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Hyperlactatemia and lactc acidosis during antretroviral therapy: causes gastritis pylori symptoms buy generic prevacid line, management and possible etologies gastritis diet for children buy 15 mg prevacid mastercard. Severe liver mitochondriopathy with normal liver histology and normal lactate levels in patents receiving nucleoside analogs gastritis diet leaflet purchase 15mg prevacid with mastercard. A syndrome of peripheral fat wastng (lipodystrophy) in patents receiving long-term nucleoside analogue therapy gastritis diet äîì buy prevacid 30 mg on-line. Hepatts C virus core protein shows a cytoplasmic localizaton and associates to cellular lipid storage droplets. Hepatocellular mitochondrial alteratons in patents with chronic hepatts C: ultrastructural and biochemical fndings. Is there a relatonship between hepatts C virus infecton and antretroviral-associated lipoatrophy Mechanisms and strategies for insulin resistance in acquired immune defciency syndrome. The impact of steatosis on disease progression and early and sustained treatment response in chronic hepatts C patents. Gaslightwala I, Bini E, Impact of human immunodefciency virus infecton on the prevalence and severity of steatosis in patents with chronic hepatts C virus infecton. A cohort study of nevirapine tolerance in clinical practce: French Aquitaine Cohort, 1997-1999. Associaton between chronic liver disease and death from hepatts A, United States, 1989–92 [Abstract A39]. Serious hepatts A: an analysis of patents hospitalized during an urban epidemic in the United States. Is hepatts A more severe in patents with chronic hepatts B and other chronic liver diseases Fulminant hepatts associated with hepatts A virus superinfecton in patents with chronic hepatts C. The efects of each virus on the natural disease progression of the other infecton are also important issues in treatment decisions. Keep in mind, this is a rapidly changing feld of study, and all treatment decisions must take into account your unique circumstances and disease status. Identifcation of Coinfection the frst issue of coinfecton management is accurate diagnosis. The stakes involved in treatment decisions are very high and the issues are complex. Therefore, we urge all coinfected persons to consult with healthcare providers who have experience managing coinfecton. A liver that has been partially or completely restored to normal function is better able to process antiviral drugs when 286 Copyright © 2008, Caring Ambassadors Program, Inc. The decision about which opton is most appropriate for your specifc circumstances is one that can be made only afer a thorough medical evaluaton by a healthcare provider experienced in the treatment of coinfecton. Overall sustained response rates in coinfected persons have been reported to be anywhere from 20% to 44%. There are some data that support the noton that the duraton of therapy can be reduced to 24 weeks without signifcant risk of relapse if the following conditons are met. Those who take this approach believe the risk of serious side efects associated with treatment in the coinfected populaton justfes the requirement for liver biopsy. The high rate of discontnuaton of therapy 47-50 in coinfected people may be related to this phenomenon. It is important to report any symptoms of depression to your healthcare provider to prevent this side efect from interfering with completon of therapy. Interferon adds to this problem by decreasing the producton of both red and white blood cells. Caring Ambassadors Hepatitis C Choices: 4th Edition Lactc acidosis is a potentally life-threatening conditon that may develop with severe mitochondrial toxicity. Lactc acid is a normal byproduct of the energy producton process that occurs inside the mitochondria. When the mitochondria are damaged, lactc acid can build up and upset the delicate chemical balances necessary for normal body functons. Symptoms of lactc acidosis include: y muscular weakness – most noticeable in the arms and legs; the weakness is often severe y nausea and/or vomiting y abdominal pain y breathing difficulty or shortness of breath y numbness or tingling in the extremities A blood test is used to confrm the diagnosis of lactc acidosis. There have been reports of fatal reactons when didanosine and ribavirin were taken together. In end-stage disease, the liver is no longer capable of performing its many vital body functons. A small study of 32 patents found an 18% response rate to pegylated inter feron plus ribavirin in liver transplant patents who had been previous non-responders to standard interferon plus riba virin. Other strategies to prevent reinfecton of transplanted livers are being researched in clinical trials. Complex and dynamic viral interactons occur and making the management of these patents difcult. A combinaton of non-invasive methods to assess liver fbrosis accurately predicts hepatc fbrosis in most cases. Moreover, treatment adherence should be considered a critcal factor for the atainment of response and must be encouraged actvely over the whole treatment period. Moreover, the use of an early tme point for treatment decision-making seems to be equally