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Medicine had largely passed beyond pre­ scriptions based on bodily hum ors effective prazosin 1mg cholesterol kinds, but its techniques were still unsophisticated in today’s terms purchase prazosin from india cholesterol test after eating. Bloodletting persisted order aricept, cauterization was used, and the use of purgatives was also common. But medicine rem ained outside the body, at least until it was clear that the body could not be understood without an exam ination o f its inner workings any m ore than, today, an automobile engine can be repaired without remov­ The Eras of Medicine 203 ing the hood. His rew ard was nearly universal denuncia­ tion by the church and by the academic world. It took approxim ately another 200 years before the investigation of what went on inside the skin was widely tolerated. And this did not occur until the m etaphor of the body as a machine was firmly planted. A ntiquarian notions such as the bodily hum ours coexisted with observations of actual function. It was now expected that knowledge would be a fund of observations rather than an elaboration of theological propositions. But until Virchow’s Cellular Pathology was published in 1858,11 medicine re­ m ained a tentative art moving alternatively through old wis­ dom and new findings. T he doctor had em erged, but a cohesive theoretical fram ework for medicine had not. T he first public health practitioner was the sham an, whose initiatives were crude, but pragmatic and probably effective. As an illustration, the sham an might direct that a residence contam inated by the illness of a resi­ dent be burned. But these measures, while conceptually consistent with pub­ lic health, were modest com pared to the measures launched in the nineteenth century. As early as 1853 a physician in London, John Snow, linked a cholera epidemic to contami­ nated water in a public water pum p. But it took the genius o f Pasteur, Koch, and others, later in the century, to firmly tie infectious disease to environm ental sources. But in the late nineteenth cen­ tury the idea was startling, and ushered in an entirely new 204 T he Transform ations of Medicine way o f perceiving the environm ent. T he perception of man as a machine also persisted, but the breakthroughs of Pasteur and others modified the m etaphor. Man was still a machine, and disease a functional disorder, but with the rise o f public health it was now conceivable that defects in the machinery could be in­ troduced by a virulent environm ent. Medicine had slowly im proved its wares, but the health of the population had not dem onstrably improved. M aternal mortality rem ained roughly constant, and longevity did not seem to be affected.

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Open groups for mastectomy patients have been advocated in the prevention of long-term morbidity order 2 mg prazosin with mastercard cholesterol ranges nz. Differences of opinion exist as to whether radiotherapy after mastectomy increases or decreases psychological morbidity buy prazosin 2mg fast delivery cholesterol oxidase. Counselling by a nurse should be given after diagnosis and before operative surgery purchase cheap cleocin on-line. The patient should be given the choice for mastectomy or a less radical procedure since this does seem to reduce the associated psychiatric sequelae. Type I involves clitoridectomy while type 2 also involves removal of the labia minora. Syphilis accounted for about one in ten psychiatric admissions during the pre-antibiotic era. The shame attached to such conditions was reflected in medical euphemisms such as ‘specific disease’ (syphilis) and ‘gram negative intracellular diplococci’ (gonorrhoea). Numerous important issues are raised by such statistics, such as emotional versus physical readiness for intimacy, condom non-use and needle-sharing, various other risk- taking behaviours, alcohol and substance misuse, and sexual assault. Dialysis This prolonged procedure, in the case of end-stage renal disease, has been associated with such adverse 2281 2282 psychiatric sequelae as depression , dementia , the dialysis disequilibrium syndrome (transient acute 2283 confusional state secondary to rapid changes in plasma osmolality ), (possibly) encephalopathy due to cytokine activation (reaction to synthetic dialysis membranes), and abnormal marital relationships with much covert anger and lack of healthy communication. Aluminium was used to reduce phosphate serum levels, but it was inferior in this regard to calcium carbonate. The pathology of dialysis dementia differed from that of Alzheimer’s 2284 2285 disease and the dementia-Parkinsonism complex of Guam. The pathology of dialysis dementia has been described as follows: increased brain aluminium levels; increased number of senile plaques; absence of neurofibrillary tangles; and abnormal tau protein processing with deposition of insoluble phosphorylated tau in grey matter as in Alzheimer’s disease. Wernicke’s encephalopathy has been noted in some cases on longterm haemodialysis who had not received vitamin supplementation. The incidence of suicide is raised among patients on chronic haemodialysis, although not all patients who withdraw from dialysis are suicidal (‘rational suicide’) even if some are also feeling depressed. Such events are much less common with the slower acting continuous ambulatory peritoneal dialysis. However, the potential full syndrome consists of nausea, vomiting, headache, myoclonus, hypertension, and (if cerebral oedema occurs) coma and seizures. Ideally, a psychiatrist should assess all patients who are being considered for long-term dialysis. Lithium and the dialysis patient Lithium is readily dialysed Patients maintained on dialysis do not excrete lithium They do not require daily lithium therapy (it is only removed at dialysis) They are usually maintained on 300-600 mg lithium after each dialysis treatment (some people need doses on non-dialysis days) Serum lithium levels are checked 2-3 hours after a dose (monthly after a dosing schedule is established) Testosterone levels may fall (often staying within the normal range) in patients with chronic renal disease and cause erectile dysfunction and reduce sperm production. Most sufferers do not seek professional advice, many cases are not diagnosed, and the taking of inappropriate remedies is common. However, according to Medcalf and Bhatia (2006) many cases may start in childhood but are not diagnosed.

