Goodman Brown’s Battle with Good and Evil Essay

In â€Å"Young Goodman Brown,† the setting plays an important role. It provides symbolism to certain events and provokes emotions amongst the characters, especially those of Goodman Brown. The central idea of the story is the conflict in Goodman Brown between joining the devil and remaining â€Å"good. † It is a very difficult journey for Brown, as he travels through the woods, all the while thinking of the â€Å"good† things he would be leaving behind, like his wife Faith. This internal conflict ultimately destroys Young Goodman Brown and creates a new man. At the beginning of the story, Goodman Brown sets out on his journey at sunset, symbolizing darkness and evil. Before Brown leaves, he kisses his wife, Faith, goodbye. The name Faith is intentionally used to symbolize the faith in God that they both share and also what Brown leaves behind to go on his journey. Faith wears pink ribbons in her hair, which give the impression that she is an innocent godly woman. Before Brown leaves on his journey, Faith says, â€Å"pr’y thee, put off your journey until sunrise. † This is showing that sunrise is a more pleasant and peaceful time to go on a journey rather than at night when it is considered dangerous to roam about. This sets the mood for Brown’s adventure and foreshadows that something horrible is about to happen to him. As Brown starts on his adventure, he remembers that his wife had dreams of this particular adventure, dreams that warned him not to go. This feeling of uncertainty sparks a feeling of anxiety in Brown as he continues walking through the forest and on with his journey. Soon after, the scenery around him begins to change and the road becomes â€Å"darkened by all the gloomiest trees of the forest, which barely stood aside to let the narrow path creep through, and closed immediately behind. † This quote describes the dark and gloomy surroundings that Brown walks through on his journey and creates the mood of fear and hesitance as he continues on his way. As Brown walks along, he comes to encounter a man dressed in grave and decent attire. The man states, â€Å"You are late, Goodman Brown,† and Brown replies by saying, â€Å"Faith kept me back awhile. † In literal terms, he speaks of his wife, but metaphorically he could be speaking of his faith in God and how it almost kept him from embarking on his journey. Later on in Brown’s journey, he meets a man with a cane that resembles a snake, symbolizing evil. Brown then protests against the devil saying, â€Å"With heaven above, and Faith below, I will yet stand firm against the devil! † He lifts his hands to pray, and a huge black cloud hides the stars to which he prays upon. This black cloud symbolizes evil destroying Brown’s faith. Throughout Brown’s journey dark and light, white and black, all play a part in creating the setting for Brown’s surroundings. When Brown returns home, it is daylight; this symbolizes innocence and freedom from the journey he just experienced. Throughout the story, Brown goes from being a static character to a dynamic one. The reason for this transformation is because of his conflict with â€Å"the devil† which is external, and by the conflict within himself which internal. The conflict Brown shares with the devil is caused by the devil tempting Brown to join the dark side. The way in which the devil lures Brown is by convincing him that his relatives and town’s people have already crossed over to the dark side and denied their faith. The struggle that Brown now faces is whether to follow his relatives and town’s people, or to follow his faith in God and deny the devil, which is Brown’s internal conflict. These internal and external conflicts turned Brown into a dynamic character by the end of the story. Instead of believing and trusting that his relatives and friends are godly, he now knows that they have all been tempted by the devil and many have crossed over to the dark side; he went from being trusting to skeptical of his friends and his faith.