appropriate in coinfected patents. Patents should be informed in advance about these side efects and how to prevent and manage them. The treatment of depression should be considered as soon as symptoms begin to develop. Accordingly, orthotopic liver transplantaton in this populaton should be limited to transplant centers experienced in the management of such patents, where a multdisciplinary team including surgeons, hepatologists, pharmacologists and infectous diseases physicians can work in concert. Moreover, they should have abstained from the consumpton of alcohol and illegal drugs for at least 6 months. The management of hepatotoxicity should be based on the knowledge of the mechanisms involved for each drug. The increased risks associated with coinfecton raise the stakes involved in treatment decisions. As these studies are completed, we hope to use the informaton to develop safer, more efectve therapies. The ultmate goal is to reduce the disease burdens currently borne by coinfected persons. Human immunodefciency virus infecton modifes the natural history of chronic parenterally acquired hepatts C with an unusually rapid progression to cirrhosis. Infuence of human immunodefciency virus infecton on the course of hepatts C virus infecton: a meta analysis. Hepatts C virus infecton related morbidity and mortality among patents with human immunodefciency virus infecton. Martn-Carbonero L, Soriano V, Valencia E, Garca-Samaniego, J, Lopez M, Gonzalez-Lahoz J. Hepatts C in patents with human immunodefciency virus infecton: diagnosis, natural history, meta-analysis of sexual and vertcal transmission, and therapeutc issues. The associaton between hepatts C virus genotype and human immunodefciency virus disease progression in a cohort of hemophilic men. Benhamou Y, Di Martno V, Bochet M, Colombet G, Thibault V, Liou A, Katlama C, Poynard T; MultvirC Group. Severe hepatc cytolysis: incidence and risk factors in patents treated by antretroviral combinatons. Risk factors for hepatotoxicity in patents treated with highly actve antretroviral therapy. Incidence and risk factors for severe hepatotoxicity associated with antretroviral combinaton therapy. Hepatotoxicity associated with nevirapine or efavirenz-containing antretroviral therapy: role of hepatts C and B infectons. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for inital treatment of chronic hepatts C: a randomized trial. Torriani F, Rodriguez-Torres M, Rockstroh J, Lissen E,Gonzalez Garcia J, Lazzarin A, et al. Pegylated interferon alfa-2b vs standard interferon alfa-2b, plus 295 Copyright © 2008, Caring Ambassadors Program, Inc. Extended treatment duraton for hepatts C virus type 1: comparing 48 versus 72 weeks of peginterferonalfa 2a plus ribavirin.
Strategies for Public Health: A Compendium of Ideas gastritis oatmeal order prevacid mastercard, Experience gastritis diet kolesterol purchase 30mg prevacid otc, and Research from Minnesota’s Public Health Professionals gastritis diet mayo purchase prevacid with a visa. An Inconvenient Truth: A Sustainable Health Care System Requires Chronic Disease Prevention and Management Transformation gastritis symptoms list cheap prevacid 15mg line. Healthy Futures: Securing New Brunswick’s Health Care System – the Provincial Health Plan 2004 2008. Perceived Versus Actual Physical Accessibility of Substance Abuse Treatment Facilities. Design for Independence and Dignity for Everyone: Vision, Hearing, Communication, Mobility, Cognition – barrier Free Design Guide. Paying More, Getting Less: Measuring the Sustainability of Government Health Spending in Canada. Perceived Unmet Need for Mental Health Care for Canadians with Co-occurring Mental and Substance Use Disorders. Waiting for Care: A Study of Physical and Psychological Symptoms and Health Care Utilization for Pain whilst Waiting for Gynaecological Surgery. Across-Province Standardization and Comparative Analysis of Time-to-Care Intervals for Cancer. Alberta’s Rural Physician Action Plan: An Integrated Approach to Education, Recruitment and Retention. No part of this publication may be reproduced in any form or by any means – graphic, electronic or mechanical, including photocopying, recording, taping or information storage and retrieval systems – without the prior permission in writing of the publishers. That new century was to see health care in the United Kingdom evolve from a largely personal, paternalistic consultation between doctor and patient, based more on medical tradition than medical science, to a complex, science-based, team-oriented and managed service. Even so, the core of medical practice has survived: the face-to-face consultation between doctor and patient. But the nature of this core activity has been irreversibly altered by a shift in the ‘balance of power’ between the participants as patients became better informed about their health, illnesses and possible treatments. A signicant catalyst in the emergence of the informed patient has been the media, including publications like this dictionary, the contents of which have during its 41 editions reected these changes in medicine. One modest constant in this sea of change, however, has been the objective of Black’s Medical