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POEMS Syndrome Symptoms and Treatment

Share this: Facebook Twitter Reddit LinkedIn WhatsApp POEMS Syndrome: Paraproteinemic neuropathies, Organomegaly, Endocrinopathy, M-protein and Skin changes Abstract The POEMS syndrome, also known as Crow-Fukase syndrome, is a rare multi organ disorder characterized by polyneuropathy, organomegaly, endocrinopathy, M-protein spike and skin changes. Other associated features, such as sclerotic bone lesions, edema, ascites, hematological disor­ders and Castleman disease can also be present. We report a case of POEMS syndrome who presented with insidious onset, progressive sensorimotor polyneuropathy, pedal edema, ascites, hepatomegaly along with skin changes. X-ray pelvis showed osteosclerotic lesions. Thyroid function tests showed hypothyroidism. M-protein (IgG) monoclonal band was seen on immunoelectrophoresis. The patient was started on melphalan and corticosteroid combination therapy. We emphasis on the importance of recognizing a challenging diagnosis of a rare disease, which is shown to be treatment responsive. Introduction POEMS syndrome is a rare paraneoplastic disorder of plasma cell dyscrasias, which was first described in 1956 by Crow and then in 1968 by Fukase [1]. The name POEMS was given to it by Bardwick and co-workers in 1980 based on five salient features: polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes [1]. It is more prevalent in men, with male to female ratio of 2.5:1. It usually manifests in 5th and 6th decades of life. Its inheritance is uncertain and its pathophysiology is still not well understood. Case Presentation A 40-year-old male presented with progressive weakness, tingling and numbness sensation in both lower limbs for two years. He had swelling of lower limbs, abdominal distention and dermatologic changes in form of discoloration and thickening of skin over the cheeks, nose, hands and feet for one year. He had also gave history of erectile dysfunction and loss of libido for six months. There was no history of syncope, bony pain or drug abuse. He had no previous history of hypertension, diabetes or tuberculosis. On physical examination, the patient had bilateral pedal edema [Figure 1.c] and abdominal distention [Figure 2.a]. Skin was thickened and hyperpigmented over the face, fingers of the hands and shin (Figure.1a,b,c). Bilateral gynecomastia and testicular atrophy were present. Abdominal examination showed hepatomegaly and ascites. Higher mental functions and speech were normal. Fundus examination showed papilledema on both side and rest of the cranial nerves examination were normal. Motor power in upper limbs was normal and in lower limbs showed predominant distal weakness [Medical Research Council (MRC) 4/5 at hip joint and 4-/5 at ankle joint). Deep tendon reflexes in upper limb were diminished ( 1) including biceps, triceps and supinator and absent in lower limbs. There was 30% loss in pain, touch and temperature sense in both lower limbs below knees. Posterior column sensations (joint position and vibration sense) were also impaired in lower limbs below the anterior superior iliac spine. Romberg sign was positive. Hemogram, liver and renal function tests, muscle enzymes (creatine phosphokinase), serum ferritin and vitamin B12 level were normal. Serum total protein was 7.1 gm/dL, albumin 3 gm/dL, globulin 4.1 gm/dl, and A:G ratio 1:1.3. Fasting and postprandial blood sugar level were normal. Thyroid function test showed raised TSH level (16.62 μ/ml). Luteinizing hormone (LH) and testosterone levels were 15 IU/L (1.8-8.6 IU/L) and 111 ng/L (300-1,000 ng/dL), respectively. Antinuclear antibody (ANA), Rheumatoid factor (RF), serum human immunodeficiency virus (HIV) ELISA test, hepatitis B and C markers were negative. Ultrasonography of abdomen showed hepatomegaly (16 cm), moderate ascites and enlargement of multiple lymph nodes along the iliac vessels. Fine needle aspiration cytology of mesenteric lymph node was inconclusive. Ascitic fluid examination revealed exudative nature (SAAG <1.1). Ascitic fluid adenosine deaminase (ADA) and malignant cells were negative. Nerve conduction study showed sensorimotor demyelinating and axonal type neuropathy in both upper and lower limbs including bilateral median, ulnar, peroneal, tibial and sural nerves [Figure 3]. Cerebrospinal fluid examination was normal. X-ray pelvic bone showed multiple osteosclerotic lesions involving head of left femur and right iliac crest [Figure. 2.b]. X-ray skull and spine were normal. The serum protein electrophoresis showed gamma globulinemia with no monoclonal M spike. Immunoelectrophoresis using immunofixation method revealed monoclonal IgG lambda band. The bone marrow biopsy showed large atypical plasma cells in the range of 8%-10% [Figure. 