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The outpatient departments have land and maintains its dedication to the high- approximately 200 cheap 30 gm himcolin mastercard doctor for erectile dysfunction,000 visits a year buy himcolin 30 gm mastercard erectile dysfunction venous leak, over est standards of service and education. The 55,000 of which are through the emergency acute general hospital has 481 acute care department. There latory surgery center performs approximately are approximately 28,410 patients admit- 9,000 procedures annually. The Outpatient Depart- ily for postgraduate education and research ments have more than 69,506 clinic visits a programs. There is an exchange of medical year and the active emergency service has house offcers and residents at various lev- more than 74,000 patient visits. The Neurology, Neurosurgery and Dentistry, most hospital has a comprehensive Psychiatric of whom hold teaching appointments in the Care Program including a 24 bed inpatient Johns Hopkins Medical School. Sinai has a large Rehabilitation grams in Obstetrics and Gynecology, Physi- Center with a 57 bed rehabilitation hospital cal Medicine and Rehabilitation, Pediatrics, for inpatients, 10 of which are traumatic brain General Surgery, and Ophthalmology. Across the street is the 292 bed also offers the Johns Hopkins/Sinai Hospi- Levindale Hebrew Geriatric Center and Hos- tal program in Internal Medicine. Residents pital, which provides subacute, chronic and from the Johns Hopkins University rotate to long-term care. Levindale merged with Northwest Hospi- There is a long-standing commitment to tal Center to form LifeBridge Health, which both basic science and clinical research. LifeBridge Health is one pathology, surgery, medicine, and animal of the regions most innovative providers of facilities to accommodate the activities of a high quality health care. Johns Hop- merged with Jewish Convalescent & Nurs- kins medical students have the opportunity ing Home. LifeBridge Health & Fitness is a to receive instruction on the clinical services national model for hospital-sponsored well- of the departments of Medicine, Obstetrics- ness centers. Gynecology, Pediatrics, Rehabilitation Medi- The Medical Staff of Sinai Hospital num- cine, and Surgery. Students at any level bers over 1,023 full-time and private practicing of training are eligible to participate in the physicians. One half-day per week is The curriculum is organized to allow each of our devoted to a precepted clinical experience, graduates to achieve the eleven educational the Longitudinal Clerkship, which provides objectives noted in the Mission and Education further training in patient-centered inter- Program Objectives for the Johns Hopkins Uni- viewing, physical diagnosis, and health care versity School of Medicine (page 9 ). Students able beginning in Quarter 4 of the Second will have a variety of lecture and small group Year. Elective courses are described in the discussions supplemented by experiential programs of the various departments in the and skill learning in each intersession. In the section under Departments and Divisions, afternoons of these intersessions students Centers, Institutes and Subjects of Instruc- will be attending a Scholarly Concentration tion. This information is supplemented by course in one of fve concentrations: Basic an elective book which is updated annually. Science Research, Clinical Research, Public Selected students may interrupt the regular and Community Health, History of Medicine, curriculum for one or more years in order to and Medicine and the Arts. These Renal, Cardiovascular, Gastroenterology, courses are intended to introduce students Reproductive Health and Endocrinology, and to the basic language and concepts of bio- Rheumatology. The Longitudinal Clerkship medical science, including molecular biol- continues one-half day per week until the ogy, cell biology, biochemistry, anatomy, and winter break. During ond Year are Substance Abuse Care, Patient Clinical Foundations, students begin training Safety and Quality, and End-of-Life and Pal- in the physician-patient medical interview, liative Care. In the fnal quarter of the Second year, Following winter break in First Year, stu- students begin the core clinical clerkships. A week of Translational Disease, Hematology-Oncology, Psychiatry, Medicine is required after each 8-week clerk- 1919 ship; during these intersession weeks, stu- integrated with the medical program are dents will return to a discussion of state of the described in a later section (“M. A limited number of stipends are elect to delay one 8 week rotation in the next available for students who wish to devote one 5 quarters, but must complete this required full year to research. Three one-month advanced clini- at institutions other than the Johns Hopkins cal rotations are required prior to graduation: University.