Dictionary. Comrie, declared his aim as being to produce ‘a work which would occupy a position somewhere between that of a Technical Dictionary of Medicine and one intended merely for the domestic treatment of common ailments. These include anaesthesia, breast screening and mammography, chronic fatigue syndrome, clinical guidelines, clin ical trials, evidence-based medicine, Gulf War syndrome, hormone replacement therapy and post-traumatic stress disorder. Ironically the greatest changes in British medicine seem to be taking place in how doctors are required to work, rather than what they actually do. Many of the bodies which constitute the National Health Service have been replaced or merged, new ones have come into existence viii Preface and functions changed. Black’s Medical Dictionary is neither a textbook of medicine nor a formulary of therapeutic drugs. The many drugs that are included are given their generic title as used in the British Pharmacopoeia. Patients are individuals who react in varying ways to injuries, diseases and their treatments. Appendix 1 explains some basic rst-aid procedures, but patients’ own doc tors are normally the appropriate source for personal medical advice. The dictionary should, however, help readers to decide when it would be wise to seek medical advice and subsequently help them to set such advice in context. Although every eort has been made to ensure accuracy, neither the publishers nor the author can be held responsible for any consequences if readers use the book for the treatment of them selves or others. Acknowledgements I am grateful to colleagues who have updated or rewritten entries. They include: Dr Phil Alderson, Professor Michael Baum, Dr Karin Fuchs, Dr Pamela Laurie, Dr Richard Lehman, Mr John McGarry, Dr Klim McPherson, Mr Michael Paynton, Dr Rob Miller and Professor Simon Wessely. Harvey Marcovitch Note: the use of small capitals – for instance – stomach, refers the reader to the entry of that name for additional information. The shape of the abdomen varies; in children it may protrude A considerably, though if this is too marked it may indicate disease. Above, and separ older people fat is usually deposited on and ated from it by the diaphragm, lies the thorax or inside the abdomen. At the Contents the principal contents of the sides the contained organs are protected by the abdominal cavity are the digestive organs, i. These soft tissues allow the necessary distension Contents of the abdomen in position. The liver lies above and to the right, largely under cover of the ribs, and occupying the hollow of the diaphragm. The pancreas lies across the spine between the kidneys, and on the Regions of the abdomen. Various processes that can occur include inammation, ulceration, infection or tumour. Abdominal disease may be of rapid onset, described as acute, or more long-term when it is termed chronic. An ‘acute abdomen’ is most commonly caused by peritonitis – inammation of the membrane that lines the abdomen. General symptoms of abdominal disease include: Pain this is usually ill-dened but can be very unpleasant, and is termed visceral pain. Pain that is felt around the umbilicus tioned high up on the left and partly behind the arises from the small intestine, appendix and stomach. The great blood vessels and nerves lie rst part of the large bowel, and low mid-line on the back wall, and the remainder of the pain comes from the rest of the large bowel. In intestinal obstruction, the onset of symptoms is usually rapid with complete con Abortifacient stipation and severe, colicky pain. There are also important non cases nowadays in which fetuses as young as 22 abdominal causes, such as in response to severe weeks’ gestation have survived. Spontaneous abortions occurring in early Jaundice is a yellow discoloration of the skin pregnancy are almost always associated with and eyes, and may be due to disease in the liver chromosomal abnormalities of the fetus. Recurrent spontaneous abortion the abdomen, their inconstant position and the (that is, three or more) seems to be a particular vagueness of some of the symptoms. Correct problem in women who have an abnormal diagnosis usually requires experience, often response of their immune system to pregnancy. For this reason suerers a lot of babies previously, cigarette smoking should obtain medical advice at an early stage, and spontaneous (but not therapeutic) abortions particularly if the symptoms are severe, persist in the past. It is particularly abortion, where the neck of the uterus has liable to be paralysed in diseases of the nervous started to open up; incomplete abortion, where system, thus leading to an inward squint. There is no evidence that bed rest is eect To abduct means to move a part of the body – ive in stopping a threatened abortion becoming for example, a limb – away from the mid line. Proper consent must be obtained, signed for A few late abortions are associated with the and witnessed. Women under 16 years of age cervix opening too early, abnormal structural can consent to termination provided that the abnormalities of the uterus, and possibly infec doctors obtaining the consent are sure she tion in the mother. Parental consent in the