Leigh A. Nelson, PharmD, BCPP

• Associate Professor, University of Missouri-Kansas City School of Pharmacy, Division of Pharmacy Practice and Administration
• Associate Professor, University of Missouri-Kansas City School of Medicine, Department of Psychiatry
• Clinical Pharmacist, Truman Medical Center Behavioral Health, Kansas City, Missouri

https://pharmacy.umkc.edu/directory/leigh-anne-nelson/

This article discusses in detail the epidemic of synthetic marijuana (called “spike” in the city involved infantile spasms 6 weeks generic 135 mg colospa, Syracuse muscle relaxant drug names order 135 mg colospa amex, New York) abuse in the city muscle relaxant starts with c cheap colospa 135 mg with visa, with the attendant public health issues that have developed as a results of the epidemic muscle relaxant antidote best order for colospa. This website provides detailed information on the medi cal and psychiatric aspects of marijuana use with sections on pathophysiology muscle relaxant vs painkiller purchase 135 mg colospa otc, epidemiology spasms under belly button order colospa 135mg without prescription, clinical presentation, physical signs and symptoms, causes, diferential diagno sis, workup, treatment and management, consultation, medications, outpatient care, deterrence and prevention, complications, prognosis, and patient education. It provides an excellent general introduction to the history of cannabis in human civilization. This article provides a thorough review of endocannabi noids that includes a history of their discovery and re search, their chemistry and pharmacology, and their roles in living organisms. It describes in detail the long history of the use of marijuana for the treatment of medical conditions. Both are good sources of the his tory and culture of these substances with special exhibits also available online on the history of marijuana smoking, the process of making hash, the history of hemp, medical marijuana, and opposition to the use of hemp and mari juana. This website tells the story of the criminalization of mari juana in the United Kingdom in the middle years of the 20th century. The author notes that the drug testing business is a large industry in the United States with a signifcant stake in 314 Marijuana keeping marijuana illegal to use. In this interview, the new advisor on marijuana to the Washington State Liquor Control Board warned of the worst possible consequences of legalizing the drug, which would include “more ‘heavy drinking,’ ‘a massive increase in use by minors,’ or ‘carnage on our highways. National Library of Medicine, is a reliable source of information about every aspect of marijuana, including basic information, research, directories, organizations, and resources. The National Institute on Drug Abuse is one of the most reliable sources of information on drug addiction and abuse available in the United States. This web page provides a general introduction to the topic of marijuana and to publications on the subject available from the institute. This website reviews recent and current research on all aspects of marijuana, related synthetic products, and de rivatives. Some applications discussed include research on sleep disorders, tumors, hepatic encephalopahty, Ehlers Danlos syndrome, schizophrenia, retinal damage, and neurological and liver disorders. It contains daily updates of important national events relat ing to marijuana, including legalization, federal laws and other actions, treatment and prevention programs, use data and statistics, and court actions. This website provides an unusually interesting and well illustrated history of marijuana. This is an enormously valuable website because of the ex tensive list of references it provides for all aspects related to the therapeutic use of marijuana. This website provides an excellent introduction to the his tory of hemp uses dating from the Neolithic period to the early Renaissance. This article discusses the problems created for marijuana researchers by federal restrictions on the drug (listed as a Schedule 1 drug), and changes that might occur in re search if the drug were to be reclassifed. This article describes three approaches to the prevention of marijuana use by high school students: drug preven tion programs, zero tolerance policies, and school-based marijuana treatment programs. This publication brings together some of the most highly regarded research dealing with ways of preventing young people from becoming involved in the use of marijuana. This publication brings together summaries of some of the programs that have been found to be most efective in the prevention of young adults’ developing an un healthy dependence on marijuana use. Annotated Bibliography 317 “Public Health’s Approach to Youth Marijuana Prevention. In connection with legalization of recreational marijuana use in Oregon, the state legislature mandated actions by a variety of state agencies to monitor impacts of the new law on marijuana use in the state. This website reports on trends in marijuana use among youth in the state and outlines recommendations for programs that can be used to reduce the rate of marijuana use among young people. This website was prepared by the state of Oregon after the use of marijuana for recreational purposes was approved in 2014. It provides answers to a wide range of questions related to marijuana, such as licensing of dispensaries, personal use laws, tax regulations, research on the drug, and water rights. As of early 2017, only psychosocial therapies, such as cog nitive behavioral therapy and family-based therapies, are available for use in treating cannabis misuse, dependence, and addiction. This article reviews some possible chemi cal treatments for those disorders, such as Marinol, Nabi lone, and gabapentin. This publication summarizes an extended list of research studies on factors that may place youth at risk for, or that may help protect youth against, the abuse of, dependence on, and addiction to marijuana. This excellent resource lists 60 scientifc studies on mari juana conducted between 1990 and 2014, providing a de scription of each study, its journal reference, and whether the report produced results in favor of or opposed to the use of marijuana for medical purposes. The authors attempt to predict the next states most likely to legalize marijuana and the reasons that they have been selected to do so. The writer reviews public opinion and studies on the ef fects of marijuana legalization in Colorado and fnds that the results are less harmful than critics had predicted be fore the November 2012 referendum. This web page provides information on 10 drugs that have been approved for one or more specifc medical purposes in the United States and other countries. This website provides basic information on the status of medical marijuana in states where it is now legal, includ ing the enabling legislation or vote, possession limits, and qualifed users. They raise a number of technical problems with such a form of delivery, but indicate that it is not without its possibilities. This article provides a general overview of synthetic mari juana, also known as spice and K2, with explanations of the ways in which the substance afects the brain’s endo cannabinoid system. This white paper was presented in 1998 on behalf of the North American Industrial Hemp Council to clarify the essential diferences between hemp and marijuana and as well as to argue for the importance of hemp as an indus trial product in the modern world. This website provides a variety of articles that explain the diference between two species of Cannabis. Annotated Bibliography 321 this website provides extensive information on the form of synthetic marijuana known as spice or K2. It also pro vides access to a book called Synthetic Marijuana: The De finitive Guide to the World’s Worst Drug, where it is for sale for $39 per copy. During that time, the plant has had a variety of uses, for the production of fibers, in the form of hemp; for the manufacture of oil, from the plant’s seeds; and as a recreational drug, produced from the dried leaves, seeds, and stems of the plant. The history of these three classes of products is long, complex, and often in dispute. The chronology provided here lists some of the most important of those dates, with points of dispute mentioned where they are appropriate. Some authorities argue that hemp is the frst plant material cultivated specifcally for use in the production of textiles. Most evidence suggests that Shen Nung was a mythological character, and that what is reputed to be his most important work, Shen-nung pen ts’ao ching (Divine Husbandman’s Materia Medica), dates instead to the fourth century bce. Cultivation and use of the fber begins to spread throughout Europe shortly thereafter and eventually becomes an essential textile material. By this time in history, the plant was also being used widely for the manufacture of canvas sails, the name of which, “canvas,” comes from the Latin word cannabis, the Greek word kannabis, and even earlier terms for “hemp. Papermaking using hemp spreads throughout Europe with the frst mills opening in France in 1189, Italy in 1268, Germany