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By D. Tuwas. University of the Arts.

There is no inconsistency between the idea of direct experience and the idea of objects of that experience which are as yet unrealized buy lithium 300 mg visa. Every plan lithium 300 mg, every prediction buy lithium 300mg fast delivery, every forecast and anticipation buy discount lithium 150 mg, is an experience in which some non- directly experienced object is directly experienced as a possibility order lithium 300mg amex. And, as previously suggested, modern experience is marked by the extent to which directly perceived, enjoyed, and suffered objects, are treated as signs, indications, of what has not been experienced in and of itself, or/and are treated as means for the realization of these things of possible experience. The ‘subjective’ factor (using the word to designate the operations of an accumulated organism) is, like ‘objective’ (physical subject-matter) a condition of experience. But it is that condition which is required to convert the conditions of kinds of objects, which as kinds represent generic possibilities, into this object. Experiencing subjects as evolved and "deployed," so to speak, and experi- enced objects as discovered, created, conceptualized and manipulated, interact to produce qualitative experience. The "conditions" of experience referred to above are the facts about subjects and about objects which make various kinds of experience possible. Bats have evolved a sonar apparatus to appreciate space and surfaces, whereas we have evolved vision and touch. The facts about our two species’ sensory systems are formal, material and quantitative, as are scientific facts about the objects we perceive. Very different experiences are made possible by the differences in us as subjects. We are not even remotely conditioned as subjects to experience the quality of bats’ experiences. Quantitative, structural, mensurable differences between us underlie our different qualitative experiences but do not in any way actually comprise them. Quantitative aspects of the objects perceived by us and by bats are similar, and certain quantitative isomorphisms of "large" or "smooth" or "impervious" must exist and affect, in vaguely similar ways, our experiences, but the qualities we experience underlying vaguely similar conclusions about spaces and objects must be radically different. Our differences exemplify the way quantitative relations underlie and make possible encounters of quality. And, I should add, there is no basis for asserting that the quality of a space experienced by a bat is less real than that experienced by ourselves. VALUES INTERACTIONAL, NOT RIGIDLY COMPARTMENTAL In Dewey’s work, "value" is a term which is closely related to "good" and "end. It is perhaps only a truism that economic value does not, for example, exist in a vacuum. Things are only of economic value when they are perceived to contribute to biological, aesthetic or psychological satisfaction. The usual view of economic value is that it also involves scarcity or the need for labor. But people invent, labor on, search for and defend the possession of scarce objects only in a milieu of actual and potential biological, aesthetic, moral or psychological satisfaction. And resources like air certainly are of value (though not except in special circumstances of market value) even prior to and apart from being scarce or requiring the investment of labor. He claims that there is no real distinction between expedient and right action when all the consequences are taken into account. In making this claim, he is focusing on and locating moral value especially in natural consequences, be they consequences for the actor or the objects acted on. His idea of expediency is not short term and narrowly construed gain at the expense of moral character, but the broad result of endeavor, reflectively assessed. The satisfaction of thirst, the provision of adequate shelter, the relief of pain, freedom of expression, the cultivation of temperance: all such desiderata are included within the spheres of both economics and morality. No human need is relegated to a despised "animal part" as merely economic, nor does any one pertain only to an unsullied transcendental soul or purely rational and disembodied intellect. Each is examined in its context and can be the subject of compassionate attention. Good teeth, good shoes, honest law enforcement, quality medical care, well built homes, courageous citizens, peaceful conflict resolutions – none of these are excluded as subjects of intelligent deliberation with ethical as well as economic implications. My reading of Kierkegaard’s Either/Or, admittedly not the standard one, is that it demonstrates how aesthetic values, when attended to exclusively, undermine themselves.