under-16s is tractions, but evidence-based studies show that not legally required, but counselling doctors these do not generally improve fetal salvage. In have a duty to record that they have advised proven cases of cervical incompetence, the cer young people to inform their parents. The evidence partner has no legal say in the decision to ter for the value of this procedure is uncertain. A similar greater than if the pregnancy were terminated – regime can be used between nine and 12 weeks of injury to the physical and/or mental health but at this gestation there is a 5 per cent risk of of the mother or any existing child(ren). Legislation in 1990 modied the Act, which An ultrasound scan is rst done to conrm had previously stated that, at the time of the pregnancy and gestation. The sac containing abortion, the pregnancy should not have the developing placenta and fetus must be in exceeded the 24th week. Now, an abortion the uterus; the woman must be under 35 years may legally be performed if continuing the of age if she is a moderate smoker, but can be pregnancy would risk the woman’s life, or the over 35 if she is a non-smoker. Some very that therapeutic abortion is associated with any experienced gynaecologists will perform abor reduction in future fertility, increased rates tions surgically by dilating the cervix and of spontaneous abortion or preterm birth in evacuating the uterine contents up to 22 weeks’ subsequent pregnancies. The greater the size of the pregnancy, the higher the risk of haemorrhage and perfor Methods of abortion All abortions must ation of the uterus.
The symptoms that develop due to gastritis diet 02 cheap prevacid 15 mg amex a vitamin C deficient state are mostly related to gastritis and colitis cheap 30 mg prevacid mastercard defective collagen synthesis—bone and connective tissue disorders gastritis diet 101 buy prevacid now, tooth loss gastritis pictures prevacid 30mg cheap, and blood vessel fragility. Carnitine plays a critical role in energy metabolism, specifically the transport of fatty acids across the mitochondrial membrane (Johnston, Corte, & Swan, 2006). This is essential for tissues whose primary source of energy is fatty acids such as skeletal and cardiac tissue. Ascorbic acid is a cofactor for two enzymes used in the production of carnitine, timethyllysine dioxygenase and 4 gamma-butyrobetaine dioxygenase (Rebouche, 1991). Specifically, ascorbic acid reduces iron to its ferrous (Fe2+) state, which is necessary for this enzymatic pathway to function. Fatigue and weakness are early signs of scurvy and can be linked directly to defective carnitine production (Hughes, Hurley & Jones, 1980). Another study found that free-living participants with marginal vitamin C status oxidized 25% less fat per 16 kg body weight during an hour long treadmill test compared to those with adequate vitamin C status (Johnston, Corte & Swan, 2006). Synthesis of specific neurotransmitters and hormones require vitamin C to reduce copper to its cuprous (Cu) state in order for enzyme activity to take place. The results of deficient neurotransmitter conversions can explain some of the symptoms of scurvy—depression and mood swings. Vitamin C is also involved in the activation of hormones and hormone-releasing factors that involve -amidations in the posttranslational steps (Murth, Keutmann & Eipper, 1987). Without vitamin C, essential hormones such as vasopressin, oxytocin, cholecystokinin, and gastrin could not be synthesized (Oldham et al. The important role of vitamin C in steroid hormone synthesis is shown through its high concentration in the adrenal glands (Patak, Willenberg & Bornstein, 2004). During times of high stress, the adrenal glands release stress-response hormones, most notably being cortisol. These ‘fight or flight’ hormones trigger the body to prepare for action, and can affect the body negatively, including immune function (Ebrecht, Hextall, Kirtley et al. Vitamin C may act as an antioxidant and work to reduce the release of stress hormones from the adrenal gland (Peters, 1997). Studies have shown that supplementation with antioxidant mixtures for up to two months can significantly reduce cortisol responses to prolonged exercise (Fischer 17 et al, 2004; Vassilakopoulos et al, 2003). More research is warranted on vitamin C’s ability to decrease cortisol release during times of stress. Supplementation of vitamin C provides a protective influence on many disease states including vascular disease, cancer, and the main purpose of this review, the common cold (Li & Schellhorn, 2007; Jacob &Sotoudeh, 2002). Much research has investigated the therapeutic effects of vitamin C and the mechanisms by which the nutrient provides beneficial effects for chronic disease states. Many epidemiological studies have found an inverse relationship between vitamin C intake and incidence of cardiovascular disease. One study concluded that treatment with vitamin C (500 mg/d for 4 weeks) can improve endothelium-dependent vasodilatation in patients with coronary artery disease, angina pectoris, hypercholesterolemia, hypertension, or diabetes (Gokce, Keaney, Frei, et al. In another study where healthy people were fed a vitamin C deficient diet