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He must first look at the face of the patient and see whether it is like that of people in good health generic 20mg levitra super active with amex erectile dysfunction pills viagra, and generic levitra super active 40mg free shipping erectile dysfunction caused by prostate surgery, particu- larly, whether it is like its usual self, for this is the best of all; whereas the most opposite to it is the worst, such as the follow- ing: nose sharp, eyes hollow, temples sunken, ears cold and con- tracted and their lobes turned out, and the skin about the face dry, tense, and parched, the color of the face as a whole being yellow or black, livid or lead colored. Physicians: A Historical Perspective 5 Hippocrates also taught that wounds should be washed in boiled water and that doctors’ hands should be clean. Many of the obser- vations that Hippocrates and his pupils made about the human body are still valid in terms of modern Western medicine. Some of these include: W hen sleep puts an end to delirium it is a good sign. Hippocrates also had a moral vision of what a physician should be—a professional assisting in the healing process in every way. Hippocratic medicine was practiced in the Egyptian medical school founded by two Greeks, Herophilus and Erasistratus. His writings on anatomy and phys- iology were held as the standard medical authority for centuries. It surged forward again after the eighth century, when the Arabs spread their empire from the Middle East to Spain, founding new medical schools and hospitals. By the beginning of the Renaissance several centuries later, new interest was aroused in medicine. During the fifteenth century, the 6 Opportunities in Physician Careers Renaissance was at its pinnacle, and medicine was studied and advanced by artists like Leonardo da Vinci, who made careful draw- ings of the structure of the human body. As the first printed anatomy of the human body, this work promoted the practice of surgery throughout the world. The Seventeenth Century—Greater Understanding During the seventeenth century, three major contributions to med- icine were made. In 1628 William Harvey, an English physician, published On the Motions of the Heart and Blood. It has remained one of the most famous medical texts ever written because it out- lines one of the most important medical discoveries ever made. Har- vey also developed the study of nutrition to improve the health of the general public. Later in the century, an Italian histologist named Marcello Malpighi filled the gap left in Harvey’s discoveries by creating the first description of the capillaries that connect arteries and veins. He used home-ground lenses with short focal lengths to observe what could not be seen before, such as red corpuscles, sper- matozoa, and bacteria. The Eighteenth Century—the Beginning of Prevention By the eighteenth century, much was known about the workings of the human body. This century was primarily a time of systemati- Physicians: A Historical Perspective 7 zation and classification. Carl von Linné (or Linnaeus), the Swedish botanist and physician, established the practice of classification both in botany and in medicine. He was the originator of binomial nomenclature in science, classifying each natural object by a fam- ily name and a specific name, like Homo sapiens for humans. The eighteenth century witnessed great strides in the develop- ment of preventive medicine. For years, smallpox epidemics had wreaked havoc with the population, killing many. When the smallpox vaccine was given to 12,000 people in London, the yearly rate of the disease dropped from 2,018 to 622. Other important medical advances were made by Caspar Friedrich Wolff and John Hunter. Wolff, a German, is noted for his major contribution to modern embryology. Wolff noted that the embryo was not preformed and encased in the ovary, as previously believed, but rather that organs are formed “in leaf-like layers. The Nineteenth Century—the Rise of Modern Medicine Modern medicine as we know it began during the nineteenth cen- tury. The causes of many diseases were beginning to be identified, and effective treatments were being developed. The nineteenth cen- tury also brought advances in medical research and the birth of modern surgery. One key discovery occurred when a French physician, Jean Corvisart des Marets, found that certain parts of the body have dif- 8 Opportunities in Physician Careers ferent sounds when thumped. Another French physician, René-Théophile Hyacinthe Laënnec, invented the stethoscope in 1819. It is said that he found percussing the chest of one of his patients too difficult, so he rolled up a cylin- der of paper and placed it against the patient’s chest to listen. His publication of successive editions of Traité de l’auscultation médi- ate became the foundation of modern knowledge of diseases of the chest and their diagnosis. In 1846, at Massachusetts General Hospital in Boston, modern surgery was born when William Morton first anesthetized a patient with ether. Unfortunately, patients continued to die on the operat- ing table from infection until chemist Louis Pasteur’s discovery that bacteria caused disease was taken seriously.