4]. The patient was diagnosed as POEMS syndrome and was given melphalan (16 mg/m2) and corticosteroid combination therapy. The patient is still in follow up. Discussion POEMS syndrome is a rare, multiple system disorder, characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein band and skin changes. Any three of the five features may be present to establish diagnosis [2]. However, some authors have proposed clinical criteria for diagnosis in which includes two major criteria, which can be either presence of polyneuropathy or plasma cell proliferative disorder. Minor criteria include sclerotic bone lesions, organomegaly, edema, endocrinopathy, papilledema or skin changes [2]. Polyneuropathy is a predominant feature of POEMS syndrome and is found in >90% of the cases. It is usually a sensorimotor, axonal and demyelinating type polyneuropathy [3]. As in our patient, both axonal and demyelinating polyneuropathy are seen on electrodiagnostic studies. The mechanism of neuropathy is not known but the recent evidence of the presence of anti-neural antibodies points to an immunological mechanism [4]. Endocrinopathies occur with a frequency of 60%-80% and the most common are gonadal failure (70%) and glucose intolerance/diabetes mellitus (50%). Hypo or hyperthyroidism, hyperprolactinemia and adrenal insufficiency have also been reported. The mechanism of endocrinopathy is also not obvious; however, involvement of direct acting antibodies against hypothalamo-hypophyseal-axis and endocrine end organs has been hypothesized [5]. In our patient, impotence, loss of libido and testicular atrophy and hypothyroidism on ancillary laboratory investigation were present. Increased levels of vascular endothelial growth factor (VEGF) are found in POEMS syndrome. VEGF increases microvascular permeability, thereby inducing edema, ascites and pleural effusions as were present in our patient [6,7]. However, measurement of VEGF level in ascites was not available in our patient. Papilledema may be seen in approximately 37% of patients and is not associated with the increase in intracranial pressure. The real cause of papilledema is not still known. Hepatomegaly may be seen in up to 50% of patients with splenomegaly and lymphadenopathy occurring less often. The hyperpigmentation over the face, legs and hands was also observed in our case. The skin changes usually observed in POEMS syndrome are hyperpigmentation, lichenification, hypertrichosis, sclerodermoid changes and glomeruloid hemangiomas. Skin biopsy may show inflammation, fibrosis, or nonspecific changes. Monoclonal protein is detected in more than 90% of patients and may become positive in the follow-up of patients who have no monoclonal gammopathy initially [8]. Nearly all cases reported in the literature show lambda positivity as in our patient. It may be rarely found in urine and cerebrospinal fluid (CSF). The natural course of POEMS syndrome is chronic, with a reported median survival for a decade (8-13.8ys). The morbidity depends on the extent and number of systems involved. The cause of POEMS syndrome is still unknown. It is tempting to incriminate the presence of lambda light chains in the pathogenesis because of their unexpected frequency (more than 95% of patients), but histopathologic review of affected organs and nerves does not support that it is a form of deposition disorder. Increased levels of cytokines IL-1ß, TNF-á and IL-6, more specifically VEGF, appear to play a pathogenic role in the disorder [9,10]. In view of the constellation of a mixed polyneuropathy, monoclonal gammopathy, osteosclerotic myeloma, extravascular volume overload, bilateral papilledema, skin changes and endocrinopathies, our patient was diagnosed as POEMS syndrome. However, other close differential diagnosis like tuberculosis and hemochromatosis were ruled out with appropriate investigations. Patient was treated with combination of alkylating agent melphalan and corticosteroid. To conclude, when a patient present with unexplained sensorimotor polyneuropathy, signs of extravascular volume overload and evidence of other system involvement, a high index of suspicion should be kept for a diagnosis of POEMS syndrome, to avoid missing this rare syndrome, which is amenable to treatment. Figure Legends Figure 1. Photographs of patient showing skin hyperpigmentation over the face, hand and limbs (thin arrows). Thick arrow showing pitting edema over the left leg. Figure 2. Photograph of patient (a) showing abdominal distention (free fluid was confirmed by ultrasonography). X-ray pelvic bone (b) showing multiple sclerotic lesion over right iliac crest (thin arrow) and one large osteosclerotic lesion (thick arrow) over the neck of left femur (b). Figure 3. Nerve conduction study showing axonal and demyelinating neuropathy in right median nerve. Figure 4. Bone marrow smear in centre reveals one large atypical plasma cell, which has prominent nucleoli and abundant cytoplasm. There is loss of normal nuclear configuration with fraying border. References Bardwick PA, Zvaifler NJ, Gill GN, Newman D, Greenway GD, Resnick DL. Plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, M proteins and skin changes: the POEMS syndrome: Report on two cases and a review of the literature. Medicine (Baltimore). 1980;59:311-322. Dispenzieri A, Kyle RA, Lacy MQ, Rajkumar SV, Therneau TM, Larson DR, et al. POEMS syndrome: definitions and long-term outcome. Blood. 2003;101(7):2496-2506. Min JH, Hong YH, Lee KW. Electrophysiological features of patients with POEMS syndrome. Clin Neurophysiol. 