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As a result of arteritis, circulatory disturbances may arise either locally or general. Sclerosis of the arteries consists of a deposit, in the vascular coats, of a quantity of hard, gritty, earthy, saline material which tho commonly considered as osseous, presents none of the true character of bone, there being no trace of bone corpuscles. As a rule, as individuals advance in life, there is a progressive increase of earthy matter in the coats of normal arteries. Here, as elsewhere, sclerosis is pathological physiology, normal increased to abnormal functionating. These changes are physiological when the lime salt is ordinarily increased, pathological, when deposited in too great a degree. We find arteritis and arterial sclerosis accompanying many inflammatory diseases, changes which are the direct result of inflammatory action. Arterio-sclerosis in the limbs shows an abnormal condition of the nerves ramifying that region, indicated by coldness of the feet, cramps and spasms of the muscles. In organs there is manifested a softening of tissue, fatty degeneration, and later calcareous deposits. Arteritis, inflammation of the blood vessels, may lead to ulceration of the coats which form the blood vessel walls; spontaneous rupture; contracture or occlusion of the interior of the cavity and lastly, dilatation and aneurisms. The earthly matter may be deposited in the form of plates, laminar calcification, or it may be arranged in a concentric manner around the muscular fibers, known as annular calcification, and, when spread over a considerable length of a blood vessel, it is termed tubular calcification. The annular deposit may transform a blood vessel into a brittle, calcareous pipe, known as the "pipe stem artery. Arterio-sclerosis is a physiological process of old age; it is pathological when occurring in youth or adult life. The morbid appearance of a blood vessel affected with arteritis is that of redness, a deep claret color, and accompanied with a loss of its physiological properties. The local symptoms of arteries are pain, tension, stiffness of the affected limb, with extreme tenderness. As the closure of the vessels are of a slow procedure, anastomosing circulation is made compensatory. There is a cord-like feeling along the inflamed vessel in which there may be observed a jerking and forcible pulsation. The pain below the part of the artery affected is severe; it may be superficial or deep. The deep pain is of a burning and lancinating character, usually following the course of a vessel. The limb gradually loses its normal temperature, becoming cold and of a dark or livid color, and yet the inordinate sensibility continues. In cases of amputation, the arteries of the stump diminish in size corresponding with the needs of the tissues to be nourished. The observance of arterial tension, whether recognized as such or not, is one of the most important acts of the physician, in fact, more so, than the study of the pulse rate, for, bear in mind, the elastic tension and the pulse rate are quite different conditions. Arterial tension is the resistance of the arterial walls to the pressure of the contained blood. The variation of temperature modifies the tension of the vascular system as well as that of the nerves, muscles and organs. High tension, when increased by exercise, excitement or hypnotism, is a natural, physiological response. High tension is pathological when the increase is caused by trauma, poisons, or auto-suggestion as in hysteria. Hypertension is functional; it may be normal or abnormal, morbid or physiological. High tension compresses the vasovasorum-the blood vessels of the blood vessel wall-between the inner coats and the fibrous coat, because the latter has reached the point of fixation by distention. Many pathologists consider high tension and a rapid pulse, as exhibited in febrile diseases, as physiological-an effort on the part of Nature to supply more blood to certain parts for a protective purpose, a poison destroyer; that the increase in tension and circulation is essential to preserve life. Others consider high tension and a rapid pulse deleterious, evil, a condition which ought to be checked or reduced, therefore, they attack it instead of furnishing the best medical aid. It is a serious question among the medical profession whether high tension, high temperature and a rapid pulse are physiological, tending toward health, or a necessary, unavoidable evil; whether vascular relaxant medicines are beneficial or detrimental. Cardiovascular tension presents a grave consideration for the cardiovascular tension presents a grave consideration for the medical man. In disease the pathologist has hypotension to consider as well as hypertension, but the former is much more rare. I had a patient who suffered from hypotension when in a recumbent posture, but as soon as he assumed, or tried to assume a sitting or standing position, hypertension and increased circulation would compel him to lie down. This case I dismissed quite well, with normal tension (tone), standing, sitting or lying. This condition of hypotension is illustrated in the critical period of acute infections. When the tension is relieved, going below normal, the patient approaches a condition of collapse. An author on pathology says, "The causes of arterio-sclerosis are numerous and varied. In regard to the treatment of the narrowing or occlusion of the arteries, pathologists have but little to say. Others ascribe the majority of cases to the result of injuries, or from lodgment within its tubular walls of some foreign body of an irritating or infectious nature. It has been associated with cardiac hypertrophy, valvular lesions, chronic diffuse, nephritis, tumors, diphtheria, scarlatina and pyaemia. Many minute nutrient blood vessels course in the external and middle coats of large or moderate sized arteries. They arise from the vessels to which they are distributed or originate in an adjacent vessel. The vasa vasorum and venae vasorum are supplied by nervi (plural of nervus) vasorum. Nerves are supplied with nervous filaments, named nervi nervorum, which are distributed to their sheaths. Thus, we see that vascular tension may be disturbed by trauma, poison or auto-suggestion, and may be returned to normal tone, the same as the elongated, thread-like structures. It is the abnormals, the exceptions to the rule, the Chiropractor has to deal with. The central extremity of a divided motor nerve may unite with the peripheral extremity of another nerve and still functionate. Langley united the central extremity of the vagus with the peripheral extremity of the sympathetic and found, after union took place, that the vagus had acquired control of all structures supplied by the cervical sympathetic, transmitting thru the sympathetic the vagus impulses. A light pressure on a nerve causes tension; a tension by nerve-stretching acts as an irritant. An increased pressure or extension up to a certain degree, increases irritation and functionating. A still greater pressure or extension causes a diminution of irritability until paralysis ensues. The process of nerve tension caused by impingement, acts as an irritant, if the pressure be light; greater pressure causes a diminution of sensation or of voluntary movements. An atlas displaced to the right or left may cause tension on one or both of the sympathetic chains of ganglia which pass in front of the transverse processes. Either condition amounts to a strain or tension causing irritation, super-heat and increased functionating. The effects of irritation or insufficient functionating caused by a displaced atlas, may be transferred thru the carotid or cavernous plexus to the cranial nerves. A large share of diseases begin with a slight chill and fever which increases as the days come and go. Why does the chill period, the cold stage, the rigor, the involuntary contraction of the voluntary muscles precede fever? Why, in others, a sensation of cold; when in fact, the thermometer shows supernormal temperature. Pressure on nerves causes them to be excited, irritated; the peripheral nerves of motion become contracted, causing the sensation of cold or chillness. It is a well known fact in physiology that physiological or pathological irritation of nerves causes contraction of the muscles to which they are attached.