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This was of course the result of the growing reliance on science and the simultaneous rise of university and mass education systems that helped to legitimize the privileged status of 240 Michela Giordano experts purchase himcolin 30gm online impotence of proofreading poem, resulting from their professional expertise buy himcolin 30gm free shipping erectile dysfunction exercises treatment, capability and competence (Chaemsaithong 2011). However, as still happens in the modern adversarial court, expert witnesses in the historical courtroom needed to construct and negotiate their identity, especially during the cross-examination when they were obliged “to counterbalance sceptical attitudes and hostile attempts aimed to undermine their testimony that accompanied their vulnerable status and image” (Chaemsaithong 2011: 472). An analysis of their discursive practices could also help shed light on the means they adopted to gain control during the interaction and (re)negotiate and (re)affirm their identity and professionalism. Analysis and discussion The defendants in the fourteen trials under investigation were all un- married women, aged 18-29 who worked as tailoresses, laundresses or domestic servants who were all accused of infanticide generally following an illegitimate pregnancy. Most of them were judged guilty and condemned to imprisonment or hard labour; some received the death penalty, and some were considered unfit to plead because of their (presumed) insanity. As can be seen from Table 3, the medical experts were generally medical superintendents, or assistant medical officers, registered medical practitioners, divisional surgeons of the police, or pathologists. Despite their titles and qualifications, as stated above, medical experts in the historical courtroom had to negotiate their professional identity and their expertise. Experts were not always allowed to expand on their answers or provide further explanations of medical evidence for the benefit of the jurors and the judge. The medical narratives in direct examinations are generally longer than in the other examinations and this can be explained by its less challenging and taxing nature. Medical jargon embedded in the legal context From a thorough reading of the transcripts, the use of two particular phrases comes immediately to the reader’s attention: separate exis- tence, referred to the newly-born baby and puerperal fever, referred to the mother. As will be explained later through the selected excerpts, the experts in the trials in the corpus appear to have had the opportunity to provide clarifications and details about the meaning of the two expressions and this can be explained by what Chaemsaithong (2011) states about expansions of response. In their answers to the lawyers’ questions, they were able to provide detailed information and to expand their replies, often adding explanations of the most difficult medical terminology or of the expressions which needed to be clarified for the lay jury and the public present in the courtroom or even for the legal professionals who had no knowledge of or even familiarity with certain scientific and medical facts. Additionally, Chaemsaithong (2011: 480) notes that, differently from lay witnesses, experts in historical courtrooms were there to convey their opinion about a particular issue based on their qualifications and thus The Old-Bailey Proceedings: Medical Discourse in Criminal Cases 243 attempted to shield themselves from blame and criticism. The expansion of responses had several communicative goals for medical experts: a) to establish their identity as experts; b) to negotiate positive self-representation and prevent their already vulnerable status from being attacked; c) to propagate and reproduce the scientific ideology. The need to elucidate on scientific principles and disseminate medical perspectives was often in contrast with the discredit and distrust that experts were sometimes subjected to. Nevertheless, as highlighted by Anesa (2012: 164), “the expert witness plays a crucial function in framing specialized (scientific) knowledge and often assumes the role of an expert mediator of knowledge”. The author refers to experts in the contemporary courtroom context, but we can safely affirm that what she says was true of the historical courtroom, where witnessing through medical and scientific evidence was also a way to make medicine and science more comprehensible and accessible to lay people. In order to try defendants in an infanticide case and judge whether they objectively committed the crime of killing their newly- born baby, the baby’s life had to be demonstrated before presupposing it was actually murdered rather than stillborn. Atkinson wrote in 1904, A child is not born alive in law, and consequently cannot claim the right of a subject of the King, until it has exhibited a separate and independent existence after complete extrusion from the body of its mother. This expulsion does not also imply the delivery of the paraphernalia of the fœtus, nor need these be disconnected, for the legal consummation of birth (539-544). Charles Graham Grant made the post-mortem examination of the newborn child and explained why, in his opinion, the fatal blow to the victim was given during its legal life: 244 Michela Giordano (1) in my opinion that bruise was inflicted during legal life according to the defi- nition given in our medical text books […] we are taught to gauge the circulation by our experience by the quantity of hemorrhage and the severity of the injury − if the prisoner were able to give the child a blow on the head directly it presented itself the results might be the same, but I cannot say positively − my opinion is that the blow was given during legal life − the hemorrhage extended over a considerable part of the surface of the brain − […] but I am going largely by the books. One of the ways in which they provided evidence that the baby was actually born before being killed is through the examination of the lungs, which were inflated to demonstrate that the baby breathed fully and deeply before receiving the lethal injuries. Then, when cross-examined, he provided expansion and further explanation of how the hydrostatic test worked, as in excerpt (2): (2) A child does not breathe so fully when only half born as it does when the birth is complete; the amount of air in the lungs varies […] – the hydrostatic test is, in my opinion, absolutely conclusive in circumstances of this kind; each lobe is separately tested to see if it floats; then each is cut into pieces, and these pieces are tested, and so you get a complete test of the lungs […] the inflation of the lungs, to my mind, proved conclusively that the child had had a separate existence, and breathed fully and deeply. Leonard Harman distinguishes between the biological (and medical) and the legal sense of the phrase born alive: (3) I told the Magistrate that I formed the opinion that the child was probably born alive − I fully appreciate the difference of the sense of the biological and The Old-Bailey Proceedings: Medical Discourse in Criminal Cases 245 legal phrases of being born alive − in a medical sense ‘born alive’ means the child has breathed, but in the legal sense it means it has breathed after it was wholly separated from the body of the mother […]. Blomfield of the Camberwell Infirmary exposed his findings resulting from the examination of the baby’s body and stated: (4) I do not think the wounds could have been inflicted before complete birth. By ‘separate existence’ I mean that the child breathed; […] that it has born and has breathed; by ‘born’ I mean that it is away from the mother; the attachment or non-attachment of the cord makes no difference. Blomfield in excerpt (5) above: 246 Michela Giordano (6) By a ‘separate existence’ I understand that the child was carrying out its life entirely apart from any circulation of its mother. Saying that the prisoner had recently been delivered of a child, thus using a passive construction rather than the active one had recently delivered a child, might hint to the fact that in the past pregnancy and childbirth were life-threatening ordeals and many women did not get through them alive.

