By U. Lukar. Mercy College.

A genetic link may be involved in the develop- ment of substance-related disorders buy cheap crestor. Children of alcoholics are three times more likely than are other children to become alcoholics (Harvard Medical School buy cheap crestor line, 2001) discount crestor 20 mg free shipping. Studies with monozygotic and dizygotic twins have also supported the genetic hypothesis order crestor uk. A second physiological hypothesis relates to the possibility that alcohol may produce morphine- like substances in the brain that are responsible for alco- hol addiction. This occurs when the products of alcohol metabolism react with biologically active amines. The psychodynamic approach to the etiology of substance abuse focuses on a punitive super- ego and fixation at the oral stage of psychosexual develop- ment (Sadock & Sadock, 2007). Individuals with punitive superegos turn to alcohol to diminish unconscious anxi- ety and increase feelings of power and self-worth. Sadock and Sadock (2007) stated, “As a form of self-medication, alcohol may be used to control panic, opioids to diminish anger, and amphetamines to alleviate depression” (p. The effects of modeling, imita- tion, and identification on behavior can be observed from early childhood onward. Various studies have shown that children and adolescents are more likely to use substances if they have parents who provide a model for substance use. Peers often exert a great deal of influence in the life of the child or adolescent who is being encouraged to use substances for the first time. Modeling may continue to be a factor in the use of substances once the individual enters the work force. This is particularly true in the work setting that provides plenty of leisure time with coworkers and where drinking is valued and is used to express group cohesiveness. Drinks in secret; hides bottles of alcohol; drinks first thing in the morning (to “steady my nerves”) and at any other opportunity that arises during the day. During a binge, drinking continues until the individual is too intoxicated or too sick to consume any more. Behavior borders on the psychotic, with the individual wavering in and out of reality. Periods of amnesia occur (in the absence of intoxication or loss of consciousness) during which the individual is unable to remember periods of time or events that have occurred. Experiences multisystem physiological impairments from chronic use that include (but are not limited to) the following: a. Peripheral Neuropathy: Numbness, tingling, pain in extremities (caused by thiamine deficiency). Wernicke-Korsakoff Syndrome: Mental confusion, agita- tion, diplopia (caused by thiamine deficiency). Without immediate thiamine replacement, rapid deterioration to coma and death will occur. Alcoholic Cardiomyopathy: Enlargement of the heart caused by an accumulation of excess lipids in myocardial cells. Esophageal Varices: Distended veins in the esophagus, with risk of rupture and subsequent hemorrhage. Gastritis: Inflammation of lining of stomach caused by irritation from the alcohol, resulting in pain, nausea, vomiting, and possibility of bleeding because of erosion of blood vessels. Pancreatitis: Inflammation of the pancreas, resulting in pain, nausea and vomiting, and abdominal distention. With progressive destruction to the gland, symptoms of diabetes mellitus could occur. Alcoholic Hepatitis: Inflammation of the liver, resulting in enlargement, jaundice, right upper quadrant pain, and fever. Cirrhosis of the Liver: Fibrous and degenerative changes occurring in response to chronic accumulation of large amounts of fatty acids in the liver. In cirrhosis, symptoms of alcoholic hepatitis progress to include the following: • Portal Hypertension: Elevation of blood pressure through the portal circulation resulting from defective blood flow through the cirrhotic liver. Symptoms of alcohol intoxication include disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus, and flushed face. Physical and behavioral impairment based on blood alcohol concentrations differ according to gender, body size, physical condition, and level of tolerance. The legal definition of intoxication in most states in the United States is a blood alcohol concentration of 80 or 100 mg ethanol per deciliter of blood (mg/dL), which is also measured as 0. Nontolerant individuals with blood alcohol concentrations greater than 300 mg/dL are at risk for respiratory failure, coma, and death (Sadock & Sadock, 2007). Occurs within 4 to 12 hours of cessation of, or reduction in, heavy and prolonged alcohol use. Symptoms include coarse tremor of hands, tongue, or