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Not only did homeopathy and a vaguely-defined sect known as eclecticism retain distinctive characteristics, but a series of healing cults flourished throughout the nineteenth and into the present century. But, lacking technical knowledge, the cults were in some ways closer to crude empiricism. Although several such heresies originated in Europe, equalitarian America offered a lush soil for their growth. These movements shared the merits of mild therapy, 'See, e,g, Shryock, Medicine and Society, pp. Russian medical science is not under consideration here, though some Western critics viewed official Russian physiology as reverting to dogmatism by 1950, 130 American Antiquarian Society and Grahamism was salutary in its personal hygiene. Samuel Dickson of Scotland, was interesting in that its one basis of illness was body temperature and its one clue to cures the use of quinine. But, as noted, all thoughtful men must reason at times, and perhaps Samuel Thomson was in his own way a thoughtful man. Interested as a farm boy in plants, he found species which made perfect remedies-the old approach of herbalists, into which his enthusiasm infused new life. Unlike most folk practitioners, Thomson attracted a wide following after publishing an account of his discoveries. This work was remarkable, not so much for its trial-and-error gropings as for its unintended tribute to speculation; that is, as evidence that even a man who disdained formal learning might seek theoretical underpinnings. More basic was his view that there were just four elements in Nature-earth, air, fire, and water, with the corresponding qualities of hot, cold, and so on. But what first demanded medical attention was cold, since that caused all illness. Rationalism in American Medicine 131 of the stomach causes canker; the physic drives all the determining powers. Thomson was more original in organizing his program: he apparently was the only American who ever patented a form of medical practice. The earlier apparatus of an organized guild, schools, societies, and journals, withered away. The same thing may be said of hydropathy, which as a dogma never rose much above crude empiricism but which tended to combine with other fringe sects in a curious eclecticism. A college which merged water cures with the latest hygienic enthusiasms was chartered by New York State as late as 1861, with a right to grant the M. Another drugless sect appeared later in the form of naturopathy, which set up several schools but now seems to be disappearing. Whether this program was akin to Naturheilung, popular in Germany under the Nazi regime, is not clear. Scientific empiricism weakened the more naive cults and was not without influence on sects which continued to survive. Trail, who-even as Thomson and the later Andrew Still-finally proclaimed a theory of pathology and cure. These values also became apparent to homeopathic and eclectic practitioners: Homeopaths in particular, who maintained their own hospitals and schools, were adopting regular medicine by the early 1900s. Along the way, the dogmas of an earlier day disappeared so gradually that it is hard to say when the process was completed. Yet at about that time two new and relatively successful cults appeared in the United States. Treatment originally emphasized a manipulation of the skeleton-particularly of the spine. Rationalism in American Medicine 133 again, was a monistic emphasis upon one body system, albeit the focus was no longer on such old favorites as the nerves or the gastro-intestinal tract. Formal teaching of the program began at the American College of Osteopathy, chartered at Kirksville, Missouri, in 1892. Osteopathy thus resembled Thomsonianism in beginning as crude empiricism and then resorting to over-simplified conjectures. In borrowing from regular medicine, however, osteopathy followed the example of homeopathy. There is no study of just how the transformation was accomplished within either homeopathy or osteopathy, but this is a matter of professional history rather than of medical thought. In the case of these major sects, what is here termed borrowing has been viewed by some as a merging of principles. Such claims are dubious, since most drugs are not effective in infinitesimal doses and vaccines are not cures. The Grahamites, for instance, anticipated in part the value of vitamins; while osteopathy may have pressured some regulars into giving more heed to orthopedic practice. In striking a balance, however, it may be repeated that sectarians made few if any scientific contributions; and that there was less excuse for doctrinaire teachings after 1850 than there had been before that time. Whether competition with sectarians helped or hindered well-trained doctors, whose practice was based increasingly on scientific empiricism, is difficult to say. In some cases, this competition probably weakened support for orthodox institutions; but, on the other hand, it may have indirectly improved the work of physicians by denying them a complete monopoly. By 1930, for example, there were in the United States some 121,000 physicians, but only about 36,000 recognized sectarians. Among these irregulars were 10,000 religious healers, 7,700 osteopaths, 2,500 naturopaths, and 16,000 chiropractors, the latter employing a type of practice similar to that followed originally in osteopathy. Rationalism in American Medicine 135 the one instance in which unverified speculation seemed to reappear, within regular medicine, was involved in Dr. Discussions, pro and con, have usually related to scientific method as such and to the values or dangers revealed in clinical experience. These issues are indeed central but they have usually been examined without reference to historical backgrounds. Few analysts or critics seem to have read such earlier systematists as Cullen, Rush, or Brown as a means of approaching Freud. If the latter is first encountered in this manner, however, the reader feels that he is still immersed in the medical reasoning of 1800. Obvious differences will be noted, of course, between the thought of Rush or of Cullen and that of Freud a century later. The main difficulty in psychiatry was obvious: it was by definition caught up in the dualism of body and mind. In consequence, either a physical or a psychologic approach could be employed, and emphasis in the field swung back and forth after 1800 between one pole and the other. Whitehorn refers to these extremes as, respectively, psychophobia and psychomania. This would place the percentage of sectarians only slightly higher than that indicated in 1930, but New England was not necessarily typical. On licensing after 1875, see Shryock, Medical Licensing in America; 1650-1965 (Baltimore, 1967), pp. But this is turn proved disappointing by 1890: no brain lesions were found to correlate with such phenomena as depressions or paranoia. Indeed, there was even a popular impression by the early 1900s that mental illness was increasing. Since something had to be done, another return to psychologic strategy seemed indicated. Revivals of religious healing in the United States, particularly Christian Science but J. Rationalism in American Medicine 137 also the so-called Emanuel Movement, may be viewed as lay gestures in this direction. Within medicine, even while neurologic orientations were still dominant, there was a revival of hypnotism in treating hysteria, by this time as a scientific rather than as an occult or quackish procedure. The manner in which the Viennese doctor arrived at his theories is too well known to bear repetition here. Most exciting was the seeming confirmation of this theory in practice; that is, the discovery that when some patients did recall-under proper management-the unconscious was apparently relieved of tensions and improvement ensued. Although few of these ideas were entirely new and Freud has been accused of not acknowledging precursors, his general synthesis was novel and imaginative. There certainly was need for help in relation to neuroses, though it would have been more promising if analysis could have envisaged aid for psychoses as well. But apart from strictly medical results, there were other aspects of analysis which encouraged its acceptance.