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Glutamate is an excitatory neurotransmitter that seems critical for the waking state buy generic prazosin from india cholesterol chart webmd, and is 317 the transmitter of the ascending reticular activating system discount prazosin 1mg on-line cholesterol medication lipitor side effects. After a true epileptic seizure there is an increase in the serum prolactin generic 60mg evista, which does not occur following a pseudoseizure; there is also a rise in the serum cortisol but this is much less specific. Attacks of bronchial asthma commonly occur at night because of exaggerated bronchial constriction and may cause insomnia; the sole symptom may be a cough; some cases of insomnia are secondary to management with adrenergic agents; fatalities are most likely among those whose peak expiratory flow rate fall the furthest. The sleeper is pale and peaceful, heart and breathing are slow, and it is difficult to rouse him/her. Speech may be indistinct, behaviour automatic, and response to the environment is reduced. Sleep drunkenness (inertia following on final awakening), sexsomia (abnormal sexual behaviour), and sleep-related violence may seen as variants of confusional arousals. This is due to removal of tryptophan from stores as a result of stimulation of protein synthesis, for which tryptophan is required. Examples are blood and urine tests, drug assays , 327 radiological examinations (skull, chest, etc. A blunted growth hormone response to insulin challenge has been reported in depression. Low serum albumin levels may be of aetiological significance in confused patients. All brain-imaging techniques utilise computers to construct a series of 2-dimensional slices from a succession of one-dimensional data. Regarding imaging, functional segregation of parts of the brain has helped understanding of symptoms, but functional integration is better for understanding fundamental disease mechanisms. Such measures must be integrated with the complete clinical picture, mindful of individual idiosyncrasies. A single lateral film is usually adequate unless specific pointers suggest further work. Meningiomata may erode bone or cause bony overgrowth, the internal 330 auditory meatus may be eroded by a neuroma, abnormal vascular marking may mean tumour (including vascular tumour), osteolytic lesions may infer multiple myeloma or multiple metastatic deposits, and the skull may appear generally thick or woolly in osteitis deformans. The posterior clinoid processes are eroded 331 332 by increased intracranial pressure , and the pituitary fossa (sella turcica: ‘Turkish saddle’) can be widens with tryptophan depletion. This meets a pouch of the floor of the third ventricle which becomes the posterior pituitary. The ‘empty sella’ syndrome is usually a result of flattening of a normally functioning pituitary. Half of all adults have a calcified pineal gland, which may be displaced by a pathological process.

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