An Introduction to Ecotourism

An Introduction to Ecotourism Ecotourism is broadly defined as low impact travel to endangered and often undisturbed locations. It is different from traditional tourism because it allows the traveler to become educated about the areas - both in terms of the physical landscape and cultural characteristics, and often provides funds for conservation and benefits the economic development of places that are frequently impoverished. When Did Ecotourism Start? Ecotourism and other forms of sustainable travel have their origins with the environmental movement of the 1970s. Ecotourism itself did not become prevalent as a travel concept until the late 1980s. During that time, increasing environmental awareness and a desire to travel to natural locations as opposed to built up tourist locations made ecotourism desirable. Since then, several different organizations specializing in ecotourism have developed and many different people have become experts on it. Martha D. Honey, PhD, a co-founder of the Center for Responsible Tourism, for example, is just one of many ecotourism experts. Principles of Ecotourism Due to the growing popularity of environmentally-related and adventure travel, various types of trips are now being classified as ecotourism. Most of these are not truly ecotourism, however, because they do not emphasize conservation, education, low impact travel, and social and cultural participation in the locations being visited. Therefore, to be considered ecotourism, a trip must meet the following principles set forth by the International Ecotourism Society: Minimize the impact of visiting the location (i.e.- the use of roads)Build respect and awareness for the environment and cultural practicesEnsure that the tourism provides positive experiences for both the visitors and the hostsProvide direct financial aid for conservationProvide financial aid, empowerment and other benefits for local peoplesRaise the travelers awareness of the host countrys political, environmental and social climate Examples of Ecotourism Opportunities for ecotourism exist in many different locations worldwide and its activities can vary as widely. Madagascar, for instance, is famous for its ecotourist activity as it is a biodiversity hotspot, but also has a high priority for environmental conservation and is committed to reducing poverty. Conservation International says that 80% of the countrys animals and 90% of its plants are endemic only to the island. Madagascars lemurs are just one of many species that people visit the island to see. Because the islands government is committed to conservation, ecotourism is allowed in small numbers because education and funds from the travel will make it easier in the future. In addition, this tourist revenue also aids in reducing the countrys poverty. Another place where ecotourism is popular is in Indonesia at Komodo National Park. The park is made up of 233 square miles (603 sq km) of land that is spread out over several islands and 469 square miles (1,214 sq km) of water. The area was established as a national park in 1980 and is popular for ecotourism because of its unique and endangered biodiversity. Activities at Komodo National Park vary from whale watching to hiking and accommodations strive to have a low impact on the natural environment. Finally, ecotourism is also popular in Central and South America. Destinations include Bolivia, Brazil, Ecuador, Venezuela, Guatemala, and Panama. These destinations are just a few where ecotourism is popular but opportunities exist in hundreds of more places worldwide. Criticisms of Ecotourism Despite the popularity of ecotourism in the above-mentioned examples, there are several criticisms of ecotourism as well. The first of these is that there is no one definition of the term so it is difficult to know which trips are truly considered ecotourism. In addition, the terms nature, low impact, bio, and green tourism are often interchanged with ecotourism, and these do not usually meet the principles defined by organizations like the Nature Conservancy or the International Ecotourism Society. Critics of ecotourism also cite that increased tourism to sensitive areas or ecosystems without proper planning and management can actually harm the ecosystem and its species because the infrastructure needed to sustain tourism such as roads can contribute to environmental degradation. Ecotourism is also said by critics to have a negative impact on local communities because the arrival of foreign visitors and wealth can shift political and economic conditions and sometimes make the area dependent on tourism as opposed to the domestic economic practices. Regardless of these criticisms though, ecotourism and tourism, in general, are increasing in popularity all over the globe and tourism plays a large role in many worldwide economies. Pick a Travel Company That Specializes In order to keep this tourism as sustainable as possible, however, it is essential that travelers understand what principles make a trip fall into the category of ecotourism and attempt to use travel companies that have been distinguished for their work in ecotourism - one of which is Intrepid Travel, a small company that offers worldwide eco-conscious trips and has won a number of awards for their efforts. International tourism will no doubt continue to increase in the coming years and as the Earths resources become more limited and ecosystems suffer more damage, the practices shown by Intrepid and others associated with ecotourism can make future travel a little more sustainable.