Kenig 30gm himcolin with visa erectile dysfunction at age 27, “Biological Effects of Extremely Low Frequency Electrical Phenomena in Atmosphere buy himcolin 30 gm with amex erectile dysfunction drugs rating,” Journal of In­ terdisciplinary Cycle Research, 12, 3; and H. Heller, “Cellular Effects of Microwave Radiation,” Symposium proceedings, Richmond, Va. This anecdote is also recorded in Watson’s Supernature, footnote 55, this chapter. The outlines of this analysis are owed to Ivan Illich in his essay, “The Political Uses of Death,” Hastings Center Studies, 2, 1 (January 1974). A Needed Ar­ mamentarium of Modern Medicine,” Social Science and Medicine, 6 (1972), 537-544. For a discussion of “sick roles,” see Miriam Siegler and Hum phrey Osmond, “The Sick Role Revisited,” Hastings Center Studies, 1, 3, 41. Gregory Bateson, Steps to an Ecology of Mind (New York: Ballantine Books, 1972), p. Gay Gaer Luce, Body Time: Physiological Rhythms and Social Issues (New York: Pantheon, 1971). These data are drawn from Fuchs, “Some Economic Aspects of Mor­ tality in Developed Countries" (see footnote 56, Chapter 2). O ther factors probably include better overall health on the part of those who marry and the regularity of the lives of m arried men. McHale says, “Though seemingly innocuous in its theoretical origins, ecology generates a radical view of hum an society, which may prove to be more ‘positively’ revolutionary. Captain Bob Hoke, “Health and Healthing: Beyond Disease and Dys­ functional Environments,” paper presented at the Annual Meeting of the American Association for the Advancement of Science, Washing­ ton, D. See also his “Man-Environment Rela­ tions and Healing,” paper prepared for the American Psychiatric Association Annual Meeting, Honolulu, Hawaii, 1973. Captain Bob Hoke, “Promotive Medicine and the Phenomenon of Health,” Archives of Environmental Health, 16, 269-278. Marc LaLonde, Minister of National Health and Welfare, A New Per­ spective on the Health of Canadians (Ottawa: Government of Canada, 1974), pp. See Disease, Life and Man, Selected Essays by Rudolf Virchow, Helfand Rather (trans. Garrett Hardin, “The Tragedy of the Commons,” Science, 162 (De­ cember 13, 1968), 1243-1248. The fact that providers of medical care do stimulate a demand for their services is incontrovertible. Departm ent of Health, Education, and Welfare, "Determinants of Expenditure for Physicians’ Services in the U. Bunker, “Surgical Manpower,” Neu’ England Journal of Medicine, 282, 3 (January 15, 1970). There are some doubters; among them is Harry Schwartz, who argues that the worst of the cost crunch is over. See Harry Schwartz, The Case for American Medicine: A Realistic Look at Our Health Care System (New York: David McKay Co. This analysis does not take into consideration earlier "medicines,” such as Greek or Roman medicine. Lord Ritchie-Calder, Medicine and Man (New York: Signet Science Library, 1958), p. See John Powles, “On the Limitations of Modern Medicine,” Science, Medicine and Man, 1 (1973), 13. See Max von Pettenkofer, “The Value of Health to a City,” lectures quoted in Bulletin of the History of Medicine, 10 (1941), 487-503. Cochrane, Effectiveness and Efficiency (London: The Nuffield Provincial Hospitals Trust, 1972). Authoritative commentators like Jerom e Frank are beginning to assess its importance. Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, 1910). Crombie, “The Future of Biology, the History of a Program,” Federal Procedure, 25 (1966), 1448-1453. Leo Tolstoy, “The Death of Ivan Illyich," in Leo Tolstoi, Short Stories, Margaret Wettlin (trans.