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If all foot pulses (dorsalis pedis and posterior tibial on both sides) are strong and present it is very unlikely that that patient will be suffering from coarctation, particularly if they have a normal blood pressure. In the presence of hypertension the femoral pulses must be examined to exclude coarctation (E Chapter 10), for although it is very rare for this condition to be undiagnosed in adults, occasionally patients do appear. The pulse should arrive at the femoral arteries and the radial arteries at about the same time as they are approximately the same distance from the heart. In coarctation, when there is severe obstruction at the site of coarctation the blood has to traverse collaterals and the femoral pulse is delayed. Blood pressure Often the blood pressures (E Chapter 13) taken initially by the nurse are simply transferred to the notes written by the doctor, without the doctor checking them; this is bad practice. This has the disadvantage that an inaccuracy in the previous blood pressure may be perpetuated, and the blood pressure may have changed in the time between the two examinations. This is an increasing problem, especially with electronic medical records, where whole sections are often cut and pasted from one consultation to the next. With the progressively more obese population it is important to use a large cuff on big arms, otherwise there is an overestimation of blood pressure levels . In tricuspid regurgitation, the v wave peaks earlier, is accentuated and becomes the dominant waveform (E. It is accentuated in the presence of right ventricular hypertrophy, pulmonary hypertension, or tricuspid stenosis but lost in atrial fibrillation. This can also occur in some other clinical situations such as right ventricular infarction . Cannon waves can also sometimes occur as a result of a ventricular ectopic beat that closes the tricuspid valve but is not electrically conducted to the atrium, which therefore is excited in the normal way. Cardiac palpation the cardiac examination always involves thorough palpation all over the front of the chest. Abnormalities may be brought out by sitting the patient forward and feeling the chest in expiration, and also rolling the patient onto their left side. In a patient in whom coarctation (E Chapter 10) is suspected, palpation of the back may reveal widespread diffuse pulsation secondary to large collaterals running in the muscles of the back. In pulmonary hypertension (E Chapter 24) the pulmonary artery dilates and produces an impulse in the second left intercostal space and the loud pulmonary component of the S2 may also be appreciated as a sharp snapping feeling in this area. Apical impulse (apex beat) the lowest and most lateral position on the chest wall where a cardiac impulse can be felt is known as the apex beat. The apical impulse or apex beat is usually located in the fifth intercostal space at the level of, or just medial to the mid-clavicular line. Chest deformity, lung disease, and obesity all reduce the intensity of the apex beat or render it impalpable. In these situations, rotating the patient to a left lateral decubitus position tips the heart towards the chest wall and makes the apex beat easier to feel. Auscultation this still remains an important aspect of the clinical cardiovascular examination but auscultatory skills are decreasing with the almost universal availability of echocardiography in the developed world. Heart sounds and murmurs are often not difficult to time in the cardiac cycle but if there is doubt, palpation of the carotid pulse is extremely useful. Abnormalities of the apical impulse the most common abnormalities of the apex impulse are as follows: Normal heart sounds S1 and S2 are usually the only heart sounds heard on auscultation of a normal heart (E. S1 results from closure of the mitral and tricuspid valves and has two components in close proximity . S2 results from closure of the aortic and pulmonary valves (A2 and P2) , and is also normally split, the dominant aortic component occurring first. This splitting is usually accentuated by inspiration when right heart filling is increased and can be detected in most patients. Pulmonary hypertension (E Chapter 24) increases the intensity of P2 and systemic hypertension (E Chapter 13) may make A2 louder . The apical impulse may be displaced to the left and have a more diffuse heaving nature. If the patient has an audible gallop rhythm this can sometimes also be palpated with a hand placed over the cardiac apex [27, 28]. Mitral stenosis (E Chapter 21) produces a particularly characteristic cardiac apical impulse. S1 has two components, mitral closure (M1) and tricuspid closure (T1); M1 is louder. S2 also has two components, due to aortic valve closure (A2) and pulmonary valve closure (P2) with A2 being the louder. Typical of mitral regurgitation, the murmur intensity varies little throughout systole (plateau pattern). Typical of mitral valve prolapsed, the murmur commences in mid-late systole, often preceded by an ejection click (C). As with (D) it continues through and masks S2, stopping with mitral valve opening. It commences immediately following S2 and decreases in intensity during diastole as the pressure difference between the respective great vessel and ventricle decreases. This results from a communication between the left- and right-sided circulations so that there is a pressure drop across the pathological structure throughout systole and diastole, hence the continuous nature of the murmur. It takes longer for this extra blood to be ejected thereby delaying P2 and widening the splitting. If a murmur is made louder by expiration it may be left sided; however, this is not definite since expelling air from the lungs decreases the amount of air between the heart and chest walls and may increase the intensity of any event whether its source is right or left sided. Further effects of respiration on auscultation In practical terms: If a murmur or sound. Its presence denotes a pliable valve and means valvuloplasty is likely to be feasible. Mid-systolic click(s): the prolapsing mitral valve tenses in mid/late systole and this produces single or multiple clicks . Prosthetic valves (E Chapter 21): mechanical prosthetic valves usually produce additional sharp clicking opening sounds which correspond to an ejection sound and an opening snap. The closing sound corresponds to the component of the heart sounds contributed by that valve, i. As there is normally no sound from the opening of normal heart valves, the high intensity, abrupt metallic click of mechanical valve opening produce additional opening sounds which in the case of the aortic valve has the same timing as an ejection sound, and in the case of the mitral valve occurs when an opening snap would occur. Both mechanical and tissue aortic valve usually causes turbulent flow and an ejection systolic murmur. Ejection sound: an ejection sound occurs as the aortic or pulmonary valve opens and is close to S1 and may be misinterpreted for a split S1. Ejection sounds are sometimes heard in normal subjects but the most common cause in an asymptomatic patient is a bicuspid aortic valve (E Chapter 21). S4: this corresponds to atrial contraction and may be present whenever atrial contraction is powerful, usually secondary to ventricular dysfunction or hypertrophy. This illustrates that the aortic (A2) and pulmonary (P2) components of S2 are widely split. Commonest cause bicuspid aortic valve Mitral stenosis (and tricuspid stenosis-rare). Systolic murmurs  Murmurs Detecting and interpreting cardiac murmurs is difficult and needs a combination of physiological and cardiological knowledge and experience. In reality, in the developed world if a murmur is heard then it is investigated further with an echocardiogram (E Chapter 4). The sound generated is louder when the pressure difference across the pathological structure is greater and higher velocity of flow and greater turbulence is generated. The murmur does not start until ejection begins and peaks when blood flow is greatest, and consequently, as stenosis becomes more severe, the murmur peaks later in systole. Thus the murmur has a crescendo/decrescendo character and is contained well within the heart sounds. The flow dependence of murmurs means that the murmur gets softer and may disappear if transvalvar flow starts to fall when a lesion is very severe and causes heart failure. Murmurs of this type that fill the whole of systole are described as pan- or holosytolic. In many patients with mitral regurgitation, however, the valve does not become incompetent until, for example, it has prolapsed Camm-Chap-01.