How to Write a Capturing Introduction for a Literary Analysis Paper

How to Write a Capturing Introduction for a Literary Analysis Paper How to Write a Capturing Introduction for a Literary Analysis Paper If you are writing a literary analysis essay it is very important that you find a way to grab your reader’s attention right from the beginning. You want to draw a reader in so that they are eager to find out what you have to say about a particular literary piece. You also want to make sure that your opening paragraph is: well-organized; gives your reader a clear indication of what your thesis or idea is; written in such a way that there is a logical progression of ideas from one sentence to the next. You may be asking yourself how you can fit all of these things into one paragraph without making it â€Å"stuffed†. Here are some tips that you can use to help you. Keep in Mind What You Are Writing and What You Are Writing about This sounds easy but it is one rule that many essayists tend to forget about. You want to keep in mind that a literary analysis paper is specifically designed to look at a particular piece of writing. Your goal, as an author, is to come up with a definitive idea regarding a piece of literature and express that idea or conclusion to your reader. It doesn’t have to be boring, and it doesn’t have to be rigid or inflexible but it does have to have a specific idea or thesis and utilize examples and information from the piece itself to support your arguments. You also need to keep the tone professional rather than conversational. An essay is more of a formal style of writing and the language you use should reflect that. Once you have figured out what you want to write about, it is time to write your opening paragraph. Remember That Your Opening Line Must Be the Most Critical Your opening line is perhaps the most critical part of your essay because it is what makes your reader want to continue. Think about it like a headline for a news article. Some headlines and opening lines immediately make you want to read more. They build excitement for the reader. Others may be more passive or less entertaining. You want to be sure that when you write, your opening sentence falls into the first category. To achieve this goal, you may want to use one of the following opening variants: A passage from the piece you are writing about; A relevant quote from someone famous. This can either be directly related to the piece or illustrate your thesis about the piece; A question that may provoke thought or emotion in your reader. From there you can continue and outline what your thesis is. Keep in mind that the arguments you will be making to illustrate your point will come later in the essay itself and do not need to be mentioned in the opening paragraph. If you structure it properly you may find that your opening paragraph flows well and feels neither rushed nor overloaded. Avoid Unnecessary Words and Phrases Of course, it is important to know what not to do when writing your essay’s opening paragraph. This is the time when language is especially important. A good opening paragraph will have language that is very precise and which can create a clear impression of what you are trying to say. Therefore, you must avoid the number of unnecessary words that do not support or illustrate your point and that may cause vague impression in the reader. It is also important to place your thesis statement in the proper position in your opening paragraph. Placing it at the end of the introductory paragraph will help ensure that your reader recognizes it for what it is: the central, unifying idea that will pull your custom written essay  together.

Innovative Organisations Essay Example | Topics and Well Written Essays - 2500 words - 2

Innovative Organisations - Essay Example Its global business far outstretches total sales, leading by about 74% of the total Topcon sales, as per the 2008 fiscal year annual report. Topcon produces many No. 1 products in the international market in the line of Positioning business, Eye Care business and Finetech business. Electronic Total Station in the Positioning business segment is holding the largest share in the global market for providing functionality and performance; it is cost-effective and has product range. The company’s major competitive strategy, according to the company President, Takashi Yokokura, is providing the No. 1 products worldwide quicker than its competitor companies. It has followed â€Å"TM-1† (Time to Market No. 1) business functions to minimise operational processes time to half, speed up business and set benchmarks in quality. Focus is more on increasing technological acumen and marketing functions. Operational processes in R&D, product quality and cost competiveness will be speeded up to attain the specific target of TM-1 Company. Topcon Group’s future growth depends on speeding the product in as less time taken as possible to reach market. Only by following this strategy, Topcon can boost its profit by exactly predicting market requirements and delivering products hassle-free, exceedingly satisfying its customers. In positioning business, Topcon is integrating different technologies – electronic and laser technology into its backbone technology – optical technology, thus, enlarging its business domain with machine control, image analysis and GPS technologies for high-accuracy 3D position information. Topcon has once again set standards by introducing GPT-9000A Series in Total Station. Topcon’s total station is a positioning tool that exactly marks measuring points, offering correct and graphic 3D position displays. The