in 1390, Holland in 1428, Switzerland in 1433, and England in 1494. By 1564, King Philip of Spain decrees that hemp is to be grown in Spanish possessions throughout the New World. The committee reports on the benefcial efects of the drug, including the cure of neuralgic pain, dysmenorrhea, uterine hemorrhage, hysteria, delirium tremens, mania, palsy, whooping cough, and infantile convulsions. The book is a collection of standards for chemical and biological drug substances, dosage forms, compounded preparations, excipients (inactive substances added to drugs), medical devices, and dietary supplements. Congress passes the Pure Food and Drug Act, the frst major piece of legislation designed to provide some monitoring of foods and drugs sold in the United States. The minimal requirement established for many drugs, including marijuana, was that products containing such drugs be labeled to indicate the drug’s presence. Chronology 327 1911 South Africa bans the use of cannabis, largely because its use by mine workers resulted in a reduction in their productivity. Congress passes the Harrison Narcotics Tax Act, which regulates and sets taxes on the production and use of opiates. Over the next three decades, Anslinger becomes the foremost proponent for the criminalization of marijuana use. Panama Canal Department concludes that “[mari ajuana] is not a ‘habit forming’ drug in the sense that the de rivatives of opium and cocaine are such drugs, as there are no symptoms of deprivation following its withdrawal. At frst, only nine states adopt the act, and it is soon superseded by the 1937 Marihuana Tax Act. The United States declines to sign the treaty because it regards its conditions as too weak. The flm eventually be comes famous under the title Reefer Madness and is re-created in a 2005 made-for-television flm and a 2011 Broadway musical. Congress passes the Marihuana Tax Act, imposing a tax on anyone who “imports, manufactures, produces, compounds, sells, deals in, dispenses, prescribes, administers, or gives away marihuana. Chronology 329 1941 Cannabis is delisted from the United States Pharmaco peia, ending its designation in the United States as a legitimate medicine. Congress passes the Boggs Amendment to the Harrison Act of 1914 (dealing with cocaine and opiates), providing for severe mandatory sentencing for the possession, sale, or use of narcotic drugs, including marijuana. The act is an efort to revise and update the complicated series of laws that deal with illegal drugs. One of its main provisions is the creation of drug “schedules” that specify the potential for abuse and medical value of various drugs. Marijuana is listed as a Schedule I drug, the highest and most dangerous category. Decriminalization difers from legalization in that it maintains the illegal status of the drug, but removes most of the penalties for using small amounts of the drug for recreational purposes. Bush terminates the program in 1992 and, as of 2016, four patients remained in the program, which is admin istered by the University of Mississippi. Congress on August 2, 1977, President Jimmy Carter endorses the fndings of the Shafer Commission and famously says that “penalties against posses sion of a drug should not be more damaging to an individual than the use of the drug itself. Ofcials of the Clinton administration announce that the actions in Arizona and California are in confict with fed eral law, and any person acting under the provisions of either act will be subject to federal prosecution. Institute of Medicine issues its report called Marijuana and Medicine: Assessing the Science Base on the medi cal uses of marijuana. Chronology 333 2004 The citizens of Montana vote about two-to-one to allow the use of marijuana for medical purposes. In 2011, both houses of the state legislature vote to repeal that vote, essentially eliminating the use of medical marijuana in the state. Congress may criminalize the production and use of home-grown marijuana, even in states where the use of the drug for medical purposes is legal. Leonhart, administrator of the Drug Enforcement Administration, denies the request, indicating that marijuana has “a high potential for abuse. Voters in Washington adopt a similar law that permits possession, but not growing, of marijuana. It is the frst country in the world to create such a comprehensive legal approach to the use of marijuana. Supreme Court, arguing that the state’s marijuana laws confict with federal laws on the growing and consumption of marijuana. The use of recreational marijuana is approved in both Alaska and Oregon, with both laws taking efect over time at later dates (2015 and 2016). Supreme Court declines to hear the suit brought by the states of Nebraska and Oklahoma with regard to the legality of Colorado’s marijuana laws. Medical marijuana is approved for the frst time in Arkansas, Florida, and North Dakota, while Montana voters expand the circumstances under which the drug can be used for medical purposes. This page intentionally left blank GlossaryGlossary Introduction Discussions of marijuana may involve terminology that is unfamiliar to the average person. In some cases, the terms used are scientific, technical, or medical expressions used most commonly by professionals in the field. In other cases, the terms may be part of the “street slang” that users themselves employ in talking about the drugs they consume, the paraphernalia associated with drugs, or the experiences that accompany marijuana use. This glossary lists and defines a few of the terms needed to understand explanations provided in this book. Its systematic name is 6,6,9-trimethyl-3 pentyl-benzo[c]chromen-1-ol, and its chemical formula is C21 H 26O2. Glossary 339 drug diversion Providing a drug to an individual who is not authorized to use it. Marijuana plants grown in hydroponic settings are said to have uniquely desirable qualities over those grown in soil. Food and Drug Administration that allows researchers to test new drugs prior to approval. The compound is commonly known 9 as delta-9-tetrahydrocannabinol (Δ -tetrahydrocannabinol). Dispensatory of the United Drug Enforcement States, 212 Administration, 261–262 District of Columbia, 113, Indian Hemp Drugs 142, 153, 206 Commission, 243–245 Index 349 industrial hemp research, Drug Abuse Information legitimacy of, 272–274 and Treatment Referral Leary v. United States, Hotline, 217 248–251 Drug Abuse Ofce and Marihuana problem Treatment Act of 1972, in New York City, 216 247–248 Drug Free America Marihuana Tax Act, Foundation, Inc. Bush Fifth Amendment, 72 administration, 152 First Annual Hemp History George Mason University, Week, 201 196 First Christian Church, 226 George School, 212 352 Index Georgetown University Law Harrington, Michael J. Lester, 152 208–209 Guilford College, 212 Heckler, Margaret, 195 Gunjah Wallah Company of hemp New York City, 37 carbon dating, 3 Gutenberg’s frst Bible, 26 ditchweed, 12 feral, 12 Hague, Te, 57, 181 Indian, 32, 58 Hague Convention, 60 marijuana vs. Drug Enforcement Africa, 21–23 Administration, China, 12–17 261–262 Europe, 23–29 Hemp Oil Canada, Inc. United States, 71, 73, Resource Center, 196 248–251 Louisiana, 68 legalization of marijuana, 136 decriminalization and, Magic Soaps, 200 88–105 Magna Carta, 26 government research Magnoliophyta, 4 support and, 148–150 Magnoliopsida, 4 resistance to , 115–116 Maine, 61 See also decriminalization “Marihuana: A Signal of of marijuana Misunderstanding,” legalization of medical 74–75 marijuana, 105–110, Marihuana problem in New 138–140 York City, 247–248 arguments in favor of, Marihuana Reconsidered, 105–109 152 arguments in opposition Marihuana Tax Act, 36, of, 109–110 65–67, 158–159, 171, legislature on medical 212, 246–247 marijuana, 136 marijuana legitimacy of medical attitudes about use of, marijuana, 166–170 86–87 Index 357 chemicals in, 134 Marriage Guide; Or, Natural controversies about use of, History of Generation: 87–105 A Private Instructor for data on use of, 237–243 Married Persons and edible, 164 Tose about to Marry, hemp vs. Anslinger, 180–183 Playboy Foundation, 218, Hemp Industries 229 Association, 198–201 Pleasant Hill Baptist Church, International Association 228 for Cannabinoid Poland, 24 Medicines, 204–206 policies on marijuana John Gettman, 196–198 common sense, 170–173 John W. Hufman, origins of, 158–161 201–204 Index 363 Keith Stroup, 227–230 in United States, 58–82 Lyster Hoxie Dewey, See also prohibition on 185–186 Cannabis sativa in Marijuana Policy Project, United States 206–208 prohibition on Cannabis National Institute on Drug sativa in United States Abuse, 216–218 attitudes about use of, National Organization for 86–87 the Reform of Marijuana controversies over use of, Laws, 218–219 87–105 Ofce of National Drug Eighteenth Amendment, Control Policy, 219–222 59 Raphael Mechoulam, federal legislation on, 208–211 63–80 Raymond P. Drug Enforcement patterns of use in, 82–86 Administration, recreational marijuana, 232–235 legalization of, 112–115 William B. Sue, 154 Schwarzer, William, 96 Soros, George, 215 scientifc name for Cannabis South Dakota, 144 sativa, 4 Spanish conquest of South Scotland Yard, 134 America, 30 Scranton, William M.