for 30 days followed by a vitamin C adequate diet for another 30 days, plasma ascorbate levels were inversely related to diastolic blood pressure (Block, 2002). Other clinical trials have conflicting results indicating that more research is needed in regards to the role of supplemental vitamin C in reducing cardiovascular disease risk. Numerous epidemiological studies provide evidence that diets high in fruits and vegetables are related to decreased risk of some cancers (Carr & Frei, 1999). Many studies suggest that the link between high fruit and vegetable diets and decreased cancer risk is due to high vitamin C content of these food items (Szeto, Tomlinson & Benzie, 2002; Rossing, Vaughan, McKnight, 1989). Vitamin C’s protective influence is stronger with cancers of the oral cavity, pharynx, esophagus, and stomach. Additionally, meta-analyses have shown an inverse relationship between high vitamin C intakes and decreased risk (20%) for breast cancer (Gandini, Merzenich, Robertson et al, 2000). A longitudinal study observed 870 men for 25 years and found that those who consumed >83 mg/d of 19 vitamin C had a marked 64% decrease in lung cancer incidence compared to those that consumed <63 mg/d (Sandras et al. Observational studies have linked increased dietary vitamin C to decreased risk of stomach cancer (Mirvish, 1994). Theoretically, vitamin C present in gastric juice inhibits the formation of N-nitroso carcinogens in the stomach. Helicobacter pylori is a bacterial infection that has been linked to an increased risk for stomach cancer and also lowers the vitamin C content in gastric secretions (Jarosz, Dzieniszewski, Dabrowska-Ufniarz et al, 1998). Vitamin C supplementation in addition to other therapies has been a suggested treatment option for patients suffering with this condition. The possible mechanisms for a decreased risk of cancer with vitamin C is thought to involve its role as an antioxidant and its ability to detoxify carcinogens or block carcinogenic processes (Block, 1992; Block, Patterson, Subar, 1992; Carpenter, 1991). Although there is evidence supporting vitamin C’s ability to reduce the risk for esophageal cancer, lung cancer, and breast cancer, the trials have not been able to distinguish between the influence of vitamin C and other components of vitamin C-rich fruits and vegetables. Furthermore, some studies suggest that vitamin C may hinder anticancer therapies via its antioxidant properties, which may promote tumor cell integrity (Perrone et al. Because results for studies regarding cancer risk and vitamin C supplementation are so conflicting, more research is needed in order to offer safe, effective advice to cancer patients. His hypothesis rested on the discovery that leukocytes had high concentrations of vitamin C, which rapidly declined during times of stress and infection (Higdon & Frei, 2002). Pauling advocated that the optimal daily intake of vitamin C for an adult consuming 2500 kcal/d should be 2300 mg/d. Numerous epidemiologic, clinical, and biochemical studies conducted since Pauling’s published work have deciphered a much more moderate vitamin C level between 100 and 200 mg/d to be associated with tissue saturation and reduced risk for chronic diseases in healthy adults (Carr & Frei, 1999; Levine, Rumsey, Daruwala et al, 1999). Even though Pauling’s views on vitamin C supplementation have been criticized, he is still seen as a pioneer in the health field that stimulated interest in the role of micronutrients to promote optimal health and prevent chronic diseases. The interest in vitamin C’s role with the immune function and its ability to treat the symptoms of the common cold has stirred continued research in order to determine the mechanisms behind the proposed immunocompetence and the specific populations that would benefit. Current research provides evidence that Vitamin C aids the immune system through its antioxidant properties, direct antimicrobial function, and/or effect on immune system modulators such as histamine (Jacob & Sotoudeh, 2002). Several trials have been conducted, however, there is still one question that cannot be fully answered: Is supplementations of vitamin C an effective measure in treating the common cold The respiratory system includes the nose and nasal cavity, mouth, pharynx (throat), larynx (voice box), trachea, bronchi, and lungs (Marieb, 2004). The first is pulmonary ventilation, which is the movement of air in and out of the lungs. This is the incorporation of oxygen into the blood and the removal of carbon dioxide from the blood. Transport of respiratory gases, the third step of respiration, is the transfer of oxygen from the blood to the tissue cells of the lungs. The final step, internal or cellular respiration, involves the exchange of oxygen in the blood to tissue cells throughout the body (Marieb, 2004). In addition to supplying oxygen to the body, the respiratory system also works to protect the body from harmful toxins that can be inhaled. The respiratory tract is lined with a mucus membrane and hair-like structures called cilia, which trap and remove particles such as pollution, smoke, or pathogens (Dugdale, 2008). This 22 tremendous heath-related loss in productivity