Creating a successful corporate culture after a merger PowerPoint Presentation

Creating a successful corporate culture after a merger - PowerPoint Presentation Example It, therefore, has culminated into a cutthroat type of competition where the aim is to reach the pinnacle in riches and power before anything and anybody else. Since the slots at the top are few and limited in number, short-cuts and illegal means among them fraud and insider trading are sought by any people in this country in their daily bid to realize their dream of greatness. Purpose of the Memo It is thus with a great urge that I write to the chairperson of the Securities and Exchange Commission with proposals whose aim is to minimize cases of fraud, insider trading and unlawful actions by people and business with the intentions of making quick money. The main aim of this proposal is to contribute to the Securities and Exchange Commission’s efforts towards reining in fraudsters and insider trading who plunder other people into poverty. The commission’s efforts cannot be assumed to have been useless in any way since they have prevented most of the cases that would hav e caused damage to the whole financial sector (Mallor, Barnes, Bowers & Langvardt, 2012). It replaces some existent rules and regulations in place since they have evidently failed to rein in the criminals and, most importantly, managing financial crimes as displayed by the 2008 global recession. Findings of numerous research studies on the 2008 global recession indicate that the spending behavior of US citizens and the laxity of the Securities and Exchange Commission are responsible for the recession. It should be put into consideration that the main aim of all regulatory bodies in this sector should be the prevention of the crimes since, as they say, prevention is better than cure. The Current Laws The United States government has made enormous efforts towards handling the issue of financial crimes by setting the Securities and Exchange Commission which has established a number of rules governing the US business environment to see to a balanced business environment for all business participants. Among these rules are those against the illegal type of insider trading and fraudulent activities in general. For instance, Rule 10b5-1 prohibits insider trading by stating that it is illegal for individual to engage in a trade arrangement using non-public information. However, the rule permeates individuals to only trade under special instances in which there is lack of knowledge that the information was non-public. Moreover, the actions of the trader must be in good faith. The second rule by the Securities and Exchange Commission meant to curb illegal insider trading is the Rule 10b5-2. It is a rule clarifying how the misappropriation theory applies to certain non-business relationships. The rule states that individuals with the privilege of access to confidential information have the obligation to maintain the privacy and confidentiality of such information. Persons violating the law are liable for breach of information confidentiality as outlined by the misappropr iation theory. The Securities and Exchange Commission has established several measures targeting at minimizing the level of financial fraud in major areas of the US business industry. These include the use of people who have inside information on the fraudulent cases being undertaken by companies who tip the Securities an

Anthropology of tourism Essay Example | Topics and Well Written Essays - 750 words

Anthropology of tourism - Essay Example on that the more people have to connect, the more reasons arise as to why people would appear to become desperate to unplug.1 It thus leads to the thesis; tourism remains to be a complex phenomenon that can be understood fully through adopting a multidisciplinary approach. The paper is thus going to justify on this these in relation to Pico Iyers concept of tourism. Right from the start of the book, Pico is explaining as to why he starts thinking of how going slow could be more exhilarating in the age of speed. More, Pico claims that he could feel more luxurious through paying attention in an age of distraction. When it comes to the age of constant movement, Pico argues that it is more fascinating when one sits still in a specific location. Pico acknowledges that one is bound to experience a tremendous time by going on a vacation to Paris, Hawaii or New Orleans.2 However, he goes ahead to justify on his idea that in case one wants to feel new, feel alive, feel full of fresh hope, and to fall in love with world, then the best place for an individual to visit if by going nowhere. Pico in such concepts is trying to explain and justify the reason why being present remains to be more beneficial than compared to jet-setting across the world. The question that one might ask is; how could a traveler like Pico Iyer, being an individual that has journeyed in many areas like Easter Island to Ethiopia and from Cuba to Kathmandu, goes about saying that sitting quite in a room could be the ultimate adventure? Part of the reason as to why Pico presents this view is that people are living in a madly accelerating world, whereby their lives are crowded, very chaotic and noisy. It is by this reason that Pico goes ahead to explain that there is a greater need for slowing down, be able to tune out and give self permission of sitting still for the purpose of achieving the ultimate goal of feeling new, feeling alive, feeling full of fresh hope, and to falling in love with world. The

Significance Of Physiotherapy Post Thoracotomy