Combining the concepts in both modules less than half of the concepts were covered (46 back spasms 7 weeks pregnant order colospa cheap. For both modules the state average coverage for Standard 2-8 was higher (73%) muscle relaxant brands buy colospa 135 mg on-line, and states were generally consistent in their coverage of these standards for each module (Table 2 muscle relaxant anxiety colospa 135 mg low price. However muscle relaxants quizlet order cheap colospa, the concept coverage (standard 1) demonstrated less coverage than standards 2-8 muscle relaxant elderly buy colospa in india. The two highest obesity states (Louisiana and Mississippi) had two of the lowest concept coverage (13 and 32% respectively) scores muscle relaxant usage purchase colospa from india, while one low obesity state (Connecticut) had similarly low concept coverage. While the concept coverage varied more and was generally lower than the coverage for standards 2-8, there is not a clear pattern. States may have responded to high obesity rates by providing a comprehensive health education program in physical activity and healthy eating. Further analysis of the Healthy Eating concept coverage revealed that 25% of healthy eating concepts were covered by only one state or not at all. Nutrient and food-specific standards (those pertaining specifically to consumption of water, fat, sugar, fiber, whole grains and iron) were the primary concepts omitted. While this information can change more frequently than the curricula are revised, states could refer to either the Dietary Guidelines for Americans (U. Department of Agriculture, 2005) or other nationally recognized sources (Institute of Medicine, 2011) for specific nutrient recommendations. Many of the state’s standards were written in very generic language (students will eat healthy foods and be active), explaining the omission of 66 these more specific content items. Free and readily available resources from government agencies could facilitate coverage of healthy eating content. The majority of states covered the concepts of choosing healthy foods and beverages and understanding the relationship between eating, physical activity and weight maintenance. There were also far fewer concepts covered by only one state or not at all (5 concepts, 9. Four of the five commonly omitted concepts could be assigned to one of two categories, recommended amounts of physical activity and the use of performance enhancing drugs. In the area of physical activity, national recommendations have recently been adopted (U. The current recommendations were not approved and made public at the time these states created or revised their curricula. Eight of these nine concepts could be tied back to themes of positive outcomes/benefits of physical activity, the relationship among nutrition, physical activity and weight maintenance and safety/injury prevention. There were additional concepts that followed these same themes but required more specific information (identify the safety equipment needed for a particular activity; identify ways to evaluate body weight/composition) that were not as well covered, again suggesting that more generic concepts were more likely to be addressed in state curricula. This presents an excellent opportunity for states to build on their existing standards by increasing the specificity of healthy eating and physical activity information provided. Average coverage of skill standards (Standards 2 through 8) was consistent, with scores ranging from 2. While average coverage of standards was strong, few states earned maximum points on the majority of standards. Washington earned the highest scores for coverage of Standards 2 through 8, earning maximum scores for five Healthy Eating and six Physical Activity standards. Four states (Connecticut, Maryland, Mississippi and Florida) earned all available points for two Physical Activity standards; two states (Maryland and Florida) achieved top scores for two Healthy Eating standards. Average total skill standard coverage scores were identical between the modules (20. Blending both statistics, states are doing a fair job addressing the scope of the skill-based standards, but there is room for improvement, especially in the area of student self-assessment. One must also consider 68 whether the presence of skill standards within a curriculum transfers to application of those skills in real-life settings. A further concern was whether skills transfer across concept areas, for example advocating in substance abuse may or may not transfer to advocating for healthy eating. Scores for standard 8, student’s ability to demonstrate influence and support other (advocacy), averaged only 2. The primary components of advocacy lie in influencing and supporting others (family, peers, etc. While sufficiently detailed to identify specific components of nutrition and being active, some concepts are written in such a way that curricula can apply 69 in a way that is very meaningful for the intended audience. For example, during the review of one state, numerous references to water safety were noted. It is logical that Florida included multiple references to aquatic safety but made no mention of preventing downhill skiing injuries. The evaluation concept pertained to basic safety precautions and reducing the risk associated with physical activity. States are provided the flexibility to address concepts in a manner consistent with the needs and interests of their communities. One, learning often requires multiple exposures to the same concept; individuals do not immediately grasp all concepts after a single introduction. Second, vertical alignment of concepts allows for introduction of increasingly complex content related to a topic. For example, young children might be taught to recognize that consuming fruits and vegetables is a healthy choice while older children should be able to incorporate the ideas of vitamins, mineral and calories in explaining why it is a healthy choice. There were 21 possible opportunities for states to demonstrate vertical alignment among Healthy Eating concepts. Two states did not have a single concept that aligned across multiple grade levels, but the states averaged alignment of 9. There were 18 identified strings among the physical activity concepts and states averaged vertical alignment of 6. Providing guidance across grades or levels that maximizes the chances a concept will be covered is 70 important for schools because often teachers at different levels. A well aligned curriculum provides information to individual teachers about what should have been covered and learned previously and what will come next. First, there was questionable vertical alignment of concepts within the Healthy Eating module. One might question how the tool can evaluate vertical alignment within a curriculum if the tool itself is not cohesive. An additional concern surrounding concept coverage was that some concepts appeared in both the Healthy Eating and Physical Activity modules, but were introduced at different grade levels. For example, the benefits of drinking water appear at the Pre-K-2 level in Healthy Eating, but not until grades 3-5 (benefits of drinking water before, during and after physical activity) in the Physical Activity module. The inconsistency between the methods of assessing standard 1 versus standards 2 through 8 was a source of confusion for this evaluator. The organization of that chapter clearly indicated that standard 1 was to be evaluated at four levels, but that standards 2 through 8 could be evaluated only once (only one physical location to record scores). A person evaluating a K-12 curriculum could record the standard 1 scores directly into the chapter but would have to make additional copies of the standards 2 through 8 pages in order to record all data. Adding an additional response field in which one would record the grade level being evaluating would serve to alleviate this 71 confusion. This might provide valuable information to a district looking to evaluate the effectiveness of its elementary or secondary health education curriculum, but did not appear to offer sufficiently valuable additional information in this global comparison of multiple curricula. Concepts for healthy eating and physical activity must be clearly delineated for school at each level. Therefore, research on transfer is recommended and until that is complete the skills should be “practiced” within content areas. In addition, topics with ties to multiple modules (for example, the dual roles of nutrition and physical activity in maintaining a healthy weight) are introduced at different grade levels between modules. Standards should provide teachers information about health specific content, the steps required to learn and teach necessary