for themselves; that is, having to put their own lives on hold, keeping from getting physically run down, dealing with their newly acquired time constraints, and viewing themselves as isolated from friends and family. Compounding this is the guilt that many caregivers feel over not caring for the dying relative as well or as patiently as they might, or secretly wishing for the caregiving experience to reach an end.

Due to the holistic nature of the care provided, the hospice team is actually an interdisciplinary team composed of physicians, nurses, psychological and social workers, pastoral counselors, and trained volunteers. This medically supervised team meets weekly to decide on how best to provide physical, emotional, and spiritual support for dying patients and to assist the surviving family members in the subsequent grieving process. This type of care can be administered in three different ways: It can be home health agency based, delivered in the patient’s own home. It can be dispensed in an institution devoted solely to hospice care. Finally, it can even be administered in traditional medical facilities (such as hospitals) that allot a certain amount of space (perhaps a wing or floor, or even a certain number of beds) to this type of care. According to the National Hospice and Palliative Care Organization's NHPCO Facts and Figures: Hospice Care in America (2013), 57.4 percent of hospices were totally independent and unaffiliated with any hospital, home health agency, or nursing home in 2012.

Principles

Hospice care attempts to enhance the quality of dying patients’ final days by providing them with as much comfort as possible. It is predicated on the belief that death is a natural process with which humans should not interfere. The principles of hospice care, therefore, revolve around alleviating the anxieties and physical suffering that can be associated with the dying process, and not prolonging the dying process by using invasive medical techniques. Hospice care is also based on the assertion that dying patients have certain rights that must be respected. These rights include a right to absent themselves from social responsibilities and commitments, a right to be cared for, and a right to continued respect and status. The following seven principles are basic components of hospice care.

The first principle is highly personalized and holistic care of the dying, which includes treating dying patients emotionally and spiritually as well as physically. This interpersonal support, known as bonding, helps patients in their final days to live as fully and as comfortably as possible, while retaining their dignity, autonomy, and individual self-worth in a safe and secure environment. This one-on-one attention involves what can be called therapeutic communication. Knowing that someone has heard, that someone understands and is concerned, can be profoundly healing.

Another principle is treating pain aggressively. To this end, hospice care advocates the use of narcotics at dosages that will alleviate suffering while at the same time enabling patients to maintain a desired level of alertness. Efforts are made to employ the least invasive routes to administer these drugs (usually orally, if possible). In addition, pain medication is administered before the pain begins, thus alleviating the anxiety of patients waiting for pain to return. Since it has been shown that fear of pain often increases the pain itself, this type of aggressive pain management gives dying patients more time and energy to respond to family members and friends and to work through the emotional and spiritual stages of dying. This dispensation of pain medication before the pain actually occurs, however, has proven to be perhaps the most controversial element in hospice care, with some critics charging that the dying are being turned into drug addicts.

A third principle is the participation of families in caring for the dying. Family members are trained by hospice nurses to care for the dying patients and even to dispense pain medication. The aim is to prevent the patients from suffering isolation or feeling as if they are surrounded by strangers. Participation in care also helps to sustain the patients’ and the families’ sense of autonomy.

The fourth principle is familiarity of surroundings. Whenever possible, it is the goal of hospice care to keep dying patients at home. This eliminates the necessity of the dying to spend their final days in an institutionalized setting, isolated from family and friends when they need them the most. NHPCO estimated that in 2012, 96.5 percent of all hospice care days are spent in patients’ own homes. When this is not possible and patients must enter institutional settings, rules may be relaxed so that their rooms can be decorated or arranged in such a way as to replicate the patients’ home surroundings. Visiting rules may be suspended when possible, and visits by family members, children, and sometimes even pets encouraged.

The fifth principle is emotional and spiritual support for the family caregivers. Hospice volunteers are specially trained to use listening and communicative techniques with family members and to provide them with emotional support both during and after the patient’s death. In addition, because the care is holistic, the caregivers’ physical needs are attended to (for example, respite is provided for exhausted caregivers), as are their emotional and spiritual needs. This spiritual support applies to people of all faith backgrounds, as impending death tends to put faith into a perspective where particular creeds and denominational structures assume less significance. In attending to this spiritual dimension, the hospice team is respectful of all religious traditions while realizing that death and bereavement have the ability to both strengthen and weaken faith.

The sixth principle is having hospice services available twenty-four hours a day, seven days a week. Because of its reliance on the assistance of trained volunteers, round-the-clock support is available to patients and their families.