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Specialties such as cardiology and cardiac surgery lithium 300 mg mastercard, which are particularly dependent on practical skill order 300 mg lithium free shipping, take the longest cheap lithium 300mg line. Others taken less acutely or seriously ill purchase lithium 300mg, who for one reason or another do not want to or cannot call their general practitioner order lithium 150 mg with visa, take themselves straight to hospital. Many accident and emergency departments include both a minor injuries unit run entirely by nurse practitioners and the consultant led medical team who provide for the patients requiring acute resuscitation, full medical assessment, or more complicated medical treatment. The consultants are in overall charge of the whole team, but the initial sorting of cases is the responsibility of an experienced nurse who also ensures appropriate destination and priority for each individual. General Specialist professional/ training basic specialist training NHS Preregistration Senior Specialist Consultant/ house officer house officer registrar specialist* Medicine/ Any specialty Specialty of choice Specialty of choice surgery 1 year About 2 years 4 years Academic Lecturer Senior lecturer Reader Professor Figure 12. Dealing with anything and everything serious, not so serious, or difficult to discern requires special skill, training, and experience, useful whatever medical specialty a doctor eventually ends up in. For that reason, many senior house officer training programmes in medicine, surgery, and several other specialties now include a period of several months in the accident and emergency department to develop this core dimension of practical professional skill. Telling the difference between the apparently trivial and a medical or surgical time bomb is an art fully learnt only through active service in front line trenches; getting it right, or at least not sending the patient home without fail safe follow up, can save tens of lives and hundreds of thousands of pounds in medical litigation fees and damages. Specific training programmes now exist leading to becoming a Fellow of the Faculty of Accident and Emergency Medicine (FFAEM). Accident and emergency is one of the few clinical specialties which readily lends itself to shift working. Most patients are treated and referred back to their GPs so there is little call for continuity of care. Learning from experience is assured by regular meetings of the whole team to review successes and failures. Anaesthetics Anaesthetics is another specialty in which continuity of care is limited: preoperative assessment, the operation itself, the early recovery period, and intermittent periods of responsibility for supervising the intensive care unit. It is a very hands on specialty and if you are up all night provision is normally made for you to be off for at least part of the next day. The work of an anaesthetist falls fairly tidily into regular and carefully defined commitments. Providing pain relief or anaesthesia during surgical operations, childbirth, and diagnostic procedures is the major task of an anaesthetist. Most also take turns in charge of the intensive care unit and an increasing number confine themselves to such work. The primary examination for Fellowship of the Royal College of Anaesthetists (FRCAnaes) can be taken 18 months after graduation, usually taken during a senior house officer post in anaesthetics, and is a test of knowledge of the scientific basis of anaesthetics and anaesthesia. On the whole, medicine and surgery attract different personalities: physicians tend to be more reflective; surgeons more executive. The difference is reflected in the respective Royal Colleges as Dr John Rowan Wilson observed some years ago but nothing much has changed: The Royal Colleges are, of course, much the smarter end of the profession; they represent the big time. However, the two main colleges, the Physicians, and the Surgeons, are very different in character. The Royal College of Physicians, like the Catholic Church, is ancient and obscurely hierarchical. It occupies a tiny Vatican in Regents Park, whose benign soft-footed cardinals pad around discussing preferment of one kind or another. To be a Member of the College (achieved by examination) counts for nothing at all. Surgeons are brash, extrovert characters who pride themselves on energy rather than subtlety. Fellowship is decided by examination, and theoretically all Fellows are equal, just as theoretically all officers are gentlemen. The "general" label, means that the physician can successfully bat any acute medical emergency balls—at least hitting them towards an appropriate fielder. In practice, this requires the ability to cope with any and every acute medical emergency, at least in the initial stage, and the ability to deal with unstructured diagnostic problems not falling obviously into any particular subspecialty at an early stage. Most British hospitals are not large enough either to have a specialist in each subspecialty of medicine or to maintain an acute medical emergency rota for patients who need to be admitted to hospital at any hour of the day or night without the participation of most of the specialist physicians. Time and again, hospital specialist practice requires well informed clinical common sense rather than intensely specialised knowledge. Professor J R A Mitchell told the story of a patient who reappeared in his outpatient clinic, having being referred from specialist to specialist, saying, "there is no point in sending me to another specialist, doctor, it is not my special parts which have gone wrong but what holds them together".