skills, assistance in how to model a skill, strategies for assessing students’ abilities to demonstrate skill and examples of appropriate assessments. The persons involved in development of standards and selection of curriculum are most likely to be experts in the area of health education. The responsibility to provide adequate references and resources must start at the top so that end-users are equipped with the knowledge and skills to effectively deliver health education content. Vertical alignment of concepts has been demonstrated as a significant factor in curriculum development. Little guidance was provided by states in their curricula to guide teachers, this was a clear weakness of all state models. There was little coordination between the modules as similar concepts were introduced at different levels in the two modules. The heart smart cardiovascular school health promotion: behavior correlates of risk factor change. The effectiveness of interventions to increase physical activity: A systematic review. A Report by the National Academy of Education Panel on Standards-Based Education Reform. A school-based intervention can reduce body fat and blood pressure in young adolescents. Physical and sedentary activity in school children grades 5-8: the Bogalusa Heart Study. School promotion of healthful diet and physical activity: impact on learning outcomes and self-reported behavior. Measuring the health environment for physical activity and nutrition among youth: a review of the literature and applications for community initiatives. Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools. Promoting physical activity and a healthful diet among children: results of a school-based intervention study. A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work. School-based health research funded by the national heart, lung and blood institute. Department of Health and Human Services Office of Disease Prevention and Health Promotion. The model suggests that there are multiple levels of influence, and that effective prevention and reduction programs should address each of these levels. These studies evaluated the effectiveness of programs and institutions with an emphasis on reducing childhood overweight and obesity. Study one evaluated the effectiveness of the Trim Kids program (Sothern, von Almen & Schumacher, 2001), a program with applications at the individual, interpersonal and organizational levels. In the second study, a macro-level initiative was evaluated, namely the health education curricula of ten states. The lack of support for either hypothesis demonstrates that there is much more research to be done in the area of program and curricular development aimed at reducing childhood overweight and obesity. Both Trim Kids and many states’ curricula provided good nutrition and physical activity concept coverage, demonstrating that knowledge alone is not sufficient for behavior change. The results of both studies suggest that strong leadership and accurate measures of actual behavior are important. Trim Kids was unable to replicate the success of the expert-led, closely-monitored success of the similar Committed to Kids program. States varied widely in their data collection methods and typically only reported outcome (prevalence rates of obesity) rather than process data. Overview of Standards Compared to National Health Education Standards 1-8, the Grade Levels for Health, Physical Activity, and Health/Physical Education Combined Benchmarks Table A4. Alignment of State Standards (n = 6) and National Health Education Standards by Number Based on All Content in the State Curricula, Including Content Beyond Healthy Eating and Physical Activity Table A5. Healthy Eating and Physical Activity Concept Coverage by State from Highest to Lowest Obesity Percentage Table A6. Scope and Sequence of the 62 Healthy Eating Concepts (Standard 1) Across Grade Levels Table A9. Scope and Sequence of the 53 Physical Activity concepts (Standard 1) Across Grade Levels Table A1. Section I: All data in regular font are from the 2007 Youth Risk Behavior Surveillance Survey (high-school aged adolescents). Most data in italicized font are from the National Survey for Children’s Health (n. Oregon had very limited data available in Promoting Physical Activity and Healthy Eating Among Oregon’s Children th th (2007, p. The first recommendation towards achievement of these goals is to gather health-related data. Summary of Healthy Eating Concept Coverage Across All States Grade level Covered by 0–1 state Covered by 9–10 states PreK-2 3 Identify the benefits of drinking plenty of water 1 Explain the importance of (8 concepts) 6 Describe body signals that tell people when they choosing healthy foods and are hungry and when they are full beverages 3–5 7 Summarize the benefits of drinking plenty of None (16 concepts) water 9 Identify foods that are high in fat and low in fat 10 Identify foods that are high in added sugars 11 Describe the benefits of limiting the consumption of fat and added sugar 16 Explain how eating disorders impact proper nutrition 6–8 11 Identify foods that are high in fiber 17 Describe the relationship (23 concepts) 12 Identify food preparation methods that add less between what people eat, their fat to food physical activity levels and 13 Identify examples of whole grain foods their body weight 15 Describe the benefits of eating a variety of foods high in iron 22 Summarize how eating disorders impact proper nutrition 9–12 7 Analyze the benefits of drinking water before, 2 Describe the relationship (15 concepts) during and after physical activity between nutrition and overall 8 Explain how to incorporate foods that are high in health fiber into a healthy daily diet 12 Describe the importance of 10 Explain how to incorporate an adequate healthy eating and physical amount of iron into a healthy daily diet activity in maintaining a healthy 11 Identify how to make a vegetarian diet healthy weight 94 Table A7. Summary of Physical Activity Concept Coverage Across All States Grade level Covered by 0–1 state Covered by 9–10 states PreK-2 1 Describe recommended amount of 4 Describe the benefits of being physically (5 concepts) physical activity for children. Scope and Sequence of the 62 Healthy Eating Concepts (Standard 1) Across Grade Levels Concept PreK-2 (n = 8) Grades 3-5 (n = 16) Grades 6-8 (n = 23) Grades 9-12 (n = 15) 1. Benefits of healthy 1 Explain the 4 Summarize the 4 Analyze the benefits of healthy 4 Analyze the benefits of eating/ consequence importance of benefits of healthy eating healthy eating on poor dietary choosing healthy eating behaviors foods and beverages 6 Describe the 8 Summarize the benefits of benefits of eating eating plenty of fruits and plenty of fruits and vegetables vegetables 2 Describe the relationship between nutrition and overall health 3 Describe the relationship between diet and chronic diseases such as heart disease, cancer, diabetes, hypertension and osteoporosis 2. Food identification/ 2 Identify a variety of 2 Explain the classification healthy snacks importance of eating a variety of foods from all the food groups 1 Name the food 1 Summarize a variety of 6 Describe the importance groups and a variety nutritious food choices for each of eating a variety of the of nutritious food food group appropriate foods to meet choices for each food daily nutrient and caloric group needs Concept PreK-2 (n = 8) Grades 3-5 (n = 16) Grades 6-8 (n = 23) Grades 9-12 (n = 15) 8 Identify nutritious 10 Differentiate between nutritious and non-nutritious and non-nutritious beverages beverages 6 Explain the similarities and 5 Explain food sources that differences among proteins, fats provide key nutrients and carbohydrates regarding nutritional value and food sources 3. Recommended 5 Describe the type of servings & portion foods and beverages control that should be limited 3 Identify the number 2 Classify the number and of servings of food appropriate size of servings of from each food group food from each food group that a that a child needs person needs each day daily 3 Explain why some food groups have a greater number of recommended portions than other food groups 5 Explain the concept 7 Describe the benefits of eating of eating in in moderation moderation 5 Describe the federal dietary 1 Describe the guidelines for teens recommendations of Dietary Guidelines for Americans 13 Explain how the Dietary Guidelines for Americans are useful in planning a healthy diet Concept PreK-2 (n = 8) Grades 3-5 (n = 16) Grades 6-8 (n = 23) Grades 9-12 (n = 15) 4. Water/hydration 3 Identify the benefits 7 Summarize the 9 Analyze the benefits of drinking 7 Analyze the benefits of of drinking plenty of benefits of drinking plenty of water drinking water before, during water plenty of water and after physical activity 5.