The seventh principle is bereavement counseling for the survivors. At the time of death, the hospice team is available to help families take care of tasks such as planning the funeral and probating the will. In the weeks after the death, hospice volunteers offer their support to surviving family members in dealing with their loss and grief and the various phases of the bereavement process, always aware of the fact that not all bereaved need or want formal interventions.

History

The term “hospice” comes from the Latin hospitia, meaning “places of welcome.” The earliest documented example of hospice care dates to the fourth century, when a Roman woman named Fabiola apparently used her own wealth to care for the sick and dying. In medieval times, the Catholic Church established inns for poor wayfarers and pilgrims traveling to religious shrines in search of miraculous cures for their illnesses. Such “rest homes,” usually run by religious orders, provided both lodging and nursing care, since the medieval view was that the sick, dying, and needy were all travelers on a journey. This attitude also reflects the medieval notion that true hospitality included care of the mind and spirit as well as of the body. During the Protestant Reformation, when monasteries were forcibly closed, the concepts of hospice and hospital became distinct. Care of the sick and dying was now considered a public duty rather than a religious or private one, and many former hospices were turned into state-run hospitals.

The first in-patient hospice establishment of modern times (specifically called “hospice”) was founded by Mary Aitkenhead and the Irish Sisters of Charity under her leadership in the 1870s in Dublin, Ireland. Cicely Saunders, a physician at St. Joseph’s Hospice in London, which was founded by the English Sisters of Charity in 1908, began to adapt the ancient concept of hospice to modern palliative techniques. While there, Saunders became extremely close to a Holocaust survivor who was dying of cancer. She found that she shared his dream of establishing a place that would meet the needs of the dying. Using the money he bequeathed her at his death as a starting point, Saunders raised additional funds and opened St. Christopher’s Hospice in Sydenham, outside London, in 1967. Originally it housed only cancer patients, but with the financial support of contracts with the National Health Service in England and private donations, it later expanded to meet the needs of all the dying. In fact, no patient has ever been refused because of inability to pay. St. Christopher’s has served as a model for the hospices to be built later in other parts of the world.

Even though hospice care did not originate with Saunders, she is usually credited with founding the first modern hospice, since she introduced the concept of dispensing narcotics at regular intervals in order to preempt the pain of the dying. She was also the first to identify the need to address other, nonphysical sources of pain for dying patients.

Two years after St. Christopher’s Hospice was opened, psychiatrist Elisabeth Kübler-Ross wrote On Death and Dying , which validated the hospice movement by relating stories of the dying and their wishes as to how they should be treated. In 1974, the United States opened its first hospice, Hospice, Inc. (later called the Connecticut Hospice), in New Haven, Connecticut. Within the next twenty-five years, over three thousand hospice programs were implemented in the United States. In Canada, the first “palliative care” unit (as hospices are referred to in Canada) was opened in 1975 by Balfour M. Mount at the Royal Victoria Hospital in Montreal. This is considered to be the first hospital-based hospice in North America.

Cost

Because of hospice care’s reliance on heavily trained volunteers and contributions, and because death is seen as a natural process that should not be prolonged by invasive and expensive medical techniques, hospice care is much less costly than traditional acute care facilities. Because hospice care is a philosophy of care rather than a specific facility, though, legislation to provide monetary support for hospice patients took a great deal of time to be approved. In 1982, the US Congress finally added hospice care as a Medicare benefit. In 1986, it was made a permanent benefit. Medicare requires, however, that there be a prognosis of six months or less for the patient to live. Hospice care is also reimbursable by many private insurance companies.

The National Hospice Organization (NHO) originated in 1977 in the United States as a resource for the many groups across the country who needed assistance in establishing hospice programs in their own communities. The purpose of this organization is to provide information about hospice care to the public, to establish conduits so that information may be exchanged between hospice groups, and to maintain agreed-upon standards for developing hospices around the country. The NHO publishes Guide to the Nation’s Hospices on an annual basis.

Advance Care Planning and Hospice

During the lead-up to and immediately following the passage of the Affordable Care Act in 2010, advance care planning—or end-of-life planning, in which patients decide ahead of time what specific types of care they do and do not wish to receive during a life-threatening event or illness—became a hotly debated topic. Many feared that cost-saving would be used as a pretext to deny life-extending care to ill patients. Because the issue became highly politicized, it was dropped from the bill and also from later regulatory language. However, by 2014, several private insurers were paying doctors to hold conversations with patients for that purpose and there was some congressional support for similar coverage through Medicare. A literature review in the September 2014 issue of Palliative Care found that such planning interventions, particularly those that go beyond writing documents such as do-not-resuscitate orders, increased the use of hospice and palliation over and against hospitalization and appeared to better address patient wishes for end of life.

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