PAIRS is designed to (1) realign attitudes and beliefs about love and re- lationships and about marriage and family life; (2) train and evolve each partner’s self-knowledge lithium 150 mg cheap, emotional literacy discount 300 mg lithium mastercard, and emotional efficacy; and (3) change ineffective behaviors that diminish intimacy by teaching those behaviors and skills that increase intimacy and relationship enhance- ment generic lithium 300mg without prescription. The PAIRS curriculum is a theory-based discount lithium 150mg otc, cohesive discount lithium 300mg mastercard, orchestrated body of concepts and practical activities that is a powerful technology for change. PAIRS has, thus far, proven effective in every population, Premarital Counseling from the PAIRS Perspective 9 including disadvantaged youth, middle and high schools, foreign cul- tures, entire families, business groups, faith-based adult education, sepa- rated and divorcing couples, premarital couples, and devitalized couples in marital doldrums. GOALS AND OBJECTIVES OF PREMARITAL COUNSELING FROM THE PAIRS PERSPECTIVE The PAIRS trained professional (PTP) translates the PAIRS concepts and tools found in the 120-hour experiential PAIRS Relationship Mastery Course into an effective counseling approach that is titled OFFICE PAIRS. A PTP is a licensed mental health professional who has been trained in the PAIRS professional training program. PTPs have had more than 100 hours of direct experience with the PAIRS concepts and training exercises. Dur- ing their training, PTPs personally experience the full range of PAIRS exer- cises, usually with their partners. After training, most PTPs teach, practice, and internalize the PAIRS concepts and tools. In OFFICE PAIRS, the PTP personally and directly helps the couple learn PAIRS competencies, prac- tice them under an experienced eye, and apply them outside the office and obtain feedback on their "homework. These competencies focus on three areas: (1) emotional literacy; (2) conjoint partner skills for building and maintaining intimacy; and (3) practical knowledge, strategies, and attitudes for sustaining positive marriage and family life. The PTP holds these competencies in heart and mind as a standard for what is needed to sustain couple satisfaction. When couples seek counsel- ing, the PTP notes which of these competencies are missing and develops priorities and strategies for offering knowledge and training in what is needed. Effectively addressing what is missing with interventions, new un- derstandings, and the teaching of new skills, especially for the premarital couple, can prevent years of confusion, misery, and probable later family disintegration. During the early romantic "illusion" stage of a relationship, moments of hurt, misunderstanding, noting differences, or use of power often trigger doubts and fears about the relationship. Those couples in early relationships coming for counseling are typically experiencing chal- lenges to illusions of perfect fit and unconditional love. This is the optimal time to develop the knowledge, skills, and strategies needed to build a solid relationship rather than an illusory one. Recognizes defensive overreactions as emotional allergies based on painful memo- ries. When feeling attacked, threatened, or denied, evaluates reality by checking out speaker’s meaning and in- tent, rather than assuming and reacting defensively via rationalizing-explaining- justifying, withdrawing, avoiding, or fighting back. Uses anger constructively to assert self, set limits, define boundaries, and effectively solve problems. Accepts having healthy needs and actively pursues getting them met, including the biological needs for physical closeness and emotional openness in an intimate relationship. Experiences and expresses emotions of a type and at an intensity that appropriately fits and that sustains action in accord with one’s purpose, intention, and circum- stances (emotional efficacy). Complain to one another regularly (without attacking) including requests for change. Use fair fighting that involves confiding, empathic listening, complaining with requests for change, and contracting, effective win-win solutions, all without manipulation and dirty fighting. Agree on areas of autonomy, areas of consultation, and areas of mutually shared own- ership and decision making. Clarify hidden assumptions and unspoken expectations to minimize misperception and misunderstanding. Help one another heal pains and disappointments, resolve emotional allergies, and clarify hidden assumptions. Meet basic needs for sensuality, appropriate sexuality, physical closeness, bonding, and intellectual and emotional sharing with one another. Follow clear, equal, negotiated boundaries regarding what is private and not shared with others outside the relationship. Initiate change when the status quo (division of roles, responsibilities, and privileges) is not satisfactory. Affirm the essential role of regular bonding with an abundance of physical closeness and emotional openness to sustain intimacy. Choose play, pleasure, recreation, creativity, and humor for the relationship to bal- ance the necessary duties and hard work required to maintain the relationship, home, family, and economic security.

