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In the course of researching the attitudes of nineteenth-century rabbis about American slavery, David Cobin found that the name Sabato Morais featured prominently among rabbis who had publicly expressed strong anti-slavery sentiments. This information sent Cobin to the American Jewish History Library where some of Morais's papers are archived to find original documents on the matter. There he found sermons from 1861 to 1862 with English script title pages and text all written in Pitman Shorthand, presumably by Morais himself. One of these, an undated document entitled The Slavery of the Bible, described as a lecture, seemed to be exactly on point. Cobin's first hurdle, however, was transcribing Morais's lecture. After a significant search he found Dorothy Roberts, who had become an expert on Civil War Pitman Shorthand specifically in order to engage in this kind of scholarly transcription. It was soon clear, however, that transcribing a more than one hundred and forty year-old shorthand written for oneself was not a simple matter. There were obsolete words, partial words, undecipherable words, words left out, references to obscure incidents, incomplete quotations, and words in multiple languages. Cobin enlisted the collaboration of his colleague Earl Schwartz as co-editor, and together they partnered in the transcription process with Dorothy Roberts. Roberts transcribed the shorthand as best she could. Cobin and Schwartz then researched the history, filled in the Judaic references and mined old dictionaries and their own imaginations for language of the times to fit the words Roberts could not fully transcribe. Roberts always made the final decision on the appropriateness of the editors' suggestions in light of the shorthand. This work yielded the transcribed lecture, The Slavery in the Bible that indeed spoke about slavery in the time of the Bible, but not about American slavery. Morais's focus was on a humane form of slavery in contrast to slavery in Sparta and Rome. Unlike Rabbi Morris Raphall's discourse on The Bible View of Slavery January 15, 1861 that was used by Southerners as a defense of slavery, Morais's lecture provided little material to fuel the conflagration then raging. The editors have concluded that Morais's lecture was likely delivered as a response to Raphall's widely publicized discourse. The Slavery of the Bible is included with the four transcribed Sabbath sermons published here.

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In the past thirty years, a growing number of biblical scholars have taken on the task originally assigned to all the king's horseman and all the king's men. One hundred and fifty years of historical critical analysis of biblical texts had left the Bible in deadened disarray. Faced with a tangle of dismembered pieces, the trend in biblical research has, in recent years, slowly begun to swing back toward synthetic exegetical approaches that attempt, in some way, to put Scripture back together again. The groundwork for renewed interest in these approaches was laid by Martin Buber and his cohorts in the years between the two world wars. At the time, Buber, Franz Rosenzweig, Umberto Cassuto and others were often dismissed as amateurs, intent upon imagining meaning-laden seams in texts where historical critics saw only scars. Their synthetic methodologies, rooted in pre-modern midrashic technique, aroused little interest among such critics. It was this obsession with undermining the literary integrity of the Hebrew Bible, without a corresponding interest in grasping an overarching organizational structure, that led Solomon Schecter to make the famous aside that "higher criticism" appeared to him to be no more than a "higher anti-Semitism." But analysis is most profitably pursued as a prelude to gaining a better understanding of the whole that the analyst has taken apart. Inevitably, the thoughtful analyst must ask: What have we learned that helps us to better understand what happens when we put it back together? David Noel Freedman, General Editor of the Anchor Bible, has been asking this question for many years now. The Nine Commandments is a popular presentation of Freedman's answer. Though intended for a non-scholarly audience, The Nine Commandments conveys the essence of Freedman's understanding of an

It is often noted that the term “ ts'daqah ” is derived from the Hebrew word for “justice.” However, this observation is rarely accompanied by a historically valid definition of the sort of justice assumed to inform Jewish sources on the issue. The dichotomizing of “ ts'daqah ” and “charity,” commonly offered in place of such a definition, oversimplifies the complex connotations of both terms. The observation that “justice” is “obligatory” or “compulsory,” whereas “charity” is a voluntary act of love, also falls short. It is true that halakhah tends to be expressed in terms of obligations rather than rights, and that this tendency has played a major role in shaping rabbinic sources on support of the poor. As Moshe Silberg notes in the course of his analysis of the moral underpinnings of Jewish law, “[the halakbah ] is not primarily concerned with the indebtedness to the claimant, but with the obligation to the debtor, with his religio-moral obligation … and it is only as though in a side effect, as a secondary result of the process, does the claimant receive his money.” Nevertheless, “obligatory giving” is by itself an incomplete characterization of the conceptual structure of ts'daqah . Moreover, beyond these theoretical considerations, confusion concerning the meaning of ts'daqah also has practical implications. The term is frequently misapplied by Jews to describe any contribution to a not-for-profit organization (excluding taxes), regardless of how the contribution is actually used. Jewish communal fund-raisers regularly refer to contributions to sundry funds and projects as ts'daqah , whether the ultimate destination of a contribution is assistance to poor people, construction of a new swimming pool at a Jewish community center, or the salary of a fund administrator.