Implementing these guidelines will be challenging in several parts How to cite this article: Post-Graduate Courses muscle relaxant for pulled muscle generic colospa 135mg overnight delivery. Pediatr of the world spasms near tailbone order 135 mg colospa with amex, but they signal a new attitude of minimizing interventions Pulmonol spasms under rib cage buy discount colospa 135mg. Maintaining Respiratory Health in Resource Poor Pneumonia in the developed world is changing as a result of Populations immunization muscle relaxant medication prescription buy generic colospa 135mg line, emerging pathogens and drug resistance muscle relaxant medicines buy discount colospa 135 mg on line, with profound differences between developing and developed countries Catherine Byrnes in the organization and efficiency of their health systems(8) muscle relaxant review 135 mg colospa mastercard. Associate Professor, Department of Paediatrics, University of Auckland & Paediatric Respiratory Specialist, Starship Children’s Hospital, Auckland, New However, a significant burden of respiratory disease − bronchiolitis, Zealand pneumonia, bronchiectasis − also exists in populations within Email: c. Pneumonia accounted for 16% of all deaths in children < 5 years of While geography and potential isolation creates difficulties in age − nearly 1 million −in 2015 alone. More than 95% were from accessing care for some (Australian Aboriginal, Alaskan First Nation developing countries, most prevalent in South Asia and sub-Saharan communities) in others, such as our own Maori and Pasifika Africa (1,2). In a has developed an algorithm pathway to health care − based on comparison of indigenous children with chronic respiratory disease simplified premises tested and retested in appropriate settings(1). These two tobacco exposure, poorer parental education resulting in early and signs have a high sensitivity, reasonable specificity, and found to be repeated acute respiratory infections (10). Pneumonia is classified into an increased risk of infections butsupplementation to reduce infection 3categories;‘nonsevere’, ‘severe’,and‘very severe’(1). By 2015, 86% of the review of 12 studies showed children with saturations <90% were at world’s children received three doses of Diphtheria-Pertussis-Typhoid 5. Even in low income countries, pulse reducing the number who did not receive these routine vaccinations oximetry is a relatively cheap and robust diagnostic tool. Treatment failure occurs in Pneumococcal vaccination is in 128 countries with 32% coverage 9–21%regardlessof theantibiotic usedandis associatedwith younger contributing to a reduction in < 5 year age mortality from 12 million in age, previous use of antibiotics, lack of breastfeeding, living in 1990 to 6. Vaccine introduction is currently overcrowded home, higher respiratory rate on assessment and lagging in middle income countries as they are less able to finance immunization status(7). Ending preventable child deaths from was associated with higher rates of cough, bronchitis, sputum, and pneumonia and diarrhoea by 2025. A mortality reduction of 36% is pneumonia of children in developing and developed countries. Risk Factor in Acute Lower Respiratory Infections in Children in Low Whole focusing on infection above, wheezing illnesses are even and Middle-Income Countries: Systematic Review and Meta-Analysis. Predictors of treatment failure for non-severe childhood wheeze in the absence of fever. This list now expert survey–the first step towards a community focused mHealth includes two inhaled corticosteroids and one bronchodilator meter risk-assessment tool? Indigenous children from three countries with non access to cost-effective interventions for both prevention and cystic fibrosis chronic suppurative lung disease/bronchiectasis. New interventions are being supplementation for preventing infections in children under five years investigated including diagnostics, recognizing genetic predisposition of age. Progress and challenges with Achieving noted that ending preventable deaths (predominantly pneumonia and Universal Immunization Coverage: 2015. Estimates of Immunization diarrhea) inyoungchildren withinthe next12 yearswas “ambitiousbut Coverage. Increased risk of respiratory illness associated with immunizations to 90% for all countries − leading to 2/3rds reduction in kerosene fuel use among women and children in urban Bangalore, deaths in children < 5 years age. Dampness, bacterial and fungal to food allergy, of which one third are due to severe, anaphylactic components in dust in primary schools and respiratory health in reactions. Peanut is one of the most potent allergenic foods, causing schoolchildren across Europe. Edu standard for diagnosing food allergy3, but the procedure is time consuming, expensive and patients may be at risk of severe reaction. In “positive” test confirms sensitization, it does not unequivocally this presentation, we discuss the burden and risk factors for mortality confirm clinical reactivity upon exposure. All-cause hospital deaths and community allergenic foods, but these decision points may differ between different populations or setting4. A diagnosis of sepsis allergenic proteins (or components, so called component-resolved and pneumothorax were the main determinants of poor outcomes. Given the heterogeneity in the recognition patterns Tel: +44 20 7594 3274, Email: a. J Allergy Clin Immunol 2001; avoidance of implicated foods, and the availability of rescue 107(5): 891-6. J Allergy Clin Oral immunotherapy involves administering very small but increas Immunol 2011; 127(3): 684-5. Molecular diagnosis of peanut and legume food immunotherapy has been shown to be effective for peanut7 allergy. However, it has to be emphasized that dietary avoidance is not a treatment, but rather a management strategy predictors of adverse events during oral immunotherapy for milk 9 allergy: severityofreaction atoralchallenge, specificIgEandpricktest. Advisory food labels: consumers requirement is now being extended to catered foods. The use of adrenaline study of ∼1000 peanut-allergic children, nearly half of them autoinjectors by children and teenagers. Clinical & Experimental Allergy experienced at least one reaction to peanut in the previous 12-month 2012; 42(2): 284-92. Trendelenburg V, Enzian N, Bellach J, Schnadt S, Niggemann B, ubiquitous in human diet, and avoidance is very difficult, especially as Beyer K. In one study, cow’s milk was detected in 43% of pre-packed bakery products sold as cow’s milk-free. Allergy 2015; 70 the bakery products, with 21% containing sufficient amount to cause (5): 591-7. Peanut allergy: overestimated in surprising that 2 in 5 children with cow’s milk allergy will have allergic 2 epidemiology or underdiagnosed in primary care? The importance of early childhood: References Respiratory disease in early childhood poses a huge burden to patients/ 1. Inadditiontotheimmediateimpacts children sensitized to peanut: Prevalence and differentiation using of time away from school and parental missed work, there are the well component-resolved diagnostics. Journal of Allergy and Clinical described longer term clinical impacts extending into adulthood and in Immunology 2010; 125(1): 191-7. Persistent allergy to cow’s milk: of greater a clinical Response to Treatment Varies concern than other food allergies. Pediatr Allergy Immunol 2013; 24(7): A number of factors, both known and unidentified, may influence 624-6. The ability to reliably assess response will allow individualized care to Alternatives to potentially useful tests which may be limited by their be delivered: optimal therapies at required doses (but not higher) for acceptability: the necessary period of time (but not longer). Protocols are being investigated both with and health, drug side-effects, antimicrobial resistance and adverse long without the administration of gases (hyperpolarized or simple term consequences. The gold standard of bronchoalveolar lavage is ivacaftor, significant benefits on lung function and exacer invasive and cannot be undertaken repeatedly. The limitations of systemically, there are opportunities to assess the impact on sample collection also restrict any ability to monitor airway other organs: sweat chloride, weight and height, markers of pancreatic