eye- lids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or illusions; headache; seizures; and insomnia. Without aggressive intervention, the individual may prog- ress to alcohol withdrawal delirium about the second or third day following cessation of, or reduction in, prolonged, heavy alcohol use. The use of amphetamines is often initiated for their appetite- suppressant effect in an attempt to lose or control weight. Chronic daily (or almost daily) use usually results in an increase in dosage over time to produce the desired effect. Episodic use often takes the form of binges, followed by an intense and unpleasant “crash” in which the individual experiences anxiety, irritability, and feelings of fatigue and depression. Continued use appears to be related to a “craving” for the substance, rather than to prevention or alleviation of with- drawal symptoms. Substance-Related Disorders ● 81 Amphetamine (or Amphetamine-like) Intoxication 1. Amphetamine withdrawal symptoms occur after cessation of (or reduction in) amphetamine (or a related substance) use that has been heavy and prolonged. Symptoms of amphetamine withdrawal develop within a few hours to several days and include fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation. It is commonly regarded incorrectly to be a substance with- out potential for dependence. Abuse is evidenced by participation in hazardous activities while motor coordination is impaired from cannabis use. Physical symptoms of cannabis intoxication include conjuncti- val injection, increased appetite, dry mouth, and tachycardia. Chronic daily (or almost daily) use usually results in an increase in dosage over time to produce the desired effect. Episodic use often takes the form of binges, followed by an in- tense and unpleasant “crash” in which the individual experiences anxiety, irritability, and feelings of fatigue and depression. Cocaine abuse and dependence lead to tolerance of the substance and subsequent use of increasing doses. Continued use appears to be related to a “craving” for the substance, rather than to prevention or alleviation of with- drawal symptoms. Symptoms of cocaine intoxication develop during, or shortly after, use of cocaine. Symptoms of cocaine intoxication include euphoria or affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity, anxiety, tension, anger, stereo- typed behaviors, impaired judgment, and impaired social or occupational functioning. Physical symptoms of cocaine intoxication include tachycar- dia or bradycardia, pupillary dilation, elevated or lowered blood pressure, perspiration or chills, nausea or vomiting, psychomotor agitation or retardation, muscular weakness, respiratory depression, chest pain, cardiac arrhythmias, con- fusion, seizures, dyskinesias, dystonias, or coma. Symptoms of withdrawal occur after cessation of, or reduc- tion in, cocaine use that has been heavy and prolonged. Symptoms of cocaine withdrawal include dysphoric mood; fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; psychomotor retardation or agitation. The cognitive and perceptual impairment may last for up to 12 hours, so use is generally episodic, because the individual must organize time during the daily schedule for its use. Dependence is rare, and most people are able to resume their previous lifestyle, following a period of hallucinogen use, without much difficulty. These episodes consist of visual or auditory misperceptions usually lasting only a few seconds but sometimes lasting up to several hours. Hallucinogens are highly unpredictable in the effects they may induce each time they are used. Symptoms include marked anxiety or depression, ideas of reference, fear of losing one’s mind, paranoid ideation, and impaired judgment.

Answer 2 Phentolamine discount crestor 5mg with mastercard, a short-acting alpha-blocker safe 20 mg crestor, may be given by intravenous injection cheap crestor 5 mg with visa, with repeat doses titrated against response buy discount crestor 20 mg on-line. Other fibres terminating in the corpus striatum bradykinesia/akinesia that characterize the syndrome known include excitatory cholinergic nerves and noradrenergic and as Parkinson’s disease. Most cases of Parkinson’s disease are serotoninergic fibres, and these are also affected, but to vary- caused by idiopathic degeneration of the nigrostriatal path- ing extents, and the overall effect is a complex imbalance way. Treatment of parkinsonism at postsynaptic D2 receptors, but it appears that stimulation of caused by antipsychotic drugs differs from treatment of the both D1 and D2 is required for optimal response. The antagonistic effects of dopamine and acetylcholine within the