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OBJECTIVE:To characterize the ED utilization patterns of the elderly population using nationally representative data.METHODS:A secondary analysis was performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide, stratified probability sample of ED encounters. Using these physician-reported data, the demographics, patient complaints, physician diagnoses, and dispositions were compared by age group, i.e., young-old (age 65-84 years) vs old-old (age > or = 85 years).RESULTS:The elderly (age > or = 65 years) represented 5,038 (19.6%) of 25,646 ED encounters for all adults (age > or = 18 years). The geriatric age groups (ages 65-74, 75-84, and > or = 85 years) accounted for 45.3%, 37.4%, and 17.2% of all the encounters by the elderly. The proportions of female patients and white patients were higher with increasing age. The proportion of elderly patients hospitalized was 4 times that of younger adults and reflected monotonic increase with increasing age among elders. Patient complaints and physician diagnoses were generally similar for the young-old (65-84 years) and the old-old (> or = 85 years).CONCLUSIONS:These findings are consistent with previous single-center studies of geriatric ED patients. This data source may be useful for investigation of clinical issues related to the care of elderly ED patients.

Despite the common occurrence of acute cognitive impairment in elderly emergency department (ED) patients, there is much uncertainty regarding the evaluation and management of this syndrome. We performed a retrospective cohort study of all patients 60 years of age and older transported by emergency medical services (EMS) to hospital EDs in Forsyth County, North Carolina, during 1990 specifically for evaluation of acute cognitive impairment. Five percent (227 of 4,688) of EMS transports during this time period were for the purpose of evaluation of acute cognitive impairment. Compared with community-dwelling patients (n = 105), nursing home patients (n = 47) had a higher prevalence of final ED diagnoses indicative of infection (42.5% v 13.3%) and a lower prevalence of diagnoses indicative of cerebrovascular disease (10.6% v 22.9%) as the etiology of cognitive impairment. The rates of hospitalization and mortality were 74.3% and 28.9%, respectively. The projected aging of the US population and the high prevalence of this syndrome among elderly patients make better understanding of this syndrome essential for ED providers.

Patterns of utilization of emergency medical services transport (EMS) by the elderly are poorly understood. We determined population-based rates of EMS utilization by the elderly and characterized utilization patterns by age, gender, race, and reason for transport. This observational, population-based study was conducted in Forsyth County, NC, a semi-urban county served by one convalescent ambulance service and one EMS service. Using data on all 1990 EMS transports and the 1990 U.S. census data, age-, gender-, and race-specific transport rates for persons aged 60 or older were calculated. Reasons for transport and frequency of repeat users were established. After exclusion of transports because of an address outside the county, a nonhospital destination, a scheduled transport, or missing data, 4,688 transports (78% of total) remained for analysis. The overall rate of transport was 1041,000 county residents. Transport rates increased for successively older five-year age groups, demonstrating a 5.7-fold stepwise increase from ages 60–65 to 85+ (511,000 to 2911,000). There was no difference in mean age between patients who were frequent EMS users (more than three transports during the year) (n = 66) and other elderly transportees. Reasons for transport differed little between those 60 to 84 years of age and those 85 years of age and older with the exception of chest pain, cardiac arrest, and seizures, all of which were significantly more prevalent in the younger age group. African-Americans used EMS at a rate 1.7 times that of whites (143.41,000 v 95.41,000, 95% confidence internal [Cl] 1.40 to 1.61), but there was little difference between genders (0.99, 95% Cl 0.93 to 1.05). Our data show that in this county, the use of EMS transport increases dramatically with age. The need for EMS transport of elderly patients will increase dramatically as the U.S. population ages. These findings have implications for care of the individual patient and for future changes in health policy.