Significance Of Physiotherapy Post Thoracotomy Many people who suffers from orthopedic, cardiopulmonary or neurology problems go to physical therapy seeking help. Physiotherapy is considered to be an important aspect of full recovery stages. It is an art and science which contributes to the development of heath. Physical therapy is one of the most important professions in the health care community where it can help the patients to recover through rehabilitation programs and exercises. The importances of physical therapy are represented in improving the quality of life for the patient, and returning the patient to his normal life without difficulties in performing his activity of daily living (ADLS) (1,2). Also, physical therapy helps in the prevention of impairments and limitations of activities, promotion of the general health of the patient, and providing post-operative care after surgery (3, 2, 4). Following any surgery, the patient must take physiotherapy in order to increase his endurance and functional independence (2). Mor e over, physiotherapy interventions can be used in assisting for the prevention and treatment of the complications whether it is a pulmonary or musculoskeletal after major surgeries (5). One of these major surgeries is thoracotomy. Thoracotomy is a surgical procedure where an incision is made in the chest wall to reach the thoracic organs (6). It can be done either laterally or anteriorly in order to enter the lungs, heart, esophagus, and major blood vessels (7). Thoracotomy can be done for several reasons such as: removing blood clots from the chest, removing a portion or entire lung, repairing the heart or the vessels of the lung and heart, and removing pus from the chest (8). Also, it is needed with collapsed lung, pneumothorax, emphysema, and with several situations like stab or gunshot wound that is located in the chest (7). Dealing post-operatively with thoracotomy is considered to be hard because this procedure is very painful so that it prevents the patient from breathing effectively causing pneumonia or atelactasis (8). Regarding to that, physiotherapy is very important post-thoracotomy. Physiotherapy can help patients post-thoracotomy in reducing the length of hospital stay, and improving the general fitness of the patient (9). Furthermore, physical therapy can clear the secretion and improve the chest wall mobility for those patients by breathing exercises and encourage them to cough (10). In addition to that, physiotherapists will make sure that these patients can walk independently by themselves or if they need another member to help them (10). Also, patients ability to ascend and descend the stairs will be assessed before going back home (10). -2- Body of knowledge: As mentioned above, there are some diseases or situations that may lead to thoracotomy surgery. One of these diseases is pneumothorax. Pneumothorax is defined as air leaking to the space that is located between the lungs and the chest wall (11). This air will lead the lung to be collapsed (11, 12). There are many causes that can lead to pneumothorax. Pneumothorax can be caused chest injuries and some medical procedures such as fractured rib, knife or gun shot wounds, car crash, insertion of chest tubes, and procedures using a scope down the throat and into the lung (11, 12). Also, underlying lung disease which causes the lung to be damaged leads to lung collapse. These diseases include cystic fibrosis, emphysema, chronic obstructive pulmonary disease, pneumonia, asthma, lung cancer, and other lung infections (11, 12). Moreover, ruptured of the air blisters is one of these causes (11). These air blisters appears on the top of the lung and there is no apparent reason of the appearance of these blisters (11). Rupture of these air blisters can occur from the change in the air pressure like scuba diving, flying, and mountain climbing (11). Further more, severe pneumothorax can be caused by the mechanical ventilation for the breathing process (11). The mechanical ventilator works on pushing and pulling the air inside and out side the lung (11). This can lead to imbalance in the air pressure of the chest and that will cause the lung to be completely collapsed (11). Pneumothorax has three types. First one is traumatic pneumothorax that is caused by penetrating chest wound (knife stab) (12, 13, 14). Second one is spontaneous pneumothorax, which is caused by emphysema or other lung disease (12, 13, 14). The last one is tension pneumothorax where the leaking air will cause a compression on -3- the chest structures and it can be caused by trauma, lung infection, and medical procedure (12, 13, 14). Moving to the sign and symptoms that are caused by pneumothorax, they involved sharp sudden chest pain that doesnt become worse by breathing (11, 12). This pain is felt at the site of affected lung where it can lead to tightness in the chest that is felt by the patient (11, 12). Also, the symptoms contain mild or severe shortness of breath (11, 12). And that will be determined by having any underlying lung disease and depending on the extent of the collapse in the lung (11, 12). In addition to that, pneumothorax symptoms may include: rapid heart rate, rapid breathing, cough, fatigue, and skin cyanosis (bluish color) because of decreasing in the oxygen levels in the blood (12). There are some risk factors that contribute in developing pneumothorax. Some of these factors are: the gender and age of the patient where men age range between 20 and 40 years who are tall and thin are more likely to develop pneumothorax than women does (12, 11). More over, risks of pneumothorax are increased by cigarettes