striatum have suggested that parkinsonism results from an imbalance between these Motor neurotransmitters (Figure 21. The therapeutic basis for treat- cortex ing parkinsonism is to increase dopaminergic activity or to reduce the effects of acetylcholine. The free-radical hypothesis has raised the worrying possibil- ity that treatment with levodopa (see below) could accelerate Substantia nigra disease progression by increasing free-radical formation as the drug is metabolized in the remaining nigro-striatal nerve fibres. This is consistent with the clinical impression of some neurolo- gists, but in the absence of randomized clinical trials it is Figure 21. Treatment is usually initiated when traindicated because of their effect on psychotic symptoms. Occasionally, amantadine or anticholinergics may be Dopaminergic activity can be enhanced by: useful as monotherapy in early disease, especially in younger patients when tremor is the dominant symptom. In patients on • levodopa with a peripheral dopa decarboxylase inhibitor; levodopa the occurrence of motor fluctuations (on–off phenom- • increasing release of endogenous dopamine; ena) heralds a more severe phase of the illness. Initially, such • stimulation of dopamine receptors; fluctuations may be controlled by giving more frequent doses • inhibition of catechol-O-methyl transferase; of levodopa (or a sustained-release preparation). In addition, this usu- Levodopa (unlike dopamine) can enter nerve terminals in the ally allows dose reduction of the levodopa, while improving basal ganglia where it undergoes decarboxylation to form ‘end-of-dose’ effects and improving motor fluctuations. Levodopa is used in combination with a peripheral phenomena are refractory, the dopamine agonist apomorphine (extracerebral) dopa decarboxylase inhibitor (e. The experimental approach of are (predictably) as common as when larger doses of levodopa implantation of stem cells into the substantia nigra of severely are given without a dopa decarboxylase inhibitor. Without dopa decarboxylase inhibitors, 95% of levodopa is metabolized outside the brain. Dopamine agonists share many of their adverse • psychological disturbance, including vivid dreams, effects with levodopa, particularly nausea due to stimulation of agitation, paranoia, confusion and hallucinations; dopamine receptors in the chemoreceptor trigger zone. This • cardiac dysrhythmias; brain region is unusual in that it is accessible to drugs in the sys- • endocrine effects of levodopa, including stimulation of temic circulation, so domperidone (a dopamine antagonist that growth hormone and suppression of prolactin. Pulmonary, retroperitoneal and metabolized both by decarboxylases in the intestinal wall and pericardial fibrotic reactions have been associated with some by the gut flora. Dopamine receptor agonists bioavailability are improved by co-administration of decar- are started at a low dose that is gradually titrated upwards boxylase inhibitors. Ergot derivatives include bromocriptine, lisuride, pergolide Drug interactions and cabergoline. Other licensed dopamine agonists include Monoamine oxidase inhibitors can produce hypertension if pramipexole, ropinirole and rotigotine. The hypotensive actions of There is great individual variation in the efficacy of other drugs are potentiated by levodopa. The initial dose is gradually titrated upwards depending on response and adverse effects. Use • gastro-intestinal – nausea and vomiting, constipation or Amantadine has limited efficacy, but approximately 60% of diarrhoea; patients experience some benefit. The problems stem from its pharmacokinetics ade of both pathways of monoamine metabolism simultane- and from side effects of severe nausea and vomiting. The gastro- ously has the potential to enhance the effects of endogen- intestinal side effects can be controlled with domperidone. Apomorphine is started in hospital after pretreatment with domperidone for at least three days, and withholding other anti- parkinsonian treatment at night to provoke an ‘off’ attack. Apomorphine is that disease progression was slowed in patients treated with extensively hepatically metabolized and is given parenterally. Both isoen- availability of L-dopa centrally can be minimized by decreas- zymes metabolize dopamine. Amantadine and centrally active antimuscarinic agents potenti-ate the anti-parkinsonian effects of selegiline. Their main use is in patients with parkinsonism damage to upper motor neurone pathways following stroke or caused by antipsychotic agents. Physiotherapy, limited sur- Mechanism of action gical release procedures or local injection of botulinum toxin Non-selective muscarinic receptor