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged > or = 65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.

The hospital emergency department (ED) has become an important means of access to health care for the elderly. Inadequacies in the current health care system for the elderly are reflected in their high utilization rates of the ED, continuing questions about the appropriateness of elderly ED patients, differences in the ED care offered the elderly versus the young, and poor coordination of care to and from the ED. Evidence of potential misuse of emergency services exists for both the ED and the emergency medical transport (EMS) systems. The increasing number of nursing home patients sent to the ED with nonemergent problems further emphasizes inadequacies of primary care in the nursing home setting. Economic, legal, and ethical issues that have changed the way medicine is practiced in other settings are finally reaching the sector of emergency services. The current and future roles of emergency medicine services, and the impact these issues will have on the practice of emergency medicine, are discussed.

Peripartum cardiomyopathy (PPCM) is a relatively rare form of acute heart failure. Onset is from the last trimester of pregnancy to 5 months postpartum. Diagnosis is made by excluding other causes of acute heart failure, such as infections or toxins, and by determining that the patient does not have an underlying cardiac problem that has been unmasked by pregnancy. Diagnosis in the last trimester is complicated by the fact that the early symptoms of this disorder may mimic the symptoms of normal pregnancy. PPCM must be considered in any patient who presents with new onset peripheral edema, dyspnea on exertion, or paroxysmal nocturnal dyspnea during late pregnancy or up to 5 months postpartum. Limited studies suggest that early and aggressive therapy is associated with a better outcome. Therapy is directed toward decreasing preload and improving cardiac function. Return of cardiac size to normal is associated with a better prognosis than continued cardiomegaly.

STUDY OBJECTIVE:To compare two related pharmacological agents used for the chemical restraint of agitated and combative patients.DESIGN AND SETTING:A randomized, double-blind, prospective study was carried out in patients requiring physical restraint in a university hospital emergency department.PARTICIPANTS:Sixty-eight violent or agitated adult patients whom the attending physician believed would benefit from chemical restraint to protect the patient and staff and to expedite evaluation.INTERVENTION:Twenty-one participants were administered 5 mg haloperidol IM; 26 were administered 5 mg droperidol IM; 12 were administered haloperidol IV; and nine were administered 5 mg droperidol IV.RESULTS:All patients were rated on a five-point combativeness scale at five, ten, 15, 30, and 60 minutes after the study drug was given. Vital signs also were recorded at these times. IM droperidol decreased combativeness significantly more than IM haloperidol at ten (P = .006), 15 (P = .01), and 30 (P = .04) minutes. There was no significant difference between the two drugs when given by the IV route (beta at the 5% confidence level, P = .78).CONCLUSION:In equal IM doses (5 mg), droperidol results in more rapid control of agitated patients than haloperidol, without any increase in undesirable side effects.

STUDY OBJECTIVE:To compare the effects of water rinse with those of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or ethanol on cutaneous phenol burns.DESIGN:Controlled trial with all animals receiving all treatments applied to different cutaneous phenol burn sites.TYPE OF PARTICIPANTS:Swine weighing 9 to 18 kg.INTERVENTIONS:In phase 1, each burn site was treated with water rinse for zero, one, or five minutes combined with either isopropyl alcohol, polyethylene glycol with industrial methylated spirits, ethanol, or no other treatment. Biopsies of treatment sites were done at 30 minutes and at 48 hours. In phase 2, a pilot study, the effect of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or water treatment on serum phenol levels was noted in animals with 5%, 10%, and 15% body surface area burns.MEASUREMENTS AND MAIN RESULTS:In phase 1, on histological examination of biopsy specimens, significant differences in tissue damage occurred among the groups (P < .05). Isopropyl alcohol and polyethylene glycol with industrial methylated spirits were the most efficacious treatments; the duration of water rinse had no significant effect. In phase 2, the systemic absorption of phenol may be greater with water treatment than with isopropyl alcohol treatment.CONCLUSION:Isopropyl alcohol and polyethylene glycol with industrial methylated spirits are equally effective in the amelioration of phenol burns of less than 5% total surface area. The wider availability of isopropyl alcohol makes it potentially the most useful treatment for these small burns. Further studies of its risks are needed.