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For example buy 300 mg lithium free shipping, a research project dealing with hardening of the arteries usually includes consideration of diet (cholesterol) purchase lithium 150 mg overnight delivery, weight discount 300mg lithium with mastercard, exercise lithium 300 mg visa, genetic factors—but if it does not include emotional factors purchase lithium 300mg free shipping, the results, in my view, are not valid. Before discussing other kinds of medical problems in which emotions may play a prominent role, it is important to make it clear that people do not do these things to themselves. It is not uncommon for patients to say to me after the diagnosis of TMS has been made, “I feel terrible; I did it to myself. Further, if one begins to understand why one reacts the way one does and wants to change, some degree of progress is possible. Another reaction of a similar nature is that of physicians who resist acknowledging the role of emotions—in cancer, for example. They say it is cruel to suggest to patients that emotions may have contributed to the onset of the cancer; it makes them feel guilty and responsible. My answer to this is that it makes a world of difference how you introduce the subject to patients. You don’t bludgeon them with the information and make it sound as though they are emotionally defective. You explain that they are not responsible as described above, and talk to them about their lives, try to identify emotional factors that might have contributed to the cancer process, and then follow it up with concrete suggestions as 148 Healing Back Pain to how they can remedy and reverse the negative factors. I do not mean to suggest that there is a well worked out therapeutic process in existence based on such ideas. THE CURRENT STATE OF THE ART OF MIND-BODY MEDICINE Readers who are interested in an excellent review of where medicine is today vis-à-vis the mind-body connection should read The Healer Within by Steven Locke, M. Locke is in the Department of Psychiatry at Harvard Medical School and has done an excellent job with his writer-collaborator describing the history and contemporary efforts to understand how the mind influences the body. However, I have the impression that the authors focus too heavily on the immune system and imply that the future of this field depends upon what they call the “science of psychoneuroimmunology. TMS is an example of a mind-body disorder mediated through the autonomic nervous system; the immune system is not involved. I suspect the immune system does not participate in the interaction of emotions and the cardiovascular system. Once more, one is intrigued by the fact that the brain crosses boundaries in responding to its psychological needs. Thus patients with the same Mind and Body 149 psychological diagnosis (though differing in severity) may develop TMS, autonomically mediated; allergic rhinitis, immune system mediated; or psychogenic regional pain, direct action on the sensorimotor system. Extremely important work is being done in the brain biochemistry section of the National Institutes of Mental Health on the subject of brain-body interaction. One of the pioneers in this research is Candace Pert, once chief of that section, whose work is demonstrating communication between the brain and different parts and systems of the body. For those interested, an excellent review of this work appeared in the June 1989 issue of Smithsonian, written by Stephen S. The mind and body interact in numerous ways; the following part of the chapter reviews some of those more common interactions. MIND AND THE CARDIOVASCULAR SYSTEM The subjects of interest to us in the category mind and the cardiovascular system are hypertension, coronary artery disease, arteriosclerosis (hardening of the arteries), cardiac palpitations and mitral valve prolapse. High blood pressure (hypertension), as everyone knows, is very common and a little scary because of its connection with heart trouble and stroke. Its association with emotions has been assumed by many, though never demonstrated in the laboratory. Neal Miller, a psychologist working at Rockefeller University, demonstrated that laboratory animals could be conditioned to lower their blood pressure, and modify, many other bodily processes too, clearly showing that the brain could be recruited to influence the body. Herbert Benson, a Harvard cardiologist, has described what 150 Healing Back Pain he calls the relaxation response and demonstrated that the blood pressure can be reduced by the application of this meditationlike process. A very important study appeared in the Journal of the American Medical Association in the April 11, 1990, issue (Vol. Schnall and a team from the Cardiovascular and Hypertension Center, New York Hospital– Cornell Medical College, in collaboration with doctors from two other New York area medical schools, published a paper which established a clear relationship between psychological pressure at work (“job strain”) and high blood pressure. The study also established the fact that there was an increase in the size of the heart in these people, which is one of the undesirable effects of sustained hypertension. Experts have long suspected that psychological factors were implicated in high blood pressure.