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Thus, the natural history and many of the clinical and laboratory findings of the admixture lesions resemble those of similar left-to-right shunts, including the development of pulmonary vascular disease. In an admixture lesion, the systemic arterial oxygen saturation is a valuable indicator of the volume of pulmonary blood flow, since the degree of cyanosis is inversely related to the volume of pulmonary blood flow. In patients with large pulmonary blood flow, the degree of cyanosis is slight because large amounts of fully saturated blood return from the lungs and mix with a relatively smaller volume of systemic venous return (Figure 6. If the patient develops pulmonary vascular disease or pulmonary stenosis that limits pulmonary blood flow, the amount of fully oxygenated blood returning from the lungs and mixing with the systemic venous return is reduced, so the patient becomes more cyanotic and the hemoglobin and hematocrit values rise. Normally, the pulmonary artery lies anterior to and slightly to the left of the aorta. Normally, the anterior blood vessel arises from the infundibulum, which is the conus portion of the right ventricle. The aorta in complete transposition arises from the infundibulum of the right ventricle. The pulmonary trunk, on the other hand, originates posteriorly from the left ventricle. Because of the transposition of the great arteries and their anomalous relationship to the ventricles, two independent circulations exist. The systemic venous blood returns to the right atrium, enters the right ventricle, and is ejected into the aorta, while the pulmonary venous blood flows through the left side of the heart into the pulmonary artery and returns to the lungs. A communication must exist between the left and right sides of the heart to allow bidirectional shunting between of these two venous returns. The communication exists in one or more of the following: patent foramen ovale, atrial septal defect, ventricular septal defect, or patent ductus arteriosus. In about 60% of the patients, the ventricular septum is intact and the shunt occurs at the atrial level. Using a single ventricle, three clinical examples are shown, each with different degrees of pulmonary stenosis and pulmonary blood flow. In patients with an intact ventricular septum, the communication (either a patent foramen ovale or a patent ductus arteriosus) between the two sides of the circulation is often small. As these communications follow the normal neonatal course and close, neonates with transposition and an intact septum develop profound cyanosis. Because a greater degree of mixing usually occurs in patients with a coexistent ventricular septal defect, cyanosis is mild in such infants with transposition and diagnosis is sometimes delayed. History Complete transposition of the great arteries occurs more frequently in males. Without intervention, almost all infants exhibit dyspnea and other signs of cardiac failure in the first month of life; infants with intact ventricular septum develop cardiac symptoms in the first 2 days of life and are more intensely cyanotic than those with coexistent ventricular septal defect. In the absence of operation, death occurs, usually in neonates, and in nearly every patient by 6 months of age. Patients with ventricular septal defect and pulmonary stenosis are often the least symptomatic because the pulmonary stenosis prevents excessive pulmonary blood flow and enhances the flow of fully saturated blood through the ventricular septal defect into the aorta; these patients resemble those with tetralogy of Fallot. Setting aside cyanosis and congestive cardiac failure, physical findings vary with the coexistent defect associated with the complete transposition. Neonates on the first day of life are often asymptomatic, except for cyanosis, but quickly develop tachypnea. With an intact ventricular septum and an atrial shunt, either no murmur or a soft, nonspecific murmur is present. The second heart sound is single and loud along the upper left sternal border, representing closure of the anteriorly placed aortic valve. Although the murmur does not diagnose complete transposition, it can indicate the type of associated defect. If pulmonary stenosis coexists, the murmur often radiates to the right side of the back. Electrocardiogram Since the aorta arises from the right ventricle, its pressure is elevated to systemic levels and is associated with a thick-walled right ventricle. The electrocardiogram reflects this by a pattern of right-axis deviation and right ventricular hypertrophy. Patients with a large volume of pulmonary blood flow, as with coexistent ventricular septal defect, also may have left ventricular enlargement/hypertrophy because of the volume load on the left ventricle. Summary of clinical findings the diagnosis of complete transposition is usually indicated by a combination of rather intense cyanosis in the neonatal period, roentgenographic findings of increased pulmonary vasculature, and characteristic cardiac contour. In views parallel to the long axis of the left ventricle, both arteries course parallel to each other for a short distance. This appearance is not seen in a normal heart, where the great arteries cross each other at an acute angle. In views profiling the short axis of the left ventricle, the aorta is seen arising anterior and rightward of the central and posterior pulmonary artery (hence the term d-transposition, or dextrotransposition). A cross-sectional view of the aortic root allows demonstration of the origins, branching, and proximal courses of the coronary arteries. In neonates with transposition, the interventricular septum usually has a flat contour when viewed in cross-section; however, as the infant ages, the septum gradually bows away from the right (systemic) ventricle and bulges into the left (pulmonary) ventricle. Ventricular septal defect represents the most important associated lesion diagnosed by echocardiography; the shunt through it and any atrial septal defect or ductus is bidirectional, consistent with the physiology of transposition described earlier. The atrial septal defect may be small and restrictive (Doppler signals are high velocity) before balloon septostomy; after, it is typically large and unrestrictive, with a mobile flap of the torn fossa ovalis waving to and fro across the defect. Cardiac catheterization Since echocardiography shows the diagnosis, the primary purpose of cardiac catheterization is the performance of interventional creation of an atrial septal defect (Rashkind procedure). In patients with an intact septum, oximetry data show little increase in oxygen saturation values through the right side of the heart, and little decrease through the left side. Among those with coexistent ventricular septal defect, larger changes in oxygen values are found. The oxygen saturation values in the pulmonary artery are higher than those in the aorta, a finding virtually diagnostic of transposition of the great arteries. When the ventricular septum is intact, the left ventricular pressure may be low; but in most patients with coexistent ventricular septal defect or in those with a large patent ductus arteriosus, the left ventricular pressure is elevated and equals that of the right (systemic) ventricle. Angiography confirms the diagnosis by showing the aorta arising from the right ventricle and the pulmonary artery arising from the left ventricle, and it identifies coexistent malformations. Aortic root injection demonstrates coronary 194 Pediatric cardiology artery anatomy in preparation for surgery. A left ventricular injection is indicated to demonstrate ventricular septal defect(s) and pulmonic stenosis. Palliative procedures Hypoxia, one of the major symptom of infants with transposition of the great vessels, results from inadequate mixing of the two venous returns, and palliation is directed towards improvement of mixing by two means. Unless hypoxia is treated, it becomes severe, leading to metabolic acidosis and death. This substance opens and/or maintains patency of the ductus arteriosus and improves blood flow from aorta to pulmonary artery. Patients with inadequate mixing benefit from the creation of an atrial septal defect (enlargement of the foramen ovale). At cardiac catheterization or by echocardiographic guidance, a balloon catheter is inserted through a systemic vein and advanced into the left atrium through the foramen ovale. The balloon is inflated and then rapidly and forcefully withdrawn across the septum, creating a larger defect and often improving the hypoxia. Infants who do not experience adequate improvement of cyanosis despite a large atrial defect and patent ductus are rare. Factors responsible in these neonates include nearly identical ventricular compliances, which limits mixing through the atrial defect, and elevated pulmonary vascular resistance, which limits the ductal shunt and pulmonary blood flow. Rarely, an atrial defect is created surgically by atrial septectomy, an open-heart procedure. The first successful corrective procedure was performed by Senning in the 1950s and later modified by Mustard.