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This phenomenon leaving a 3-minute rest period between each set of is known as ‘well-limb training’ quality himcolin 30 gm best erectile dysfunction doctor in india. This means that the desired training effect – cises to condition the key stabilization muscles of the postural correction – is at best flawed and at worst order himcolin 30gm without a prescription erectile dysfunction from stress, lumbosacral region. In contrast, if an athlete is training for power point exercise to condition the transversus, while we with a heavy set of squats, but feels that he/she recov- may use a prone or side-lying exercise to condition ered from the previous set within 90 seconds, he/she the multifidus. This means that in the javelin throw in general, the trunk must the Type 2a fast oxidative fibers will be recruited, with rotate to generate force, we are not looking for the result that it’s not the explosive Type 2b fast gly- the kind of bracing described by McGill (2002) colytic fibers that are being conditioned. The training and Siff (2003); instead we are looking for an in this instance would actually make the athlete abdominal hollowing to allow for both stability and mobility (see ‘Inner unit’ above). We 4A Trendelenburg sign indicates weakness, inhibition or should see a uniform hollowing throughout the paralysis of the gluteus medius of the weight-bearing leg. In gait, a Trendelenburg sign is classically observed as a tail-wag – often volitionally accentuated in catwalk before release of the javelin. A compensated Trendelenburg may also occur where, hollowing, and/or hollowing of just part of the rather than letting the pelvis drop, the patient leans their body abdominal wall, is a failed assessment. With (in the frontal plane) over the leg of the weak gluteus medius experience this can be seen at full speed – during weight-bearing. The stick test allows the examiner to apply graduated load to the patient’s spine and observe for dysfunction in a more controlled manner than, for example, loading the spine with a barbell. It also allows for assessment within the neutral zone, thereby minimizing risk of injury. The stick test Use a wooden dowel rod (or equivalent) and ask the patient to take hold of it firmly with both hands and hold it up in front of them – shoulders flexed to 90°. The patient should be stood with their back to a mirror, with the examiner looking over their shoulder to observe the response of their back in the mirror. Explain to the patient that you are about to move the stick in various directions and that this process will start with light pressure, but the intensity of the movements will gradually increase. Start by lifting up the stick in the sagittal plane (flexion- extension of the shoulder joint) and observe for striations in the patient’s back. If striations are noted, the side, the spinal level, and the severity of the striation should be noted (usually with a subjective descriptor such as ‘mild’, ‘moderate’ or ‘severe’). Next, try to push the patient into lateral flexion using the stick – this is testing for frontal plane stability. Finally, try to rotate the patient via the stick – thereby assessing transverse plane stability. Combinations of the above motions and sudden changes in force provide a more functional assessment of the patient’s ability to maintain functional stability in the lumbopelvic region. This is a common outcome for those In the example given above, the same exercise has who use weight training without truly understanding been used to induce a different postural effect, while subtleties of the physiological adaptation they are tar- achieving similar performance goals. A more common clinical example may the extension with 2–2-6 tempo means that the patient is chronic back pain patient who needs to retrain their working their gluteus maximus for 10 seconds for multifidus. Since a part of the means by which the each repetition, but for 6 seconds in its inner range lumbar multifidus stabilizes the lumbar spine and and for 4 seconds in its outer range. This exercise is sacrum is through the hydraulic amplifier mechanism useful to correct a patient with a lower crossed pos- (Chek 2002, Lee 2004), this system requires that the tural pattern. The supine hip extension with the 4-4-2 multifidus has good trophic levels – if it is atrophied, tempo works the gluteus maximus for 10 seconds per the mechanism is ineffective. In this case, the multifi- repetition, yet in this instance, the muscle is being dus first needs to be consciously activated through worked for 8 seconds in its outer range and only 2 isolation training, and then integrated into functional seconds in its inner range. At this stage, loads that are designed to hyper- version of the supine hip extension perfect for someone trophy the muscle (in the 8–12 rep maximum range) with a layered or sway muscle imbalance, as it trains must be prescribed for efficient restoration of the gluteus maximus to be strong in a lengthened function. Note: Contraindications to such loading would include pain, any sign of inner unit dysfunction (such as abdominal bloating or striations at the spine), lack Sequencing the client’s rehabilitation of proper conditioning and instructing on technique. Tempo allows the clinician and the patient to perform a series of exercises to fatigue the to know how much time under tension the muscle(s) abdominal wall, multifidus and gluteus medius, is receiving. It can also be used to stress different parts then is asked to squat carrying a heavy load, of the exercise. The may only be worked in the outer range (rather than supine hip extension exercise with the back on a Swiss in the critical inner range where strength needs to be ball is a descent of the squat pattern – so may also be developed).

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