antagonism is believed to (see below) all have a role to play. Drugs that reduce spasticity restore, in part, the balance between dopaminergic/cholinergic include diazepam, baclofen, tizanidine and dantrolene, but pathways in the striatum. Although spas- Key points ticity and flexor spasms may be diminished, sedating doses are Treatment of Parkinson’s disease often needed to produce this effect. Less sedation is produced than by equi-effective inhibitor (carbidopa or benserazide) or a dopamine doses of diazepam, but baclofen can cause vertigo, nausea and agonist (e. There is specialist with loss of effect at the end of the dose interval, and interest in chronic administration of low doses of baclofen to reduce ‘on–off’ motor fluctuations. It is used doses with a regrettable but inevitable increased intravenously to treat malignant hyperthermia and the neu- incidence of side effects, especially involuntary roleptic malignant syndrome, for both of which it is uniquely movements and psychosis. Botulinum A toxin is given by local injection into affected muscles, the injection site The γ-aminobutyric acid content in the basal ganglia is reduced being best localized by electromyography. It depletes neuronal become weak over a period of 2–20 days and recover over two terminals of dopamine and serotonin. It can cause severe dose- to four months as new axon terminals sprout and restore trans- related depression. The best long- there is no effective treatment for the dementia and other mani- term treatment plan has not yet been established. Electromyography has detected evidence of • The most common drug-induced movement disorders are systemic spread of the toxin, but generalized weakness does ‘extrapyramidal symptoms’ related to dopamine receptor not occur with standard doses. Metoclopramide, an anti-emetic, also Botulinum B toxin does not cross-react with neutralizing anti- blocks dopamine receptors and causes dystonias. Side effects include nau- • ‘Cerebellar’ ataxia – ethanol, phenytoin sea, vomiting, dizziness, vertigo, tachycardia, paraesthesia • Tremor and liver toxicity. These interact with postsynaptic nicotinic cholinoceptors at the neuromuscular junction. Clinically, the The precise stimulus for the production of the antireceptor anti- distinction may be difficult, but it is assisted by the edropho- bodies is not known, although since antigens in the thymus nium test. It tran- inhibitor of acetylcholinesterase, which produces a transient siently improves a myasthenic crisis and aggravates a cholinergic increase in muscle power in patients with myasthenia gravis. Because of its short duration of action, any deterioration of The initial drug therapy of myasthenia consists of oral anti- a cholinergic crisis is unlikely to have serious consequences, cholinesterase drugs, usually neostigmine. If the disease is although facilities for artificial ventilation must be available. In non-responsive or progressive, then thymectomy or immuno- this setting, it is important that the strength of essential (respira- suppressant therapy with glucocorticosteroids and azathioprine tory or bulbar) muscles be monitored using simple respiratory are needed. It reduces the number of circulating T-lym- Myasthenic crises may develop as a spontaneous deteriora- phocytes that are capable of assisting B-lymphocytes to produce tion in the natural history of the disease, or as a result of infection antibody, and a fall in antibody titre occurs after thymectomy, or surgery, or be exacerbated due to concomitant drug therapy albeit slowly. Corticosteroids and immunosuppressive drugs with the following agents: also reduce circulating T cells. Cholinesterase inhibitors enhance both muscarinic and nicotinic cholinergic effects. The Myasthenic crisis is treated with intramuscular neostigmine, former results in increased bronchial secretions, abdominal colic, repeated every 20 minutes with frequent edrophonium tests. Excessive muscarinic effects may be blocked by giving atropine or propantheline, but this increases the risk of over- Key points dosage and consequent cholinergic crisis. Myasthenia gravis Pyridostigmine has a more prolonged action than neostig- mine and it is seldom necessary to give it more frequently than • Auto-antibodies to nicotinic acetylcholine receptors four-hourly. The effective dose varies considerably between lead to increased receptor degradation and neuromuscular blockade. Azathioprine (see Chapter 50) has been used improves a myasthenic crisis while transiently either on its own or combined with glucocorticosteroids for its worsening a cholinergic crisis, allowing the appropriate ‘corticosteroid-sparing’ effect.