disease such as fecal elastase-16. Although they are used relatively frequently in some centers, concerns over radiation limit their use in others. In Summary – Physiology: lung function testing, the mainstay of monitoring Childhood lung disease is of major importance not only because of the for older children and adults with lung disease is not easy in burden to the child and family at the time, but also as it provides the very young children. It is therefore crucial that the right most useful in the early stages of disease, requires significant treatments at the right dose are provided tothe right patients at the right expertise and sufficient time to be performed well, so is time. Personalized therapy, as opposed to a ‘one-size-fits-all’ approach currently only available in a small number of centers, most is only possible when treatment response can be assessed accurately commonly on a research basis. Consider doing easy things more frequently: References – an example of this would be sputum induction in young 1. Developments in multiple – further, the development of smart technology coupled with breath washout testing in children with cystic fibrosis. Curr Med Res inhaler/ nebulizer devices provides a real opportunity for us to Opin. These findingshave suggestedthat opportunities for electronic monitoring in a real-world asthma randomized controlled asthma prevention could arise from interventions that prevent either trial. Comparison of Lung Studies of children raised in rural communities, and especially on Clearance Index and Magnetic Resonance Imaging for Assessment of animal farms, have provided solid evidence indicating that increased Lung Disease in Children with Cystic Fibrosis. Am J Respir Crit Care exposure to environmental microbes and microbial products during Med. Of interest, oral lyophilisates of bacterial extracts have been used empirically for decades in Europe and Latin American for the prevention of viral #5. However, genome-wide sensitization to the development of asthma by blocking the effects of association studies have identified polymorphisms in a gene cluster allergic inflammation on lung remodeling during the preschool years. References Complex analyses of patterns of sensitization to aeroallergens in early life have shown that a subclass of young children that tested 1. The Group Health and may thus predispose for the development of atopic asthma later in Medical Associates. Rhinovirus wheezing illness and genetic risk of childhood nitric oxide in children with asthma receiving xolair (omalizumab), a onsetasthma. Viral infections and atopy in asthma pathogenesis: protein synthesis or function is useful, especially in view of new rationales for asthma prevention and treatment. Exposure to environmental microorganisms and allow ribosomes to continue translation through the premature stop childhood asthma. With the increasing use of genetic engineering homozygous for the F508del mutation. Ivacaftor has shown improved lung safety in order to reduce the morbidity and mortality related to food function, weight, and patient-reported respiratory symptoms, allergies. Food allergy: riding the second wave of the Class V is characterized by a reduced amount of normally functional allergy epidemic. J Allergy Clin Immunol advanced type of individualized personalized treatment, geared for 2012;129:906-20. Preventing Food Allergy: Early Consumption or Randomized trial of peanut consumption in infants at risk for peanut Avoidance allergy. In the developed countries, one in three children Randomized Trial of Introduction of Allergenic Foods in Breast-Fed suffers from at least one allergic disorder and these include food Infants. It is interesting to note successful reduction of clinical allergenicity of food by genetic that the natural history of different types of food allergies vary modification: Mal d 1-silenced apples cause fewer allergy symptoms dramatically. Exposure to microbes early on in life may affect maturation of the immune system resulting in protection against allergies and may include the #8. Interstitial Lung Disease in Childhood: Current Status of protection against food allergies. The common allergens resulting in Diagnosis and Management food allergies in developed countries include egg, milk, fish, wheat, peanuts and tree nuts (2). Anaphylaxis is the most severe form of food Matthias Griese allergy and can be fatal. There have been several clinical trials Hauner Childrens Hospital, University of Munich, Lindwurmstr. This helps to keep population but it was rather difficult to introduce so many foods in the various entities in order and to accommodate rapidly novel young infants such that the results in the intention-to-treat analyses entities. Indeed, for such mutations, “classical“ (groups labeled “A”) need to be recognized every now and then, and clinical trials are not possible due to low numbers of patients and their the pediatric pneumologist is expert for this. Such pre-assessment may tachypnea of infancy (A3), allowing differentiation in usual and become a standard basis for a drug clinical use in a precision medicine aberrant cases. Personalized Medicine for Lung Disease [5] Ramsey et al (2011) N Engl J Med 365:1663-72 Margarida D. Novel Treatments for Acute Asthma expressed at the apical membrane of epithelial cells. One of the known factors for a “high risk” patient with acute therapies for exacerbations is wheezing in preschool children. Children asthma is the presence of previous severe asthma and / or under 5 years account for the majority (approx. However, we still dysfunctional breathing and this will become worse during periods of have little to offer for either prevention of attacks, or the treatment of the worsening control and more symptoms. Themostlikelyreasonforfailedresponseto question a diagnosis of acute severe asthma in the presence of therapyinthisagegroupisthatmost,ifnotall,acuteattacksarecausedby normoxia. A severe asthma attack in the absence of hypoxia may not respiratory infection, most commonly viruses7 which are known to be be an asthma attack at all. A large clinical saturations are reliable and reproducible between observers and trial has shown that there was no significant reduction in unscheduled shouldbeusedbothtomakeaninitialassessmentoftheseverityofthe healthcare visits between children that received montelukast or placebo acute episode, but also to assess response to therapy. However, the route of administration and use of the most reducedoral steroidswere prescribed for the montelukast group,but that appropriate device is also critical. However, the choice of significantly less being issued with asthma action plans and education at 4 antibiotic (azithromycin) that was used in the two large recent clinical discharge. Child and parental education, checking inhaler technique and trials that have been undertaken, suggests the mode of action was administration of asthma action plans for each child at discharge is predominantly anti-inflammatory, not anti-bacterial. The data from the essentialastheonlywaytopreventfutureattacks,andareasimportantin 10 trials have been summarized elsewhere, but it is accepted that the care pathway for an acute attack as the treatment at presentation. The dilators and are often administered with the anticholinergic ipra data showed development of macrolide-resistant organisms, very tropium bromide. Current evidence from pediatric trials hospitalization,unscheduled healthcare visits,oron useoforal steroids. Summary However, despite this lack of evidence both are widely used as part of the most important aspect of management of acute asthma in any the management of acute asthma in children. It is important to consider why children may not respond to Finally, if there is further deterioration, then the institution of non bronchodilators during an acute asthma attack. A prospective multi invasive ventilation, or high flow oxygen via nasal cannula are options center study that included children aged 1–17 years presenting with that can be tried to avoid the need for ventilation, but the evidence for acute asthma has investigated reasons for failed emergency depart their efficacy is very limited. J Paediatr Child Health 2016; 52: to exacerbation severity (oxygen saturation <92%), detection of virus 187-191.