smoking, genetic factors where it can cause a certain type of pneumothorax, and history of previous pneumothorax (11). Any individual may develop another pneumothorax after two or three years of having an old one (11). It can be developed either in the same or the other lung (11). After discussing the risk factors of pneumothorax, complications will be now debated. Complications of pneumothorax resulted from an injury or a disease may include: recurrence of pneumothorax and persistent air leak (11). This leaking air is resulted from the lung opening that fails to close where it requires surgery in order to close that leaking (11). And, in the case of severe pneumothorax, complications may involve: cardiac arrest, respiratory failure, low blood oxygen levels, and shock (11). -4- Pneumothorax can be identified or diagnosed by examining the chest using stethoscope where it shows the decreasing or the absent in the breathing sounds (12). This examination can be supported by chest x-ray to confirm the existence of pneumothorax (12, 11). In certain situations, computerized tomography can be used in order to give detailed images (11). Regarding to the treatment of pneumothorax, it rely on the severity of the disease (11). The goal of this treatment is represented in relieving the pressure that lies on the lung, preventing recurrences, and give the lung its freedom to re-expand again (11). In case of small pneumothorax the treatment contains bed rest so that the collapse is not aggravated and it will be resolved by itself within one to two weeks (11, 12). While in case of larger pneumothorax, which is companion of underlying lung disease, chest tube is used (12, 11, 14). This chest tube is located between the ribs to the area that is filled by the air which compresses on the lung (11). The chest tube works on the removing that air from the chest cavity and it can be kept for hours or days (11). Chest tube may have some complications such as pain, infection, hemorrhage, and fluid accumulation in the lung (12). In certain situations, chest tube cannot do the desired job so that surgery is required (11, 12). Some of these situations are bronchopleural fistula (lea king that doesnt close), failure of lung re-expansion, and recurrent spontaneous pneumothorax (12, 11). Example of the surgical options involves thoracotomy (13). Pneumothorax prognosis depends on two important things: extent and type of pneumothorax (12). As mentioned before, small pneumothorax doesnt need treatment (12). But the other type (larger pneumothorax), leads to 15% of mortality rate so that it needs urgent and immediate treatment (12). Both types of pneumothorax create a recurrence rate about 40% (12). Shifting to another disease stage that also may requires thoracotomy. This -5- disease is hemothorax disease. Hemothorax is an accumulation of blood in the pleural cavity which is a space located between the chest wall and the lung (15, 16). The main cause that can leads to the development of hemothorax is a trauma to the chest (15, 16, 14). This trauma leads to a rupture for the serous membrane that covers the lung or line the thorax causing the leakage of blood to the pleural cavity (15). Other causes of hemothorax may include patients with a defect of blood clotting, placement of central venous catheter, death of lung tissue, lung or pleural cancer, and tuberculosis (15). This disease is associated by many signs and symptoms such as chest pain low blood pressure, rapid heart rate, shallow breathing, shortness of breath, and restlessness (16). Also, the symptoms may include tracheal which means a deviation to normal side, cyanosis, decreased or absent of breath sounds on the affected side, and possibility of subcutaneous emphysema (15). Every disease is accom panied by complications. In hemothorax, the complications that are associated with it may involve pneumothorax, shock, fibrosis or scarring of the pleural membrane, and death. Hemothorax diagnosis can be done using several tests like chest x-ray, CT scan, pleural fluid analysis, and thoracentesis (16). After diagnosing hemothorax, immediate intervention should be taken to stop the bleeding and removing the blood from the pleural cavity (15). Removing that blood is the job of the chest tube which is inserted in the chest wall in a procedure that is tube thoracostomy (16, 15). The blood that is existing in the chest can be thickened and clot in the pleural cavity or within the chest tube (16). That will cause retained hemothorax in the plural cavity or occlusion of chest tube (16). As pneumothorax, if the chest tube fails in the control of the bleeding, thoracotomy surgery is necessary in order to control and stop the bleeding (15). Regarding to the prognosis of hemothorax, it rely on the cause and the -6- quick treatment for hemothorax. If hemothorax doesnt be treated, the collected blood will place a pressure on the mediastinum and the trachea (15). And this pressure will play a role in causing the deviation of trachea to normal side (15). Last disease that will be discussed is lung cancer. Lung cancer is a disease where an uncontrolled growing of the cells in the lung tissue occurs (17). This disease is the leader of the death in 1.3 million men and women worldwide (17). In case of the cancer that develops in the airway, it can causes obstruction in the air flow leading to difficulty in breathing (17). Because of this obstruction, the secretion will be accumulated and will cause pneumonia (17). Lung cancer can be caused by carcinogens like tobacco smoke that leads to synergistic effect and cause lung cancer. Also, viruses can cause lung cancer by affecting