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Medicine man (quoted in Sandner2) One difficulty in preparing a short chapter is the complexity of the North American scene with vastly different geographical/economic/political/ cultural regions buy crestor 20 mg low price. Clearly crestor 20 mg low price, this can contribute to regional differences in the questions that healthcare practitioners commonly face; some may field questions over magico-religious/ceremonial practices more than do others discount crestor generic, although nowadays crestor 10 mg overnight delivery, with the promotion of herbs as ‘dietary supplements’, all practitioners can expect questions on ‘aboriginal’ Aboriginal/traditional medicine in North America | 45 herbs. In anchoring this chapter on current issues, information from a Saqamaw (chief) of a Canadian aboriginal reserve is noted in a number of places (the reserve is the Conne River Reserve [the Miawpukek First Nation] in Newfoundland, Canada); however, it reflects the efforts among many aboriginal peoples to revitalise traditions and values, while situating them in the development of modern communities. Today’s rediscovery of many traditions and values only minimally rebalances a long history of aboriginal acculturation driven by North American governments, church policies and broad social changes. Although the thrust of the chapter is directed at practitioners of conventional healthcare – in a doctor’s surgery, hospital ward, pharmacy, etc. As a result of this, conventional practitioners are known to side- step discussion with patients on any ‘unproven’, ‘alternative’ or ‘unscien- tific’ practice by peremptorily dismissing it as being outside the scope of their practice. By using general approaches to patients’ questions and practices (covering herbal medicines and magico-religious or spiritual approaches), this also focuses on the importance of reflecting on conventional medical thinking and attitudes. Although accounts of aborig- inal (and other traditional) practices directed at conventional healthcare providers invariably concentrate on belief systems, the premise of this chapter is that effective communication in our increasingly complex multicul- tural communities also demands an awareness of how conventional thinking shapes professional attitudes to ‘unproven’ therapies. Gathering and processing information and responding non-judgementally to patients’ questions about aboriginal use is not easy for a number of reasons. One could even be a practitioner’s recognition that he or she is being compared with a traditional healer whom the patient is visiting for the same problem. To be able to respond to aboriginal practices, conventional healthcare providers need not only to understand belief systems, social circumstances and attitudes (perhaps including uncertain trust in conventional practitioners), but also, as indi- cated, to appreciate the factors that can shape professional attitudes toward non-conventional treatments. As the latter is more for formal education (undergraduate, continuing professional, etc. Moreover, having the relevant knowledge is important when negoti- ating different viewpoints between practitioner and patient. No health tradition is entirely static, and it is clear that infor- mation was often consciously shared so that it is difficult to say whether or not an aboriginal practice is ‘indigenous’. Modern compilations of tradi- tional practices commonly straddle aboriginal and Euro-North American self-care traditions. It is easy to speculate that, as an increasingly common medical term, high blood pressure was seen to fit with the long history of popular medicine (aboriginal and other) of blood purifi- cation, and so was added to lists of uses for ‘blood purifiers’ (alder, consid- ered below, is an example). Blood purification continues to be a popular notion; it extends into the complementary/alternative medicine literature, and merits the attention of conventional practitioners. As William Osler reminded physicians: ‘The greater the ignorance, the greater the dogma. Quick assessments are difficult and demand some evaluation of the record of published and other information from practitioners and of the popularity of usage over time. If, for example, a weak tradition is indicated by a database (and confirmed by a comprehensive literature search), there is no ‘scientific’ justi- fication for encouraging, say, the use of a compress of alder leaves as a generally effective treatment for a headache (see below). On the other hand, given the safety and absence of known allergic reactions of alder leaves as a traditional external application to relieve or ‘cool’ insect bites and inflam- mation, a practitioner may well support a patient wanting to try the treatment. Maybe the query comes from an aboriginal person who is comfortable following a traditional aboriginal regimen that includes a spiritual component, e. Other aspects of a regimen may be important such as changing the leaves frequently to maintain a ‘cooling’ action, which may well provide comfort and a feeling ofrelief;anactiverolebypatients in any therapy is often recognised as helpful. Occasions arise when differences of opinion between patient and practitioner need to be brokered so as to develop or maintain an effective relationship. This is facilitated, partly through background knowledge (step 1), both by uncovering and understanding a patient’s own circumstances and beliefs towards non- conventional approaches, and by critically evaluating published information. A three-step strategy implies one step after the other; however, this may change in practice depending on a particular situation (e. Moreover, the understanding of a specific concept (step 1’s preparation) may need to be revisited or learned for the first time after a case history has been taken (step 2). In this