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Activated, depolarized hippocampal neurons release the cannabinoids as postsynaptic calcium levels rise. Both the synthesis and the release of the cannabinoids are calcium dependent, which actually had been known for some time (Di Marzo et al. It means that the cannabinoids are telling inhibitory neurons to stop inhibiting quite so much, thus, paradoxically, increasing excitation. This finding was simultaneously made by a group in Japan and published in the same month (Ohno-Shosaku et al. Wilson showed that the process occurred in a very rapid fashion in hippocampal cells, providing discrete evidence of a neuromodulatory role for the cannabinoids. As she states, "Our study represents the first identification of a physiological process mediated by endogenous brain cannabinoids. The researchers make the point that the retrograde mechanism is important to both synaptic strength and rapid time scales. The diffusible and short-lived endocannabinoids, therefore, have a notable role in modulation of both inhibitory and excitatory neuronal communication. It is known that the exogenous cannabinoid marijuana reduces memory and learning functions. Mechoulam and colleagues emphasize that there are significant pharmacological differences between the exogenous and the endogenous cannabinoid ligands (Martin et al. It is likely that marijuana overwhelms the receptors and results in a physiological picture very different from endocannabinoids, including deficient memory processes. There is one other study that we want to share with you because it is related to the hippocampus. A group of scientists at the Institute of Experimental Medicine, which is part of the Hungarian Academy of Sciences, have done work on the cannabinoids (Hajos et al. A little anandamide comes along and modulates the synchronicity of the hippocampus. These results leave wide open the possibility that the endocannabinoids play a part in expression of emotion and, in particular, might participate in the regulation of fear (perhaps correlated to the reported symptoms of paranoia with some marijuana users). It appears that the factors could range from experiences of intense peace to significant fear. Most people are in alpha and theta when they meditate or engage in any number of other of the modalities you will read about in the next chapter. Therefore, it makes logical sense that the cannabinoid ligands are potentially neuropeptides of deep relaxation. However, the physiological effect may leave the individual in a state of deep and profound tranquility. In Chapter 11, we will describe the neurological complement to this hormonal phenomenon. We now have the first biochemical verification for the physiological underpinnings, not only of relaxation medicine, but also for energy medicine, which will be discussed in Chapter 7. In response to an antipsychedelic sentiment sweeping the country in the late 1960s, Congress passed a law in 1970 that put many of the psychedelic drugs into a legal category that highly restricted their use for research. Several subjects described seeing clowns, lights, colors, and encounters with other "beings. Strassman himself had spent years of his life researching melatonin in his quest for "a biological basis of spiritual experience. The presence of -carboline in our bodies is important because having a hallucinogenic-type experience while we are engaged in daily functions would be extremely disruptive. These compounds were the same substances found in urine samples from acutely psychotic patients who were not taking any type of medication (Pomilio et al. Perhaps, the association is akin to the reciprocal relationship between norepinephrine and epinephrine, which organically resemble one another yet have distinct operational components. It has already been established that melatonin is secreted during meditation, even of the alpha-wave frequency. Physicians, family, and friends all have the power to support or seriously hinder the patient in his or her efforts to heal. The researchers made sweeping conclusions about there being no justification for placebos outside of their use for clinical trials. In doing so, they swept under the carpet the fact that they had found a correlation between placebo and pain and that the reviewed studies may have been too few to provide the statistical power to elucidate other such small subgroups. Paradoxically, I agree, the placebo no longer exists because we now can call it psychoneuroimmunology. Helping patients to believe that some type of "healing" can happen in their lives directs the course of both the mental and physical aspects of the disease. Caregivers, families, and friends all hold similar power to support the patient and foster wholeness. As you will recall from the Introduction to this book, it kept Steve alive for 10 years. I do not know whether you have taken note of it, but there is a distinct interweaving of the hormones of relaxation. The research is not yet all there, as it is for the stress response, but what is known so far is intriguing. Then consider that -carboline, nicotinamide, inosine, hypoxanthine, melatonin, and the cannabinoids all share actions, if not receptors, with the benzodiazepines. And finally, melatonin and the benzodiazepines seem to have at least somewhat similar mechanisms of action, as they each reduce stress in a manner that is dependent upon bolstering the immune system. We do not yet have the exact hormonal sequence or the corresponding physiological repercussions that have been established for the stress system. We also do not know exactly how the various hormones contribute to the relaxation system, but it seems very likely that each are contributing members of a complex network of relaxation hormones. Undoubtedly, the most dramatic finding is that the endogenous cannabinoid ligands have the ability to influence the relaxation system in a retrograde manner and modulate both inhibition and excitation. We have our first confirmed picture of how the neuroendocrine system operates during relaxation. It is my contention that deep relaxation places humans within a "target zone" for the endogenous release of any of the family of neuropeptides of relaxation. I like to refer to the interface as limbic therapy because the theta resonance is the "healing zone" in which traumatic and repressed memories can be neutralized. While the neurons that facilitate an endogenous relaxation response can individually fire rapidly, the hormones work in retrograde and localized fashions. Slow and steady is their modus operandi, often taking years to reset our patterns of neuronal firing. Their mode of action reflects what happens to us as we try to live more peaceful lives. Sometimes it can take years to change just one aspect of your personality with which you are not pleased. A whole new set of hormonal reactions must be secreted in situations that previously caused stress, anxiety, fear, or whatever the emotion. Giving the mind and the body more time to practice relaxation, such as periods of meditation, promotes the endogenous learning of how to instigate a cascade of relaxation rather than stress hormones. Have you ever wondered what prolonged relaxation-true, deep relaxation-could do for your physical health? In the chapter on stress (Chapter 3), we discussed the concept of encoded engrams, which stem from repressed or imbalanced emotions that create an energetic imbalance and may result in functional pathology. Encoded trauma and memories that promote fear or reduce our self-worth are engrams, which are very hard to change. They crystallize, but we now have a schematic of the endogenous hormonal pattern that can change them. Experiences of deep peace, as encountered in the theta range, allow us to release the pain associated with memories (i. I call it limbic therapy because the emotion associated with the memory, which has been encoded in the hippocampus, can actually be released. As we train our minds to observe our reactions, we can learn to mitigate our responses to stress. In the next chapter, we will review numerous techniques that can engender this state of relaxation.