It is a thousand miles from coast of land of Israel to city of Rome, over sea that is called in both Hebrew and Latin, the Sea In-Between. The closing chapters of book of Acts tell of Apostle Paul's journey over that sea, from Caesarea to Rome, around year 60 C.E. By this time, of course, Paul had made many journeys in his life: from Tarsus to Jerusalem, Jerusalem to Damascus, to Ephesus, Athens, Corinth and numerous other cities east of Rome. At conclusion of his Epistle to Romans, Paul mentions that he planned to visit Rome as well, on his way to Spain.1 But as best we can tell, when Paul did finally come to Rome, his wanderings ended, for he came as a prisoner, and it was in Rome, according to Church tradition, that he was eventually put to death. In book of Acts, portrayal of events leading up to Paul's journey to Rome-its description of his arrest and subsequent appearances before various courts and authorities-is clearly reminiscent of Gospel descriptions of Jesus' arrest and execution approximately thirty years earlier. In both accounts, we read of disturbances in Temple, crowds of angry Jews calling for an innocent victim's death, his arrest and confrontations with both Jewish and Roman authorities, and acknowledgement by representatives of Rome of victim's innocence. However, conditions surrounding two series of events suggest two very different historical moments. And Paul's response to those who would sit in judgment of him, and to jurisdictions they represented, at least as recorded in Acts, suggests a sea of difference between Paul's outlook and that of his Lord. Although we must be cautious in using such sparse evidence, drawn from a single, often uncorroborated written witness, nevertheless, a judicious comparison of New Testament portrayals of Jesus and Paul before their judges may yet contribute to our understanding of their respective worlds and worldviews. Though we do not possess a record of a formal trial of Jesus before either a Jewish or Roman court, Gospels do present us with

Deep-vein thrombosis of the upper extremity, that is, axillosubdavian vein thrombosis, is a relatively rare and potentially overlooked diagnosis in the emergency department (ED). It can be the cause of significant morbidity and it may be life-threatening. Reported here is the case of a 23-year-old man who presented to the ED with left upper extremity pain and swelling. Venography confirmed the diagnosis of ax1Hosubclavian vein thrombosis. Hospitalization and treatment with intravenous heparin led to a satisfactory recovery. The clinical presentation, predisposing factors, diagnosis, treatment, and complications of this rare entity are discussed.

Study objectives: To survey faculty attrition in emergency medicine and compare it with faculty attrition in the specialties of orthopedic surgery and cardiology.Design: Chairmen of the three departments were surveyed regarding faculty attrition, work hours, and motivation for leaving. Those emergency physicians having left also were surveyed.Main results: Responses were obtained from 67 of 68 emergency medicine programs, 53 of 58 orthopedic programs, and 47 of 54 cardiology programs. Overall, there were 670 total faculty in emergency medicine, of which 67 (10%) left their positions during 1988 - 38 to enter private practice, 18 to take another academic position, and 11 to do something un-identified. There was no difference in faculty attrition among the three specialities or in what the physicians left to do (P = .75). Both the orthopedists and cardiologists worked more total hours each week (P = .001) but fewer night hours (P = .03) than the emergency physicians. Among the 67 emergency medicine programs, 28 reported no attrition; 39 reported one or more physicians leaving the program. These two groups of programs did not differ in terms of faculty size, hours worked, or night hours worked.

Because the signs and symptoms of acute renal artery occlusion mimic those of many more common diseases, prompt diagnosis is aided by an awareness that an occlusive renovascular event may have occurred. No routine, noninvasive laboratory test can confirm the diagnosis. Renal arteriography is the procedure of choice after excretory urograms have ruled out an obstructive uropathy. Early assessment of kidney viability is important. The endpoints of emergency treatment are to decrease symptoms, decrease diastolic blood pressure to less than or equal to 105 mm Hg, and to maintain urine output at greater than 50 mL/h. Restoration of a lower blood pressure must not be so prompt that renal perfusion decreases too rapidly. Definitive surgical treatment versus medical management of the renal artery occlusion remains a controversial topic. Where surgery is not feasible, medical management consists of streptokinase acutely followed by heparin and then chronic coumarin therapy.