the cell cycle and by the inhibition of apoptosis which plays a role in the uncontrolled cell division. There are two main types of the lung cancer: non-small-cell lung carcinoma and small-cell lung carcinoma. It is important to determine the type of the cancer because depending on that, the treatment will vary. Sometimes non-small-cell lung carcinoma is treated by a surgery that is called lobectomy in the early stage. While in small-cell lung carcinoma using chemotherapy and radiation are more effective and give better results. Having lung cancer is associated by some signs and symptoms. These signs and symptoms involve shortness of breath, hemoptysis that means coughing up blood, wheezing when listening to the chest, fatigue, and loss of appetite. Moreover, chest pain or abdomen pain, weight loss, dysphagia where the patient face difficulty in swallowing, and dysphonia which means having a hoarse voice. This disease can be diagnosed by the chest radiograph and the CT scan. In order to detect the lung cancer early, examining of the patients sputum with other screening examination are necessary. Lung cancer treatment contains several ways: -7- surgery, chemotherapy, and radiation therapy. For the prognosis of the lung cancer, it is poor for the both main types. There are some prognostic factors that may affect the prognosis. In non-small-cell lung cancer, these factors include the pulmonary symptoms, tumor size, cell type, and vascular invasion. And in the small-cell lung cancer, the factors are the performance status, gender, and the stage of the disease (17). All of these diseases may require thoracotomy surgery. Regarding the thoracotomy surgery here in Kuwait, the most common surgery that is performed normally during thoracotomy is the lobectomy surgery where it means removal of a whole lung lobe. Thoracotomies surgeries usually take 3 to 4 hours (8). During the procedure, the patient will be under general anesthesia and he will be lying on his side with an elevation of his arm (7, 8). Then an incision will be made (7,8). If it is an anterior thoracotomy, the incision will be vertical from the base of the neck to the l ower end of the sternum (7). And if it is a lateral thoracotomy, the incision will be between two ribs from the front to the back where the ribs will be spread from each other (7, 8). In some cases part of the ribs will be removed (7,8). Lateral thoracotomy Anterior thoracotomy After that, chest tube will be inserted when the procedure is done in order to ensure and allow the blood and the air to get out from the chest (7, 8). Finally, stitches will be used to close the incision and the chest will be bandaged to avoid the infection (7, 8). Following thoracotomy, the patient will stay at the hospital for 5 to 10 days unless -8- complications have been developed (8). Some of these complications are: bleeding, infections, blood clots, and severe pain (8, 7, 6). The risk of these complications may be increased by several factors such as previous stroke or heart attack, age, trauma, and heavy smoking (8). AS any surgery thoracotomy patients will receive post-operative care. At the hospital, the patient will be on IV lines and tubes and he will receive antibiotics, pain medicine, anti nausea drugs. And the patient will be referred to the physical therapy (8). After being discharged from the hospital, the patient must follow some guidelines in order to help in early recovery. Some of these guidelines are drinking plenty of fluids, avoid smoking, and avoid environments that have germs or chemical irritants (8). Most of the patients are worried about returning to the work after the surgery. While working some activities should be avoided like lifting or pushing heavy objects until he completely recovers and the inc ision completely healed (8). Also, patient should avoid prolonged standing for several weeks (7). Moreover, the patient must contact his doctor in case of any of the following occurs: difficulty in breathing, coughing up yellow, green or bloody mucus, severe vomiting, excessive bleeding and increasing in pain (8). PT Role: Back to the role of physiotherapy, it is very important in enhancing the patients health after thoracotomy surgery. Physiotherapy interventions will cover three main areas: chest care, general mobility, and home advices (18). Regarding to the chest care, any individual who is undergoing major surgery will develop chest problems (18). These chest problems will occur either if the patient has or has no history of smoking and chest problems (18). There are many reasons behind the development of these problems after thoracotomy surgery. These reasons include: the anesthetic gases -9- where they work on increasing the amount of secretion production, making the patient breaths shallowly, and making the patient cough less effectively of the gluey secretion (18). Also, the operation itself is one of these reasons. While performing thoracotomy surgery, the lungs are not fully inflated so that they need to be re-expanded following the surgery (18). Other reasons are the wound and the patient posture where the feeling of the discomfort may leads to the inhibition of the deep breathing and coughing effectively, and the patients posture also leads to chest problems. Slumped posture whether it was in sitting or lying can leads to the inability of taking full deep breath. In addition to all that reasons, decreased in the activity level of the patient considered to be one of the chest problem reasons. This decrease in the level of the activities after the operation can cause an accumulation of the secretion and the shallow breathing. In