contributes to the significant economic burden caused by the common cold. Colds cost Americans and their healthcare providers approximately $40 billion each year—$17 billion from direct medical costs and $22. The economic burden of the common cold is greater than conditions such as congestive heart failure, high blood pressure, asthma, and migraines (Fenrick et al, 2003). It can be transmitted through various mechanisms including aerosol, droplet, or direct hand-to-hand contact with infected secretions followed by contact with the nasal mucosa or conjunctivae (Musher, 2003). A quantitative study that examined the transfer of respiratory viruses to and from fingers of adult subjects found that 37. Furthermore, a systemic review conducted on the persistence of pathogens found that rhinovirus could be detected on dry inanimate surfaces up to 7 days after contamination (Kramer, Schwebke & Kampf, 2006). Thus, transmission occurs more commonly in crowded areas, one great example being a college dorm. The “common cold” refers to acute rhinosinusitis, which is caused by viral infection of the upper respiratory tract mucosa (Rabkin). Symptoms include nasal congestion and/or discharge, sneezing, sore or dry throat, and headache.
So long as they were following him they could have been considered as something belonging to gastritis jelovnik buy cheap prevacid 30mg on line him gastritis toddler discount prevacid 15 mg overnight delivery, something which high protein diet gastritis purchase prevacid 30 mg line, in passing judgment on his person gastritis diet mango buy genuine prevacid online, had somehow to be taken into consideration. And it occurs to Blumfeld that the best way of rendering the balls harmless would be to put them to their original use. There in the hall stands the boy; Blumfeld will give him the balls, not lend them, but actually present them to him, which is surely tantamount to ordering their destruction. So Blumfeld has to call the boy and pronounce his name, a name that to him seems as ludicrous as everything else connected with the child. Without taking their eyes off Blumfeld they beckon to the boy, but cannot fathom what kind of present is awaiting Alfred. The latter seems to have figured it all out and climbs stiffly, clumsily up the steps. Not even in his gait can he manage to belie his mother, who, incidentally, has appeared in the basement doorway. To make sure that the charwoman also understands and in the hope that she will supervise the carrying out of his instructions, should it be necessary, Blumfeld shouts excessively loud. The girls, however, promptly begin to jump around Blumfeld and ask him for the balls. He could of course give the balls to the girls, but they strike him as too unreliable and for the moment he has more confidence in the boy. Blumfeld has tried to make everything particularly clear to this hopelessly dense creature, but for this very reason has repeated everything too often, has in turn too often mentioned keys, room, and wardrobe, and as a result the boy stares at him as though he were rather a seducer than his benefactor. The girls, on the other hand, have understood everything immediately, press against Blumfeld, and stretch out their hands for the key. If only the mother would say that she has Page 219 understood him and take matters in hand for the boy! Instead of which she still stands down by the door, smiles with the affectation of the bashful deaf, and is probably under the impression that Blumfeld up there has suddenly fallen for the boy and is hearing him his lessons. It had required enough of his self-control as it was to entrust the key of his wardrobe for a whole day to this family. It is certainly not in order to save himself trouble that he is handing the key to the boy rather than himself leading the boy up and there giving him the balls. It could tempt one into saying more than one intends, if only to fill the vacancy with sense. They are shrewd and have realized that they can obtain the balls only through using the boy as an intermediary, but that they themselves have to bring about this mediation. He would in fact far prefer to be several streets away when the Page 220 girls first open the door of his room. While on his way to the linen factory, where Blumfeld is employed, thoughts about his work gradually get the upper hand. He quickens his step and, despite the delay caused by the boy, he is the first to arrive in his office. This office is a glass enclosed room containing a writing desk for Blumfeld and two standing desks for the two assistants subordinate to him. For them of course this is very uncomfortable, but it also makes it very difficult for Blumfeld to keep an eye on them. They often press eagerly against their desks not so much in order to work as to whisper to one another or even to take forty winks. This work involves supervising the whole distribution of fabrics and cash among the women homeworkers who are employed by the factory for the manufacture of certain fancy commodities. To appreciate the magnitude of this task an intimate knowledge of the general conditions is necessary. When Blumfeld, who up to then had been managing the entire department with the help