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There are also cells here that respond to only thresholds are usually unchanged distant from the chemical stimulation buy levitra super active 40 mg free shipping impotence medication, including histamine release in injury site buy generic levitra super active 20 mg erectile dysfunction caused by neuropathy. A small population of One such cascade includes Ca2+ activation of nociception-specific cells are located in the deep dor- the enzyme phospholipase A2 (PLA2); this frees sal horn. This “classical” pathway projects to cyclooxygenase and results in the production of somatosensory (S1) cortex and is postulated to be prostaglandins. Prostaglandins (PGs) diffuse out of integral in sensory discrimination of pain, that is, the spinal neurons and back to the central terminal of where is it, is it sharp, is it hot, and so on. There, they act on specific PG receptors to posterior thalamus (VMpo); this nucleus, in turn, increase the amount of neurotransmitter released per projects to posterior insula cortex. Other recently been proposed to be a unique cortical pain enzymes, including nitric oxide synthase, are acti- center as well as to be involved in homeostatic control vated by Ca2+ in a similar manner, also resulting in a of the internal environment, including tissue integrity. This alternative hypothesis proposes that dorsal pos- Prostaglandins also act via specific PG receptors on terior insula rather than S1 cortex is the primary focus astrocytes to activate them and cause them to release of the sensory-discriminative aspect of pain. This area projects to the anterior cingulate that use of local anesthetics around the incision cortex. This medial pathway is likely to represent the (injury site) would block the high-frequency C-fiber motivational affective component of pain. Studies with maintained peripheral blockade of afferent input are under way. They bind to µ and κ opiate receptors on the central terminal of nociceptive pri- mary afferent fibers (presynaptic) and, by reducing Sorkin LS, Wallace MS. Surg Ca2+ entry when the action potential invades the ter- Clin North Am. Pain: Nociceptive and cally (on the dorsal horn neurons) to µ and δ opiate neuropathic mechanisms with clinical correlates. Aβ Yaksh TL, Lynch C, Zapol WM, Maze M, Biebuyck JF, fibers do not have presynaptic opiate receptors. This is one theory of why Aβ-mediated pain is relatively opiate resistant. Yaksh, PhD monoamines are released primarily from axons whose cell bodies are located in various branstem nuclei. Analgesic actions are potentiated by monoamine NERVE INJURY PAIN STATES reuptake (tricyclic antidepressants) inhibitors and are synergistic with morphine. There will be an initial dying back (retrograde chro- This increased ionic conductance may result in the matolysis) that proceeds for some interval at which increase in spontaneous activity that develops in a time the axon begins to sprout, sending growth sprouting axon. Collections of these proliferated growth cones form CHANGES IN AFFERENT TERMINAL SENSITIVITY structures called neuromas. DORSAL HORN REORGANIZATION This scenario is consistent with the observation that Following peripheral nerve injury, a variety of events following nerve injury, the postganglionic axons can occur in the dorsal horn which suggest altered pro- initiate excitation in the injured axon. Spinal Glutamate Release There is little doubt that the post-nerve injury pain state is dependent on an important role of spinal glu- EVOKED HYPERPATHIA tamate release. Nonneuronal Cells and Nerve Injury Following nerve injury (section or compression), Spinal Dynorphin there is a significant increase in activation of spinal Following peripheral nerve injury, there occur a wide microglia and astrocytes in spinal segments receiving variety of changes in the expression of dorsal horn input from the injured nerves. SYMPATHETIC DEPENDENCY OF NERVE INJURY PAIN STATE Loss of Intrinsic GABAergic/Glycinergic Inhibitory Control After peripheral nerve injury, there is increased inner- In the spinal dorsal horn are a large number of small vation of the peripheral neuroma by postganglionic interneurons that contain and release GABA and 19 sympathetic terminals. After nerve injury, spinal neurons may regress to The ability of low-threshold stimuli to evoke pain a neonatal phenotype in which GABA-A activation behavior after peripheral nerve injury has been a sub- becomes excitatory. Gunshot Bennett and Xie (four loose ligatures around the Wounds and Other Injuries of Nerves. Chemical sympathectomy Seltzer and Shir (hemiligation of the sciatic nerve) for neuropathic pain: does it work? Case report and system- Kim and Chung (tight ligation of the L5 and L6 30 atic literature review. Wiesenfeld-Hallin Z, Aldskogius H, Grant G, Hao JX, The Bennett model is widely used to study thermal Hokfelt T, Xu XJ. Central