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The costal element is occasionally found separated from the posterior half and constituting a cervical rib. This is because of the independent centers of ossification in the anterior and posterior roots. The interval between the neck of the rib and the front of the transverse process, forms an arterial passage which corresponds to the vertebraterial canal in the transverse processes of the cervical vertebrae; the anterior bar is homologous with the head and tubercle of the thoracic rib, whilst the posterior part corresponds with the thoracic transverse process. The cervical rib is, therefore, due to the independent development of the costal root of the transverse process of the seventh cervical vertebra. Cervical ribs, as a rule, are of small size; they seldom exceed an inch in length, but may reach the sternum as do other ribs. A cervical rib may possess only a head, neck and tubercle; its shaft may end freely and join the first thoracic rib, or the sternum; this union may be by bone cartilage or ligament. A spinal column recently came into my possession which had twenty-five ribs, the extra one being a right cervical of two and three-quarter inches in length. The distal end was comparatively large and articulated midway on the upper surface of the first thoracic rib, but articular cartilage was lacking. The twelfth pair of ribs in this specimen were each one and a half inches in length. The eleventh and twelfth vertebrae were ankylosed and wedge-shaped, making a sharp kyphosis. The bodies of the third and fourth lumbers had oozed out a portion of their substance, which was loose-not attached to the vertebrae as usual. Some thirty years ago, a distinguished woman of letters published a small book entitled the Age of Science, which began by announcing as the greatest discovery ever achieved by man, the invention of the new Prospective Telegraph, which enables the obstacles of time to be effectually conquered as that of space has been by the electric telegraph. Other works of fiction have occupied our attention in more recent years with notions that are very likely to he realized in the near future. The great poets of the world have ever been its prophets, and imaginative writers have often substantiated their claims to foretell the future. The Age of Science dealt chiefly with the time when the churches would all be abolished, and their buildings devoted to the use of the medical profession, and for physiological and other researches, "for which the vaults beneath offer peculiarly interesting specimens. Amongst the Schedules of Gravamina and Reformanda the inadequacy of the fees to be legally claimed by doctors was dealt with. The laws relating to Medical Heretics were considered, and it was arranged that a solemn protest, carried by 50,000 doctors in procession, should march down Witehall to demonstrate against the interference of the Secular Power in Things Medical. In police reports we have accounts of the flogging of a number of men and women for neglecting to send their children to the new Science Classes in the Tower that they might learn the rudiments of Astronomy and Paleontology. Justice Draco sentenced all five prisoners to be vivisected for the instruction of the students at the magnificent new School of Physiology in Carlton Gardens. Some sympathy was expressed for an elderly nobleman in feeble health, who seems to have feared being inoculated by the saliva of mad dog. Lady Clara Vere de Vere implored that she might even be Ratified sooner than given over to the experiments of Dr. Several medical heretics, who had contumaciously refused to take medicine according to law, were ordered to be burnt before the doors of the London University. These are but a few specimens of this brilliant brochure, and as I read it many years ago I confessed to myself that I saw no reason why it should not ultimately be no satire but a record of awful doings to come. The world, which has complacently witnessed the tortures and persecutions of the past in the interest of theologians-speculative as were the doctrines concerned-may tolerate in an age when materialization has dethroned God, and science has abolished religion-a medical domination equaling, if not surpassing, in tolerance the cruelties of a theological epoch. Could we see anything in these demonstrations but the determination of medical students to make their profession dominant? The toy dogs they carried in procession were the emblems of their laboratory researches. Their ribald songs were their defiance of the humanitarians who try to impede their cruel work, and the whole spirit of the riots meant the claim of orthodox medicine to rule the public in the interests of their craft. Those who cannot see in these disturbances, and in the spirit which animated them, the warning of what will come when science rules us unchecked by a nobler spirit must be deficient in the ability to discern the signs of the times. Dominated by a medical priestcraft the world will be worse off shall it was under the rule of the clerics. A science can not be impure, foul, dirty, unclean, filthy, unwholesome, adulterated. To use Chiropractic and Naturopathic as adjectives, to qualify physician, a man who gives medicine, is to misqualify what is already qualified, by using opposite meaning terms. To combine those three words is to use terms which are counterterms, words which are opposite in meaning. Cure of disease follows Chiropractic adjustment" because it is accurate and exact in locating subluxations. From expressions found in this booklet, I am satisfied that the author has copied Chiropractic expressions which he does not comprehend. They looked well in other literature, why not use as good judgment in compiling his reading matter as he did in furnishing his treating rooms? Nature is thus again free to make right whatever is diseased in the body functions. The free flow of nerve is cut off, the nerves are shriveled up and disease of the organs to which these nerves lead is the inevitable result. We know that Nature always works along the lines of health and that it is Nature that cures. These criticisms should set him to thinking; if so, there will be a good show for improvement, inasmuch as he is now a subscriber for the Adjuster. But for the man or woman who will not think, there is but little show for advancement. These unthinkables will be found in all classes of all schools-are you one of them? No wonder such teachers are unable or unwilling to learn Chiropractic as a science. They look wise when the first question is asked, flounder on the second, and shake their heads on the third. Those who receive such pseudo-Chiropractic education are not to blame for thinking it to be Chiropractic. The Adjuster fills a long-felt want, Shall we advance in Chiropractic or retrograde? How can you outline a principle, a source or origin, that from which anything proceeds? I have read this leaflet thru very carefully and do not find the basic principle of Chiropractic, or any of the principles derived from the fundamental principle. When the writer of this leaflet reads this, I want him to reread the leaflet and underline the principles of Chiropractic which he has outlined. It means just what the two Greek words signify, cheir the hand and practos done-done by hand. He makes a systematic exercise of his adjusting; he makes of it a practical exercise of practice. He writes me, "I am working in a regular course of adjustment correcting a number of subluxations for the drink habit. We do not heal by first, second or third intention, by adhesion, by scab or by granulation. There are those who believe that all diseases originate in the mind by wrong thinking. This Chiropractic Naturopathic Physician believes that disease has a cause in the body, that the cause of diseases is physical and not mental, whereas, "Dad Chiro" says the causes are traumatic, toxic, or auto-suggestive. The doctor says disease is specifically physical, specially of the body and not of the mind. So, he analyzes the body causes of disease and not those of traumatic, toxic or auto-suggestion. The word Innate is used several times in this leaflet and is misspelled each time. It will be seen that the impulses of Innate and those of Educated (the mind) have different origins, are each transmitted over their special nerves, the splanchnopleure to the inner or visceral portion and the somatopleure to the body wall.