Phrenology the belief that char­ 116 The Cam bridge Illustrated H istory of M edicine acter is determined by the relative size of the different parts of the brain and hence can be known by feeling the bumps of the head —and mesmerism (and their hybrid form spasms under right rib cage cheap 135mg colospa with mastercard, phreno-mes merism) were others spasms lung generic 135mg colospa otc. Each argued in its own language that the whole system of allo­ pathic medicine was radically wrong kidney spasms causes order colospa online now. Characteristically spasms while peeing order colospa 135mg mastercard, they accused the orthodox of striving to blitz disease with poison­ ous drugs muscle relaxant for anxiety buy generic colospa. Each offered a new plan of life based on Nature’s way muscle relaxant patch purchase colospa 135 mg on line, and claimed to use more natural modes of healing using herbs alone or pure water. Each professed to invest the indi­ vidual with new control over his health as part of a culture of self-improvement and realization. Medical heretics typically doubled as heretics in politics and faith as well, while cultivat­ ing unorthodox lifestyles. But, as is evident, in attacking the scientific sim­ Many nineteenth-century plicities of regular medicine, alternative medicine creates a simplistic, alternative medicines com­ black-and-white philosophy of its own. They are threatening your well-being with bined a popular, anti-ortho­ chemicals and pesticides, processed food, and pollution. You can safeguard it by dox message with the colour­ following Nature eating natural fare and, in so doing, discovering your natural ful appeal of the skilful adver­ tiser. Moreover, alternative cults often carry Morison; he was later out­ unsavoury, victim-blaming hidden agendas. But this turns out to be another variant on sturdy Protestant ly earnest, anxious, and des­ self-help, masquerading as a radical alternative: working-out is the old Protestant perately busy Victorian mid­ work ethic in a new guise. Medicine has enjoyed exceptional suc­ scribed by regular physicians cess: of special symbolic significance was the final global eradication of smallpox above all, their fiercely in 1979. Alternative tion grows; dreams fade, promises are broken, people vote with their feet and try medicine could thereby claim for itself that exaltation of the alternative medicines and psychotherapies. Faced with ‘yuppie flu’, chronic fatigue, strange allergies, and today’s sickness salad-bar, the medical profession has made hostile and dismissive W hat is Disease? For one thing, diseases, like empires, rise and fall: plague has declined although occasional localized outbursts remain severe but cancer has worsened. One does not need to embrace a modish sociological scepticism to rec­ ognize that diseases, like beauty, are somewhat in the eye of the beholder: people see what they want or are programmed to see. Particular anxieties, academic training, new technologies, and so forth cause conditions to come into focus and create pressures to create labels. People doubtless died of heart complaints in ear­ lier centuries, but it took the outlooks and diagnostic apparatus of modern medi­ cine to create the modern categories of the heart attack and coronary thrombosis, or to perceive how the condition long seen as ‘dropsy’ (oedema) was actually due to heart disease; weaknesses depicted in earlier medicine became crystallized into diabetes. Different circumstances lead to different facets of life pains, fevers, bad habits, impair­ ments being called disease. The fit between what someone experiences as sick­ ness and what doctors deem disease may be close or it may be loose. Wider issues are often at stake: quests for research funds, insurance company regulations, med­ ical exoneration before the law or at the workplace, social excuses. But it must be remembered that medicine has always been embedded both in human cultural milieux and in the diverse needs of intelligent warm-blooded bodies. The doctor might be in a hospital emergency room or in a local clinic, but, historically, gen­ eral practitioners have been the first point of call. This is a story of how patients and general practitioners have collided and colluded over the past two centuries. The story could, of course, be extended much further back in time than the late eighteenth century. Yet that is when the practice of medicine, which had been fairly constant in its humoral theories and drastic treatments over the centuries, began to change. Although medical theories had been in flux over the seventeen centuries from Galen of Pergamon to Herman Boerhaave of Leiden, the actual practice of medicine, or primary care, had changed little. With the infusion of sci­ ence into medicine late in the eighteenth century, however, the story begins to change. Many of the subsequent travails of primary care may be understood as the confused efforts of doctors and patients to come to grips with the ever-changing realities of medicine imposed on them by science, on the one hand, and by sub­ jective views of ‘medical correctness’ on the other. Most of his diagnos­ tic methods were old tried and tested ones, such as tak­ ing the pulse. Modesty inhib­ ited extensive physical exami­ nation, especially with female patients. To attract patients, they often felt obliged to offer whatever it was the patients wanted. As George Bernard Shaw wrote in his preface to the Doc­ tor’s Dilemma (1911), the doctor who has to live by pleasing his patients in com­ petition with everybody who has walked the hospitals, scraped through the examinations, and bought a brass plate, soon finds himself prescribing water to teetotallers and brandy or champagne jelly to drunkards; beefsteaks and stout in one house, and ‘uric acid free’ vegetarian diet over the way; shut windows, big fires, and heavy overcoats to old Colonels, and open air and as much nakedness as is compatible with decency to young faddists, never once daring to say either ‘I don’t know’, or ‘I don’t agree’. This desire to placate patients’ ideas of what constitutes good medicine is one of the basic motors of change in pri­ mary care. Tradi­ tional patients often had (to us) bizarre notions of what was wrong with them and Debate ranged in pre-modern how it might be fixed. One popular idea in the eighteenth century stressed ridding medicine as to the curative properties of sweating as a the body of the poisons that cause disease by drawing them out through the skin. Free perspiration was this entailed sweating cures, and patients cherished the idea as did physicians claimed by some to be neces­ to a lesser extent of sweating a patient with a fever. Edinburgh physician sary for removing poisons William Buchan wrote in his best-selling medical guide Domestic Medicine in from the body (especially 1769, ‘It is a common notion that sweating is always necessary in the beginning of syphilitic contagions). The common practice is to heap clothes upon the patient, and to give any case regarded fever him things of a hot nature, as spirits, spiceries, &c. Bleeding Thomas Sydenham, by con­ was much beloved by the common people, extending past the time when it lost trast, were advocates of ‘cool methods with fevers plenty popularity with physicians. There were many other popular strategies for elimi­ of ventilation and cold drinks. One was vomiting, relinquished relatively early by academic medi­ By 1800, the sweating cure cine but cherished until the twentieth century by patients. One day a peasant in the practice of Kussmaul’s father sent word that he was ailing, weak, losing weight, and unable to arise from bed. The father, busy 120 The Cam bridge Illustrated H istory of M edicine at that moment, sent on by messenger some remedy containing a sweet syrup that could at least do no harm. Arriving at the peasant’s cottage, the doctor found the man restored, at that very moment delecting a roasted dove and drinking a glass of wine. Apparently, the messenger had fallen asleep en route, and as he snoozed under a tree the cork had popped out of the bottle, giving a local ant colony a chance to check out the syrupy prescription by climbing into the bottle. The peasant, so implicitly convinced of the restorative powers of emetic therapy, had vomited heartily after downing the ants and was well again. The point is that sweating, bleeding, and vomiting, in addition to