inhibitory dysfunctions: hyperalgesia while the Chung model displays a well- Mechanisms and clinical implications. Degeneration and regenera- have been widely employed to investigate the phar- tion of the peripheral nervous system: From Augustus macology of the pain states associated with the par- Waller’s observations to neuroinflammation. Characteristics of Of particular interest, these models show sensitivity ectopic discharges in a rat neuropathic pain model. Distinct potassium channels on pain- In contrast, while thermal hyperalgesia in the Bennett sensing neurons. Increased sensitivity of This difference may reflect the fact that large low- sensory neurons to tumor necrosis factor alpha in rats with threshold afferents are not thought to possess opiate chronic compression of the lumbar ganglia. Cross-excitation in dorsal root ganglia of nerve-injured and intact rats. Peripheral nerve It is not at present clear to what degree some or all of injury triggers central sprouting of myelinated afferents. Increased uptake and transport of cholera toxin B-subunit in It is clear, for example, that not all post-nerve injury dorsal root ganglion neurons after peripheral axotomy: pos- states possess a sensitivity to sympathetic blockade. NMDA receptors as targets for drug action in Similarly, it seems certain that after nerve injury a neuropathic pain.

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A compari- son of faces scales for the measurement of pediatric pain: Children’s and parents’ ratings generic 20 mg levitra super active free shipping impotence icd 9 code. A comparison of faces scales for the measurement of pediatric pain: Children’s and parents’ ratings discount levitra super active 20mg with mastercard erectile dysfunction reasons. Spatial summations of pain processing in the human brain as assessed by cerebral event related po- tentials. Social and medical influences on attributions and evaluations of chronic pain. The contributions of interpersonal conflict to chronic pain in the presence or absence of organic pathology. Environmental stressors and chronic low back pain: Life events, family and work environment. The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patient. Relationship of pain impact and significant other rein- forcement of pain behaviors: The mediating role of gender, marital status and marital satis- faction. In Aging and society: Taking charge of the future, Official program book of the 31st Annual Scientific and Educational Meeting of the Canadian Association on Gerontology (p. Psychometric development of a pain as- sessment scale for older adults with severe dementia: A report on the first two studies. An examination of pain perception and cerebral event-related potentials following carbon dioxide laser stimulation in patients with Alzheimer’s disease and age-matched control volunteers. Pain-relevant support as a buffer from de- pression among chronic pain patients low in instrumental activity. Subjective judg- ments of deception in pain expression: Accuracy and errors. Are physicians’ ratings of pain af- fected by patients’ physical attractiveness? A theoretical framework for understanding self- report and observational measures of pain: A communications model. Using facial expressions to assess musculoskeletal pain in older persons. Age- and appearance- related stereotypes about patients undergoing a painful medical procedure. Measuring movement exacerbated pain in cognitively impaired frail elders. Beautiful faces in pain: Biases and ac- curacy in the perception of pain. Detecting deception in pain expressions: The structure of genuine and deceptive facial displays. Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates. Pain and cognitive status in the institutionalized elderly: Perceptions and interventions. Development of an observation method for assessing pain be- havior in chronic low back pain patients. The relation- ship of gender to pain, pain behavior and disability in osteoarthritis patients: The role of catastrophizing. The Pain Behavior Check List (PBCL): Factor structure and psychometric properties. The role of marital inter- action in chronic pain and depressive symptom severity. The effects of experimenter gender on pain report in male and female subjects. The effect of disabil- ity claimants’ coping styles on judgements of pain, disability and compensation: A vignette study. The tragedy of dementia: Clinically assessing pain in the confused, non- verbal elderly. Infant crying as an elictor of parental behavior: An examination of two mod- els. Individualized patient education and coaching to improve pain control among cancer outpatients. Pain complaints and cognitive status among elderly institution residents. The effects of perceived versus enacted social support on the discriminative cue function of spouses for pain behaviors.

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