order to recover and prevent the chest problems, the physiotherapist will give the patient a variety of breathing exercises like segmental breathing exercise and sustained breathing exercise. And these exercises must be done in the up right position. Also, physiotherapists will teach the patient the effective way of coughing in order to get rid of the secretion. In addition to that, the patient will be taught how to use the spirometer to increase the amount of inhaled and exhaled air. Moving to the general mobility that can also aids in the prevention of the chest problems and other complications. Following the surgery, physiotherapist will make the patient sit out of the bed in a chair to enhance and increase the depth of breathing. Then, the physiotherapist will work on making the patient walks as soon as possible. Walking exercises helps in the airway clearance, taking deep breath, and increasing the patients strength after thoracotomy surgery. Day by day the physiotherapist will increase the amount of walking. Also, shoulder mobility is one of the mobility -10- exercises that will be given to the patient. Shoulder mobility on the affected side is an important exercise that must be done after the surgery to help in the improvement of the range of motion and in the prevention of the joint stiffness. Moreover, physiotherapist will provide the patient with postural exercises and advices because he will lean toward the operated side in order to decrease the pain. This leaning will lead to a neck and back pain and stiffness. So being in the up right position will prevent that pain and stiffness. When its the time to return back home and being discharged, the physiotherapist will give the patient a home program. After being discharged, the patient must continue with the exercises that he was doing with the physiotherapist in the hospital. The patient must keep on doing the breathing exercises to enhance the function of the lungs. Also, the patient must not stop the shoulder and the postural exercises so that the therapist makes sure that the movement will be maintained. Finally, the patient has to continue with the walking exercise and gradually increase its amount and he also can climb stairs to improve his strength (18). There are some studies that were done in order to prove the effectiveness of the physiotherapy post-thoracotomy surgery. Back in the year 2006, Ganzalo Varela and others did a study. This study was done to evaluate the influence of implementing a routine program of intensive chest physiotherapy on post operation respiratory morbidity and hospital costs in a series of pulmonary lobectomy patients during thoracotomy. 639 patients were asked to stop smoking before 3 weeks from the surgery. Subjects were assigned into control and physiotherapy treatment group. Before starting the physiotherapy program, patients were encouraged by the nurses to ambulate and to perform deep breathing maneuvers using incentive spirometer. The physiotherapy program was started before one day of surgery till the discharge day. -11- During the physiotherapy program, the patients were using a treadmill and an ergometer bicycle under the supervision of the physiotherapist. Using the treadmill and the ergometer bicycle helps in performing an effective cough and deep inspiratory maneuvers. Also, the program contains arm and shoulder exercises to prevent upper extremity impairment. The outcomes that were studied were the occurrence of post operative pulmonary complications (pneumonia and atelectasis), post operative death, and the length of hospital stay. Regarding the length of stay, it was measured from the admission date to the discharged date. The results of the study were positive. Concerning the mortality rate, it was lower in the physiotherapy treatment group (0.8% in physiotherapy group, 3.5% in the control group). And for the rates of the pneumonia and atelectasis, they were also lower in the physiotherapy treatment group. Rates of pneumonia were 5% in physiotherapy group, and 9.2% in the control group. For the atelectasis rates, they were 2% in the physiotherapy group and 7.7% in the control group. Finally concerning the length of stay, its median was 5.73 days (range, 3-22 days) in the physiotherapy group and 8.33 days (range, 3-40 days) in the control group (19). Another study was done in the year 2008, in order to look for the physiotherapy effectiveness in the reduction of the post operative pulmonary complications, pain, and lenght5 of stay. The subjects were assigned to a group that receive physiotherapy treatment or a group that receive an information sheet only. And the results of the study were proving the effectiveness of physiotherapy interventions (20). -12- Conclusion: According to the previous discussion and studies, the physical therapy has a role in preventing and treating the patientà ¢Ã¢â€š ¬Ã¢â€ž ¢s problems post- thoracotomy surgery. From the preventive side, the physiotherapists work on eliminating, decreasing, and preventing the impairments and the limitations of the patientà ¢Ã¢â€š ¬Ã¢â€ž ¢s activity. These limitations and impairments can be developed after the surgery if there was no care or if they have been neglected. Because of that, the physiotherapists are taking these preventions in order to limit those limitations and impairments. And from the treatment side, the physiotherapists are giving the patients treatment exercises that help in solving and treating the complications that already develop after thoracotomy or any surgery. These complications are the chest problems either it was secretion production, decreased chest expansion. -13-