of only one servant, demanded an assistant, weeks of bitter fighting ensued. When Blumfeld had entered the firm, a time Herr Ottomar probably could not remember, they had employed some ten seamstresses, today the number varied between fifty and sixty. Such a job requires great energy; Blumfeld could guarantee that he was completely wearing himself out in this work, but that he will continue to master it completely he can henceforth no longer guarantee. Not actually to Blumfeld, Blumfeld is no romantic, pleasant as honor and recognition may be, Blumfeld can do without them, in spite of everything he will stick to his desk as long as it is at all possible, in any case he is in the right, and right, even though on occasion it may take a long time, must prevail in the end. One might have thought Ottomar had realized he could express his contempt for the department even better by granting rather than by refusing it these assistants. It was even possible that Ottomar had kept Blumfeld waiting so long because he was looking for two assistants just like these, and as may be imagined took a long time to find them. Needless to say, Blumfeld complained just the same, but only because his predicament all but forced him to do so, not because he still hoped for any redress. Nor did he complain emphatically, but only by the way, whenever the occasion arose. Nevertheless, among his spiteful colleagues the rumor soon spread that someone had asked Ottomar if it were really possible that Blumfeld, who after all had been given such unusual aid, was still complaining. To which Ottomar answered that this was correct, Blumfeld was still complaining, and rightly so. He, Ottomar, had at last realized this and he intended gradually to assign to Blumfeld one assistant for Page 223 each seamstress, in other words some sixty in all. The whole thing was a fabrication of the loafers in the offices on the first floor. Blumfeld ignored it if only he could as calmly have ignored the presence of the assistants! According to their credentials they had already passed school age, but in reality this was difficult to believe. When left to themselves they promptly doubled up in their weakness, standing hunched and crooked in their corner. Blumfeld tried to point out to them that if they went on giving in to their indolence they would become cripples for life. To ask the assistants to make the slightest move was to take a risk; once when one of them had been ordered to carry something a short distance, he had run so eagerly that he had banged his knee against a desk. The room had been full of seamstresses, the desks covered in merchandise, but Blumfeld had been obliged to neglect everything and take the sobbing assistant into the office and there bandage his wound. Once, at a time of the most intensive work, Blumfeld had rushed past them, dripping with sweat, and had observed them secretly swapping stamps among the bales of merchandise. He had felt like banging them on the head with his fists, it would have been the only possible punishment for such behavior, but they were after all only children and Blumfeld could not very well knock children down. Originally he had imagined that the assistants would help him with the essential chores which at the moment of the distribution of goods required so Page 224 much effort and vigilance. He had imagined himself standing in the center behind his desk, keeping an eye on everything, and making the entries in the books while the assistants ran to and fro, distributing everything according to his orders. Blumfeld soon realized that all these hopes had been in vain and that he could not afford to let them even talk to the seamstresses. From the beginning they had ignored some of the seamstresses, either from fear or dislike; others to whom they felt partial they would sometimes run to meet at the door. Blumfeld of course soon put an end to this mischief and the moment the seamstresses arrived he ordered the assistants back into their glass-enclosed cubicles. Blumfeld, their superior, who from his earliest youth has considered it natural to arrive half an hour before the office opens not from ambition or an exaggerated sense of duty but simply from a certain feeling of decency often has to wait more than an hour for his assistants. Soon he is immersed in his work and thinking of nothing Page 225 else when suddenly he receives such a shock that his pen continues to tremble in his hand for some while afterwards. One of the assistants has dashed in, looking as though he is about to collapse; he is holding on to something with one hand while the other is pressed against his heaving chest. As it is, he just glances at him for a moment, points with outstretched hand at the cubicle, and turns back to his work. Arm in arm, they appear to be telling one another important things which, however, are sure to have only the remotest and very likely irreverent connections with the office. One of them seizes the door handle but fails to turn it; they just go on talking, listening, laughing. But when the assistants come in, Blumfeld no longer feels like quarreling, ignores their greetings, and goes to his desk.
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