situation, admitting lack of knowledge to a patient is often appro- priate. Although this is problematic for many practitioners, they can be reas- sured that patients accept practitioners’ frank statement that they need to research a topic outside their customary practice before giving advice. The three-step strategy is therefore intended primarily to ensure that all relevant information is considered when responding to issues of efficacy and safety in the context of cultural sensitivity. The strategy for evaluating remedies used empirically Practitioners (and nowadays many patients) want ‘scientific’ evidence to support effectiveness and safety. Indeed, it is noteworthy that some aborig- inal peoples are backing scientific research in the hope of marketing their traditional medicines. Anecdotal knowledge (or evidence) is that which has been built up over an extended period of time among generations of practitioners and others who develop a specialised knowledge (e. Anecdotal knowledge not only is a feature of much aboriginal/traditional medical practice, but also has long been a key element of conventional medical practice. Examples of applying the three-step approach to herbal remedies in aboriginal usage Selection of examples of herbs out of the vast armamentarium of aborig- inal/traditional remedies (with much regional variation) is not easy. The two chosen (alder and black cohosh) have been selected to illustrate different challenges in response to questions about aboriginal usage. Alder, unlike black cohosh, has not become a major dietary supplement and few scientific data are available to assist in evaluation. In contrast, the top-selling black cohosh has been subjected to many laboratory and clinical studies, albeit with inconsistent findings. At least both herbs reflect a widespread belief that a core of empirical knowledge, long held by herbalists (some called yerberos), lies behind the use of herbs – a view that underpins much research on constituents of aboriginal and other traditional medicinal plants. On the other hand, whether or not some form of ceremony or ritual accompanied the administration and contributed to therapeutic benefits is not always clear (see below). On hearing about its use by Mi’kmaq people in Newfoundland, a patient asked whether it was good for headache – better than aspirin which upset the questioner’s stomach. It is also an example of one of many herbs about which the busy practitioner has difficulty finding useful information to confirm whether or not it has some general value. One is to Alnus rubra (a different species) as an ‘emetic and purgative for headache and other maladies’, and the other is to an infusion of the twigs as a ‘liniment for pain of sprains, bruises, backache Aboriginal/traditional medicine in North America | 51 and headache’. However, citing Moerman’s work to support any specific usage needs a critical appraisal of the sources of information culled by Moerman; these, variable in quality, commonly raise questions over, for example, the correctness of plant identification, type of preparation used or other details, some of which Moerman felt necessary to omit given the scope of the database. Such limited information strongly suggests that the use of alder for a headache is a local reputation – all the more so as published accounts of Mi’kmaq usage do not record ‘headache’. Black cohosh This second herb for consideration, black cohosh, offers a different set of circumstances for discussion with patients. As a top-selling dietary supple- ment – largely because of a reputation for relieving menopausal symptoms (and, to a lesser extent, menstrual symptoms, e. However, although tradi- tional aboriginal knowledge has seemingly been superseded by modern scientific/clinical studies, practitioners may well face queries on at least two matters: (1) the aboriginal reputation and (2) efficacy and safety. Uses Published accounts of both the herb and its commercial promotion commonly refer to a history of aboriginal usage, e. Aboriginal women have specifically 52 | Traditional medicine asked practitioners about how it was used by their people before modern natural healthcare products marketed it in capsules. Safety and efficacy Questions/concerns arise because recent research studies offer conflicting conclusions. Aboriginal women today are among the women who are concerned about hormone replacement therapy; many look to such ‘natural remedies’ as black cohosh. As mentioned, assessing the evidence of whether a herb reaches the level of anecdotal knowledge is not easy. Two topics are noted here as illustra- tions, both pertinent to an evaluation of black cohosh. Evaluating recorded information In addition to issues already noted in Moerman’s Native American Ethno- botany, step 1’s preparation also needs to examine the often glib claims that a herb has been used for ‘hundreds of years’ by ‘Indians’ and others. Careful historical study is often required to determine whether this is justified. Information on aboriginal treatments published up to the early nineteenth century generally came from travellers who, often with some knowledge of medicine, were curious about aboriginal ways. However, understanding aboriginal therapeutic practices was far from easy given the limited time and opportunities; thus early observations, although in many ways invaluable, have to be treated cautiously. Moreover, because of copying by one author from another, the frequency of references to a particular usage cannot be accepted, without careful review, as providing the level of evidence that reaches, say, anecdotal knowledge. Specifically, with regard to black cohosh, early observers undoubtedly found it more difficult to assess emmenagogue action and effects on menstruation among aboriginal women than, for example, the obviously vigorous purgative action of mayapple (Podophyllum peltatum).