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Corneal ulceration and full-thickness corneal melts associated with the use of these agents is a serious complication. The majority of cases were related to the generic ophthalmic diclofenac sodium solution manufactured by Falcon Laboratories, and ultimately this product was removed from the market. Current Medications Available in the Therapeutic Class Generic Food and Drug Administration Dosage (Trade Name) Approved Indications Form/Strength Bromfenac sodium Treatment of pain and inflammation Ophthalmic solution: ophthalmic* associated with cataract surgery 0. Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution. American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract. Safety and efficacy of bromfenac ophthalmic solution (Bromday) dosed once daily for postoperative ocular inflammation and pain. Nepafenac dosing frequency for ocular pain and inflammation associated with cataract surgery. Comparison of the anti-inflammatory effects of diclofenac and flurbiprofen eye drops after cataract extraction. Efficacy and tolerability of preservative-free and preserved diclofenac and preserved ketorolac eye drops after cataract surgery. A comparison of topical diclofenac with prednisolone for postcataract inflammation. Topical diclofenac sodium for treatment of postoperative inflammation in cataract surgery. Effects of dexamethasone, diclofenac, or placebo on the inflammatory response after cataract surgery. Comparison of topical prednisolone acetate, ketorolac tromethamine and fluorometholone acetate in reducing inflammation after phacoemulsification [abstract]. Ketorolac-tobramycin combination vs fluorometholone-tobramycin combination in reducing inflammation following phacoemulsification cataract extraction with scleral tunnel incision [abstract]. Prospective, randomized trial of diclofenac and ketorolac after refractive surgery [abstract]. Corneal sensitivity and burning sensation: comparing topical ketorolac and diclofenac. Treatment of acute pseudophakic cystoid macular edema: diclofenac vs ketorolac [abstract]. Pseudophakic cystoid macular edema: ketorolac alone vs ketorolac plus prednisolone [abstract]. Comparison of diclofenac and fluorometholone in preventing cystoid macular edema after small incision cataract surgery: a multi centered prospective trial. Ketorolac vs prednisolone vs combination therapy in the treatment of acute pseudophakic cystoid macular edema. Non-steroidal anti-inflammatory agents for cystoid macular edema following cataract surgery: a systematic review. Comparison of diclofenac sodium and flurbiprofen for inhibition of surgically induced miosis [abstract]. The effect of pre-operative topical flurbiprofen or diclofenac on pupil dilatation [abstract]. Effect of preoperative use of topical prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery: a randomized trial. A combined analysis of two studies assessing the ocular comfort of antiallergy ophthalmic agents. These agents achieve their therapeutic effect via several different mechanisms of action. Abatacept (Orencia ) is a T-cell activation inhibitor, tofacitinib (Xeljanz ) is a Janus kinase inhibitor, and vedolizumab (Entyvio ) is an 4-7 integrin 1-17 receptor antagonist. Because the immunomodulators are biologic agents made from living organisms and are extremely difficult to duplicate, congress has struggled to create regulations to approve generic versions of these agents. Currently, none of the agents in this class are available generically; however, the recently upheld Patient Protection and Affordable Care 36 provides a legal framework for regulatory approval of biosimilar drugs. Hidradenitis suppurativa is characterized by inflamed, painful lesions typically located around the 37 armpits and groin, on the buttocks and under the breasts. Other treatment options for people with hidradenitis suppurativa include surgery to remove skin affected by the disease and antibiotics to treat infections that may occur. Current clinical guidelines and systematic reviews and clinical literature currently guide the treatment of hidradenitis suppurativa. Generally, topical or oral antibiotics, intralesional steroids, retinoids, zinc, anti-androgens or laser surgery are recommended for mild (stage I disease). Consistently, immunomodulators have shown greater improvement in symptoms over the 49-144 comparator. The second study concluded that There was a 64% relative reduction in the risk of flare for patients in the canakinumab group as compared to 77 those in the placebo group (hazard ratio of 0. The safety and efficacy of secukinumab was evaluated in four multicenter, randomized, double-blind, placebo-controlled trials. In one of the trials, secukinumab 300 mg and 150 mg groups were compared to etanercept. In one trial in rheumatoid arthritis patients who were either intolerant or were not candidates for methotrexate treatment, significantly greater improvements were observed in patients treated with tocilizumab compared to 126 adalimumab. In another trial in rheumatoid arthritis patients with inadequate response to methotrexate, similar responses were observed in patients treated with abatacept and 127,128 the inclusion of adalimumab arm in one phase 3 trial of tofacitinib allowed adalimumab. The few direct head-to-head trials available prevent clearly determining superiority of one agent over another. The approval was based on the results of a single trial 143 demonstrating sustained improvements in affected patients over 60 months. In general, no one agent is preferred over another; however, given the paucity of clinical experience and long-term safety data, the use of tofacitinib for rheumatoid arthritis is 18 recommended primarily after biological treatment has failed. Braun J, van den Berg R, Baraliakos X, Boehm H, Burgos-Vargas R, Collantes-Estevez E, et al. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on the biologics. Guidelines of care for the management and treatment of psoriasis with topical therapies. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. Rheumatoid arthritis: national clinical guideline for management and treatment in adults. Golimumab for the treatment of rheumatoid arthritis after the failure of previous disease-modifying anti-rheumatic drugs. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Efficacy of certolizumab pegol on signs and symptoms of axial spondyloarthritis including ankylosing spondylitis: 24-week results of a double-blind randomised placebocontrolled Phase 3 study. Outcomes of a multicentre randomized clinical trial of etanercept to treat ankylosing spondylitis. Efficacy and safety of up to 192 weeks of etanercept therapy in patients with ankylosing spondylitis. Clinical efficacy and safety of etanercept vs sulfasalazine in patients with ankylosing spondylitis: a randomized, double-blind trial. Treatment of active ankylosing spondylitis with infliximab: a randomized controlled multicentre trial. Systematic review: the short-term and long-term efficacy of adalimumab following discontinuation of infliximab.