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Local anesthesia is achieved in the skin overlying the triangular ac- cess window and is carried down to the peridiscal soft tissues with a 22- or 25-gauge spinal needle discount 300 mg lithium amex. The spinal needle is advanced slowly generic lithium 150 mg fast delivery, and if any radicular symptoms are provoked on needle advancement lithium 150 mg visa, the po- sition of the traversing nerve is noted and the spinal needle is withdrawn and reoriented to approach the disc medial to and below the position of the nerve root as close as possible to the superior articular process purchase lithium 150mg with visa. After local anesthesia proven lithium 300mg, a skin dermatotomy is made with a scalpel blade and the 17-gauge introducer needle is then advanced along the 126 Chapter 7 Intradiscal Electrothermal Annuloplasty FIGURE 7. AP radiograph angled in craniocaudal fashion, parallel to the L4-5 intervertebral disc; the superior endplate of L5 and the inferior end- plate of L4 are seen en face. The nee- dle is advanced slowly to avoid encountering the traversing root, and if radicular symptoms are elicited, the needle is withdrawn and reori- ented to avoid the root. A tactile resistance and gritty crunching is en- countered when the needle first enters the annulus, and the fluoro- scope is then repositioned in a posteroanterior (PA) projection. Care should be taken not to advance the needle beyond the disc margins, and if there is any confusion about the position of the needle tip dur- ing advancement, the position should be checked fluoroscopically in two orthogonal planes. The patient may report transient localized back pain as the needle penetrates the annulus. Radicular symptoms are not expected and may indicate needle position too close to the descending root. The needle position is checked in the PA projection confirming the tip position just inside the annulus. Under lateral fluoroscopy, the introducer needle is then advanced minimally to achieve positioning of the tip in the nucleus pulposus just in the anterior half of the disc. Optimal positioning is with the tip between a 12 and a 3 o’clock posi- tion (Figures 7. The needle is rotated to ensure that the opening in the needle tip points medially to facilitate catheter naviga- tion. The stylet is removed from the introducer needle, and the catheter Historical Perspective 127 FIGURE 7. Lateral diagram showing angulation (arrows) necessary for parallel approach to the lumbar discs. Cau- docranial angulation is required for accessing the upper lumbar discs, and craniocaudal angulation is necessary for accessing the lower discs. Oblique lateral radiograph demonstrating projection for safe disc ac- cess at discography or annuloplasty. An- gulation is chosen parallel to the disc to be accessed, and obliquity is chosen to opti- mize access to the central disc and avoid the traversing nerve root. Optimum access is typically obtained when the superior ar- ticular process of the level below the disc has traversed between one third and one half of the disc under fluoroscopy. In the oblique projection, the access window to the disc is defined by a roughly triangular window delineated by the supe- rior articular process medially, the superior endplate below, and the traversing nerve root laterally and above. Staying close to the superior articular process keeps the needle as far as possible from the travers- ing nerve root. The catheter must be aligned such that the curve in the catheter tip points medially to allow the curve in the catheter tip to deflect off the inner margin of the disc annulus. Oblique lateral radio- graph demonstrating disc access with the introducer cannula. The needle enters the annulus in the access win- dow parallel to the angulation of the disc. Axial diagram depicting optimum posi- tioning of the introducer needle in the disc. For IDET, optimum catheter positioning is just in the anterior half of the nucleus between 12 and 3 on the clock face. This approach facilitates guiding the catheter along the inner aspect of the anterior annulus. If significant resistance is met, posi- tioning should be checked fluoroscopically to ensure that the catheter is not damaged, and the catheter should be removed and reoriented. The curve in the catheter is utilized to steer the catheter around the in- ner margin of the annulus. Lateral fluoroscopic monitoring allows the operator to visualize the catheter curving off the anterior and poste- FIGURE 7. The cannula is oriented parallel to the disc and positioned between 12 and 3 o’clock in the anterior half of the nucleus. The catheter should be visualized gently curving off the anterior and posterior mar- gins of the disc without extending significantly beyond the margins of the vertebral bodies above or below (Figure 7.

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