Excellent and untiring work was done by The specimens of the previous editions also depicted in this our secretaries buy generic crestor 10 mg line, Mrs discount crestor 5 mg visa. Lisa Köhler and Elisabeth Wascher buy discount crestor 20mg line, and as volume were dissected with great skill and enthusiasm by Prof purchase genuine crestor on line. Mutsuko Takahashi not only performed excellent new drawings but revised effectively (now Tokyo, Japan), Dr. Conse- skull bones, for example, was not presented in a descriptive way, quently, the advent of a new work requires justification. We but rather through a series of figures revealing the mosaic of found three main reasons to undertake the publication of such a bones by adding one bone to another, so that ultimately the book. First of all, most of the previous atlases contain mainly schematic Finally, the authors also considered the present situation in or semischematic drawings which often reflect reality only in a medical education. As a consequence, students do not tions and spatial dimensions in a more exact and realistic manner have access to sufficient illustrative material for their anatomic than the “idealized”, colored “nice” drawings of most previous studies. Furthermore, the photo of the human specimen corre- observation, but we think the use of a macroscopic photo instead sponds to the student’s observations and needs in the dissection of a painted, mostly idealized picture is more appropriate and is courses. Thus he has the advantage of immediate orientation by an improvement in anatomic study over drawings alone. The majority of the specimens depicted in the atlas were prepared Secondly, some of the existing atlases are classified by systemic by the authors either in the Dept. The present atlas, however, tries to portray macroscopic the spinal cord demonstrating the dorsal branches of the spinal anatomy with regard to the regional and stratigraphic aspects of nerves were prepared by Dr. The specimens of the ligaments of the vertebral diate help during the dissection courses in the study of medical column were prepared by Dr. To all regions of the body we added schematic drawings for their unselfish, devoted and highly qualified work. This will enhance the understanding of the details Erlangen, Germany; Spring 1983 J. The principle of polarity: Polarity is reflected mainly in the formal and functional contrast between the head (predominantly spherical form) and the extremities (radially arranged skeletal elements). In the phylogenetic development of the upright position of the human body, polarity developed also among the extremities: The lower extremities provide the basis for locomotion whereas the upper extremities are not needed anymore for locomotion, so they can be used for gesture, manual and artistic activities. The anatomical structures (vertebrae, pairs of ribs, muscles, and nerves) are arranged segmentally and replicate rhythmically in a similar way. The principle of bilateral symmetry: Both sides of the body are separated by a midsagittal plane and resemble each other like image and mirror-image. There are also different principles in the architecture and function of the inner organs: The skull contains the brain and the sensory organs. They are arranged like mirror and mirror-image and are the basis of our consciousness. The thorax contains the organs of the rhythmic system (heart, lung), which are only to some extent bilaterally organized. In the abdominal cavity, the most important abdominal organs (intesti- nal tract, liver, pancreas) are arranged unpaired. Regional lines A = parasternal line B = midclavicular line C = anterior axillary line D = umbilical-pelvic line The bones of the skeletal system are palpable through the localized. On the ventral side, the clavicle, line, the anterior axillary line, the umbilical-pelvic line. Further- By means of these lines, the heart and the position of the more, the anterior iliac spine and the symphysis can be vermiform process can be localized. Position of the lnner Organs, Palpable Points, and Regional Lines 3 E F F 3 G 19 G 10 20 7 8 11 H H 21 22 12 Position of the inner organs of the human body Regional lines and palpable points at the dorsal side of the (posterior aspect). Regional lines E = paravertebral line F = scapular line G = posterior axillary line H = iliac crest 1 Brain 2 Lung 3 Diaphragm 4 Heart 5 Liver 6 Stomach 7 Colon 8 Small intestine 9 Testis 10 Kidney 11 Ureter 12 Anal canal 13 Clavicle 14 Manubrium sterni 15 Costal arch 16 Umbilicus 17 Anterior superior iliac spine At the dorsal side of the body, the posterior spines of the 18 Inguinal ligament vertebral column, the ribs, the scapula, the sacrum, and 19 Scapular spine the iliac crest are palpable. Lines of orientation are the 20 Spinous processes 21 Iliac crest paravertebral line, the scapular line, the posterior axillary 22 Coccyx and sacrum line, and the iliac crest. Osteology: Skeleton of the Human Body 7 Axial skeleton Head 1 Frontal bone 1 2 Occipital bone 3 Parietal bone 4 4 Orbit 6 5 Nasal cavity 