salivating, urinating, purging, and many other ways of getting the bad humours out, had a hold on the popular mind that reached back for centuries, existing alongside med­ ical doctrines of belief in such procedures. Thus the patients arrived in primary care with their own definite views of what was needed. Fever, a symptom of the body’s response to invasion by bacteria and viruses, occupies a minor role in Western medicine today, mainly in the form of initial childhood encounters with common microorganisms and of colds and coughs (upper respiratory infections). Fever was the axis about which the traditional con­ sultation turned the hot bedridden patient, his pulse quickened and respiring rapidly, the doctor making a house call. The diary of Richard Kay, a doctor who lived near Bury in Lancashire in the mid-eighteenth century, shows how immersed in fever was the typical practi­ tioner. Chippingdale at Ewood, ‘she being very bad’, ill appar­ ently with typhus, a tick-born bacterial infection characterized by malaise, severe headache, and sustained high fever. By the time another year would pass, the author’s father, his sister Rachel, and his sister Elizabeth were also dead of fever. Late in the nineteenth century Arthur Hertzler, a small­ town doctor on the Kansas frontier, was called to a case of empyema, or pus in the lungs. As 1 entered the sickroom I saw a boy fourteen years of age half sitting up in bed in deep cyanosis [caused by lack of oxygen], with grayish-blue skin and heaving chest, his mouth open and his eyes bulging. Grabbing a scalpel I made an incision in his chest wall with one stab he was too near death to require an anesthetic. As the knife penetrated his chest, a stream of pus the size of a finger spurted out, striking me under the chin and drenching me. After placing a drain in the opening, I wrapped a blanket about my pus-soaked body and spent another three hours reaching home. The nineteenth-century physi­ cian was regarded and often idealized as a wise, grave man who was a friend, even to the poor. A gentler and more desirable form of bleeding when it was called venesection was to put a leech on the affected part. They may be placed anywhere on the body to extract the leech engorge itself with supposed excess blood. Before he complied with his lancet in his right hand, between the thumb and first finger contract, he sold out. At present they are only in the ther directions followed on bandaging the wound and also 8 reach of the rich. Some critics of the technique believed that George Washington was bled to death in his last illness on Friday 13 December 1799. Primary Care 123 In medical practice well into the twentieth century, fever was omnipresent. Pneu­ monia, for example, counted as ‘the old person’s friend’, because it was so com­ mon in the elderly and often fatal after a short illness. And few physicians would not face the sadness of death in the young from the epidemic diseases of child­ hood. In the case of an attractive seven-year-old child in whom the disease had invaded the larynx, I had inserted an O’Dwyer intubation tube [Herrick had practised the technique in the morgue of the Cook County Hospital). This gave relief for several hours; then it was evident that the tube was becoming clogged. I explained the desperate nature of the trouble, the extreme weakness of the circulation due to the tox­ aemia, and the danger of even mild manipulative treatment. The mother left the room, the father took the child in his arms, and with little difficulty the tube was removed. In memory I can still see the room, the exact location of the bed, the chair, the limp child in the father’s lap, the adjustment 9 of the light. Before the twentieth century, therefore, infectious diseases dominated over all others. Tuberculosis, syphilis, diphtheria, plague, meningitis, malaria, and post­ partum sepsis were the diseases against which medical graduates and physicians everywhere had to struggle. For this task, the doctrines of traditional physicians had singularly ill-equipped them. In the middle of the nineteenth century, medical theories about the causes of disease would be turned inside out. But before that time notions of disease causa­ tion were constructed along ‘humoral’ lines, attributing illness to imbalances of the fluids, or humours, which the Ancients believed to be the constituents of the body: black bile, yellow bile, phlegm, and blood (see page 58). By the eighteenth century, these Galenic humoral doctrines had undergone considerable modification. The Dutch physician Herman Boerhaave, for example, added to the ancient theories baroque elaborations that distinguished between disorders of ‘the solids’ and those of ‘the blood and humours’. Tuberculosis was an example of weakness of the solid parts, thrombosis and blood clots examples of overly rigid fibres. Give milk and iron for weak fibres; do bloodletting for rigid ones, Boerhaave coun­ selled in the early eighteenth century. Yet virtually all theorizing about the mech­ anisms of disease before 1800 was like a castle built in the air: it had little empirical foundation and was completely false in modern scientific terms. Therapies derived from these humoral theories were almost without exception injurious to the patient. Little was cured and much damage caused by depleting 124 The Cam bridge Illustrated H istory of M edicine the body of its natural physiological constitutents and dosing it with toxic metals. A variety of mechanical contrivances, from the little folding knife called the ‘lancet’ to the elaborate ‘scarificators’ of the early nine­ teenth century fiendish devices whose multiple blades would cut simultaneously into the skin testify to its commonness. A proper physician (as opposed to a surgeon or an apo­ thecary) might disdain such procedures as bloodletting and setons in favour of giving ‘physic’, or medicine. Towards 1800, Edward Sutleffe, a medical man of long experience in London’s Queen Street, called on Mrs. Her fingers were painful and swollen, ‘thickly studded with eruptions, from which issued a semi-trans­ this title-page of one of parent excoriating ichor. I suspected the latent cause, and told her she had Herman Boerhaave’s works neglected her bowels in particular’. Sutleffe pre­ shows him addressing a large scribed for her ‘a tepid bath and mild aperients [laxatives]’. Benjamin Rush popularized the use of mercury, calling it in 1791 ‘a safe and nearly theory) of medicine at Leiden a universal medicine’. Traditional medical therapeutics therefore amounted to making patients In 1718, he was further anaemic through bloodletting, depleting them of fluids and valuable electrolytes appointed to the chair of via the stool, and poisoning them with compounds of such heavy metals as mer­ chemistry. Even some contemporary physicians had the wit to notice what quintessential scientific physi­ damage traditional therapeutics inflicted. Boston’s William Douglass observed in cian and medical teacher of the early Enlightenment. His 1755: ‘In general, the physical practice [giving medications] in our colonies is so introduction of the study of perniciously bad, that excepting in surgery and some very acute cases, it is better the natural sciences into the to let nature under a proper regimen take her course (naturae morborum curatri medical curriculum was espe­ ces) than to trust the honesty and sagacity of the practitioner. Physicians used blistering agents such as cantharides (spanish fly) or acetic acid to raise a serum blister on the skin. In these cases, we find that issues do cauterizing, to cleanse and seal a wound; on the right, little good unless they be somewhat painful, or be in the another is applying a seton. It was the excesses of traditional therapeutics, not its basic principles, that caused unease among sufferers, making primary care seem more a last resort than a route to wellbeing. The sight of them is enough to make a man serious, for we may lay it down as a maxim, that when a nation abounds in physicians it grows thin of people. At the outset of the story of primary care, therefore, we find the doctors in the grips of (to us) ludicrous and dangerous theories, the patients ter­ the brusque physician on the rified, and in search of alternatives. Science, however, brought the two opposing right is a caricature by Charles de Villiers of the dis­ parties together.

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