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Injuries Football Medicine Manual increased physiotherapy efforts, but sometimes arthroscopic debridement and mobilisation are needed to regain a full range of motion. Late sequelae are more likely to occur if the meniscus has been removed, articular cartilage lesions have been diagnosed, or if other ligament structures show insufficiency leading to instability or post-traumatic osteoarthritis. All grafts undergo initial necrosis due to avascularity followed by secondary revascularisation. Creeping substitution with the ingrowth of new functional tissue to replace the necrotic tissue is a process that takes about nine to 12 months, during which time the graft is liable to stretch out. For more information about the treatment of meniscus injuries and articular cartilage injuries, see 3. Complete tears with avulsion of a bony fragment from the tibia are seen mostly in young players. While substance tears are rather uncommon, femoral avulsion tears occur more often. Risk factors include previous injuries to the knee, insufficient rehabilitation of a previous injury, insufficient conditioning, weakness of the thigh muscles, hyperlaxity, body contact and foul play. Symptoms and signs A hyperflexion or hyperextension trauma as well as impacts from the side or from the front can result in either an isolated or a combination injury. Injuries Football Medicine Manual 167 sag sign due to a spontaneous posterior displacement of the tibia (Figure 3. The posterior drawer test is a classic test to reveal straight posterior instability. Arthroscopy may give the definite answer about the injury, especially when the ligament is probed. The patient may remain clinically unstable but experience functional stability without any symptoms. Rehabilitation programme During the early phase of the rehabilitation programme, a brace which limits the posterior drawers should be used even during the functional period of training. Active motion can be started immediately and muscle training should be focused on the agonistic quadriceps muscle. Especially during the initial four to six weeks, the hamstrings should not be trained specifically. Many players experience patello-femoral pain and may develop early patello-femoral osteoarthritis. However, each player must be evaluated individually and combination injuries in particular require close follow-up. Fixation of the foot and contracting of the quadriceps muscle leads to anterior translation of the tibia towards its normal position. Concomitant meniscus and articular cartilage injuries require individual attention (see 3. More often a lateral blow or impact to the lower thigh or knee with direct contact may be the cause of valgus stress and external rotation by extrinsic forces. Swelling of the joint is not common and might indicate a more severe injury in the joint itself. Treatment For grade 1 and minor grade 2 injuries (stable knee, partial tear) the rehabilitation programme with weightbearing and early motion may start as early as possible. If there is satisfactory progress leading to full extension, no effusion and decreased tenderness after two to three weeks, the player is advised to optimise his range of motion and muscular strength before returning to training and competition, which usually occurs within four to eight weeks. The treatment of major grade 2 and grade 3 injuries (unstable knee, complete tears) depends on associated injuries. Early motion and weightbearing starts as soon as possible within the limits of pain. It may take up to six to eight weeks or longer before the player can return to football. Sometimes stiffness can be a problem but is less frequent with early motion and weight-bearing. Muscle exercises aimed at regaining at least 80% of the initial strength are of great importance for a safe return to football (Figure 3. A return to training and match play is permitted as soon as the player has recovered a full range of motion, adequate muscular strength and acceptable stability on testing. Stable knees may return within four to eight weeks, while unstable knees may require four to six months. Other stabilising factors are the posterolateral fibrous capsule, the arcuate ligament, the popliteo-fibular ligament and the lateral gastrocnemius tendon and muscle. Causes, mechanisms and risk factors the mechanism of injury might be a medial impact to the knee or an external rotation with the foot in a fixed position, causing internal rotation of the tibia and varus stress to the knee. A varus opening of less than 5mm indicates a partial rupture and can be treated conservatively with an early range of motion and weight-bearing, protective bracing and muscle strengthening. Complete ruptures and injury to the posterolateral corner should be treated surgically to avoid late varus instability. Genu varum is an important factor to correct in severe posterolateral corner insufficiency and should be done by tibial osteotomy. For partial ruptures with preserved stability, the prognosis is good and a return to football is usually possible within four to eight weeks. In a case of complete ruptures with instability, acute surgery is recommended and a return to football may not be possible before four to six months, depending on the individual recovery process. Unfortunately, removal of the meniscus results in unphysiological loading of the articular cartilage, which will erode over the course of time and finally result in osteoarthritis. The meniscus plays an important role in shock absorption for the knee joint, in dispersing the weight-bearing load as well as in the stabilisation of flexion-extension and rotational movements of the knee. The anterior and posterior horn of the medial meniscus is attached to the tibial plateau, the joint capsule and the medial collateral ligament (see Figure 3. The incidence of meniscal injuries that result in meniscectomy has been shown to be 61 per 100,000 in a common U. Treatment of meniscal lesions with arthroscopy has become the most common orthopaedic surgical procedure in the majority of orthopaedic centres and constitutes 10-15% of all surgery. When a player is examined after a distortion trauma, a medial meniscus tear should always be suspected with medial symptoms and a lateral meniscus tear with lateral symptoms. Articular cartilage injuries may mimic meniscus injuries and may be present in about 40-45% of players with meniscus injuries. Furthermore, an anterior cruciate ligament injury or collateral ligament injury may mimic meniscus injuries. The most common diagnosis after a knee distortion is a medial meniscus, which occurs five times more often than injuries to the lateral meniscus. Medial meniscus injury is common in combination with medial collateral ligament injury. Functional anatomy In the past, the meniscus was thought to be a dispensable structure. The treatment of an injured meniscus therefore often resulted in its complete Figure 3. Injuries Football Medicine Manual 171 the lateral meniscus has an anterior and posterior attachment to the tibia but has no attachment to the lateral collateral ligament. The capsular attachment of the lateral meniscus is also less tight than that of the medial meniscus, which renders the lateral meniscus more flexible. The peripheral third of the meniscus near its capsular attachment is richly vascularised. In the intermediate third, vascularisation decreases closer to the centre, while the inner third is not vascularised at all.