6 Maxilla 7 Zygomatic bone 8 8 Mandible 9 Trunk and thorax Vertebral column 15 9 Cervical vertebrae 10 Thoracic vertebrae 17 11 Lumbar vertebrae 12 Sacrum 21 13 Coccyx 14 Intervertebral discs Thorax 15 Sternum 11 16 Ribs 17 Costal cartilage 18 Infrasternal angle 22 23 Appendicular skeleton Upper limb and shoulder girdle 19 Clavicle 24 20 Scapula 25 21 Humerus 22 Radius 26 23 Ulna 24 Carpal bones 25 Metacarpal bones 31 26 Phalanges of the hand Lower limb and pelvis 27 Ilium 28 Pubis 34 29 Ischium 30 Symphysis pubis 31 Femur 32 32 Tibia 33 33 Fibula 34 Patella 35 Tarsal bones 36 Metatarsal bones 37 Phalanges of the foot 38 Calcaneus 35 36 37 Skeleton of a 5-year-old child (anterior aspect). Coronal section of the 3 Diaphysis of the femur proximal and distal epiphyses displaying the 4 Compact bone spongy bone and the medullary cavity. Osteology: Ossification of the Bones 9 The ossification of the bones of the limbs starts within 3 the ossification centers of the primary cartilagenous 2 bones. X-ray of the upper and lower limb of a newborn child (left: upper limb, right: lower limb). The metacarpophalangeal joints are biaxial, as is the carpometacarpal joint of the thumb (✽ in the figure). Synovial joints are characterized by a joint cavity enclosed by a joint capsule containing synovial fluid, which is produced by the articular capsule. The kind of movements depends not only on form and structure of the articulating bones but also on ligaments incorporated into the articular capsule. In some synovial joints, fibrocartilagenous articular Schematic drawing of the knee joint as an example of discs develop, when the articulating surfaces of the a synovial joint, characterized by a joint cavity enclosed by a joint bones are incongruous. Myology: Shapes of Muscles 13 Fusiform Bicipital Tricipital (triceps surae, Quadricipital (palmaris longus) (biceps brachii) gastrocnemius, and soleus) (quadriceps femoris) Digastric Multiventral Multicaudal Serrated (omohyoideus) (rectus abdominis) (flexor digitorum prof. The movements themselves vary to a great extent indi- systems in which they are involved, i. A = axis of humero-ulnar joint; arrows = direction of movements; red = flexion; black = extension. The flexor retinaculum protects the 8 Pectoralis major muscle flexor tendons passing through the carpal tunnel (arrow). In order to carry out movements are coordinated by special groups of muscles certain directions of movements, often the tendons of (synergists). At those places, Movements can only be carried out harmoniously if the the tendons often develop synovial sheaths, e. Red = arteries; blue = veins (from Lütjen-Drecoll, Rohen, Innenansichten des menschlichen Körpers, 2010). D C B The center of the circulatory system is the heart, which is situated in the thoracic cavity and in contact with the diaphragm. In the right ventricle, the venous blood is collected and pumped through the pulmonary artery and into the lung where the blood is oxygenated. Red = arteries; blue = veins (from Lütjen-Drecoll, Rohen, Innenansichten des through the aorta and its branches (arteries) in the human menschlichen Körpers, 2010). The venous A = pulmonary circulation C = portal circulation blood from the intestine reaches the liver via the portal B = systemic circulation D = lymphatic circulation vein. Organization of the Lymphatic System 17 1 3 3 1 2 4 7 5 5 4 6 7 8 Major lymph vessels of the trunk (green). Dotted red line = border between lymphatic vessels 3 Left venous angle 7 Cisterna chyli draining toward the right and the left venous angles. The lymphatic vessels of the These resemble veins but have a much thinner wall, more right half of the head and neck, the right thorax, and the valves, and are interrupted by lymph nodes at various right upper limb drain toward the right venous angle; those intervals. Large groups of lymph nodes are located in the of the rest of the body, toward the left venous angle. The solar plexus with its connection to the vagus nerve and the sympathetic trunk has been dissected. The spinal cord, which shows a segmental structure and The ventral rami of the spinal nerves form the cervical and serves predominantly as a reflex organ. The autonomic nervous system, which controls the the ventral rami of the lumbar and sacral spinal nerves form involuntary functions (subconscious control) of organs the lumbosacral plexus, which innervates the pelvis and and tissues. Anteriorly, the facial bones, the facial muscles, and the muscles of mastication have been developed 1 (viscerocranium). The base of the skull is slightly bent so that the structures of the viscerocranium become located underneath the neurocranium, a specifity of the human head. The different bones are indicated in 28 External acoustic meatus color (numbers cf. The skull comprises a mosaic of numerous complicated The bones of the skull base are formed out of cartilaginous bones that form the cranial cavity protecting the brain tissue (chondrocranium), which ossifies secondarily.

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