2005;116(4):965-968. Kelly JJ Jr, Kyle RA, Miles JM, O’Brian PC, Dyck PJ. The spectrum of peripheral neuropathy in myeloma. Neurology. 1981;31:31-34. Reulecke MD, Dumas M, Merrier C. Specific antibody activity against neuroendocrine tissue in a case of POEMS syndrome with IgG gammopathy. Neurology. 1988;38:614-616. D’Souza A, Hayman SR, Buadi F, Mauermann M, Lacy MQ, Gertz MA, et al. The utility of plasma vascular endothelial growth factor levels in the diagnosis and follow-up of patients with POEMS syndrome. Blood. 2011;118(17):4663-4665. Watanabe O, Maruyawa I, Arimura K, Kitajawa I, Arimura H, Hanatani M, et al. Overproduction of vascular endothelial growth factor vascular permeability factor is causative in Crow-Fukase (POEMS) syndrome. Muscle Nerve. 1998;21(11):1390-1397. Miralles GD, O’Fallen JR, Talley NJ. Plasma cell dyscrasia with polyneuropathy; the spectrum of POEMS syndrome. N Eng J Med. 1992;327:1919-1923. Kanai K, Sawai S, Sogawa K, Mori M, Misawa S, Shibuya K, et al. Markedly upregulated serum interleukin-12 as a novel biomarker in POEMS syndrome. Neurology. 2012;79(6):575-582. Soubrier M, Dubost JJ, Serre AF, Ristori JM, Sauvezie B, Cathebras P, et al. Growth factors in POEMS syndrome: evidence for a marked increase in circulating vascular endothelial growth factor. Arthritis Rheum. 1997;40:786-778. Share this: Facebook Twitter Reddit LinkedIn WhatsApp
Art, Music, and Creative Writing homework help. Maladaptive Behavior & Psychopathology | FP6005 A01Assignment 2: Diagnostic Case ReportsClickÿhereÿto go to the Faces of Abnormal Psychology website. There, you will see twelve different disorders listed. For this module, view the following disorders:Borderline Personality DisorderSubstance UseAfter clicking a disorder, click the Diagnostic Overview tab in the left column. This will cover the major diagnostic features of the disorder. After that, click theÿDSM-5Features tab. You can then go though the Case History, Interview, and Treatment sections on the website. Finally, in the Assessment section, you can complete an optional multiple-choice quiz. You have to write a case report for each case study. You should use the format provided on the web page. There is a sample report that you can also view by clicking the link in the upper-right corner.The format for the sample report is as follows:Your NameInstructor’s NameClass/Section NumberBackgroundOutline the major symptoms of this disorder.Briefly outline the client’s background (age, race, occupations, etc.).Describe any factors in the client’s background that might predispose him or her to this disorder.ObservationsDescribe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.Describe any symptoms or behaviors that are inconsistent with the diagnosis.Provide any information that you have about the development of this disorder.DiagnosisDid you observe any evidence of general medical conditions that might contribute to the development of this disorder?Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?As per your observations, what is the client’s overall level of safety regarding the potential harm to self or others (suicidality or homicidality)?What cross-cultural issues, if any, affect the differential diagnosis?Therapeutic InterventionIn your opinion, what are the appropriate short-term goals of this intervention?In your opinion, what are the appropriate long-term goals of this intervention?Which therapeutic strategy seems the most appropriate in this case? Why?Which therapeutic modality seems the most appropriate in this case? Why?WritingWrite in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation. Include citations in the text and references at the end of the document in APA format.Submission Details:save your report as M2_A2_Lastname_Firstname.doc and submit it to theÿM2 AssignmentArt, Music, and Creative Writing homework help

All the instructions are mentioned in the attached word document. No references needed but used the attached powerpoints to

All the instructions are mentioned in the attached word document. No references needed but used the attached powerpoints to. All the instructions are mentioned in the attached word document. No references needed but used the attached powerpoints to refer to the topics in them to answer the case study question. It does not need to be 6 pages exactly as i specified but it should be sections as below Use the following steps to answer each quation in the case: 1. Introduce the context of the key leadership issue(s) of the business case that you have to find relevant solutions. It should run into 2-3 sentences. 2. Please identify and use the relevant theoretical frame(s), as discussed in the MGT522 course, as a lens to understand and analyze the business case to find relevant practical solutions to the leadership issue(s). It should run into next 2-3 sentences. 3.Use the above selected theoretical frame(s) to diagnose the leadership issues in detail to find out relevant solutions. It should run into next 4-5 sentences. 4.Do not forgot to write the concluding sections to your arguments as above. It should run into next 2-3 sentences. The attached slides are to support but not to limit; again no references needed and do not reference the slides but rather use the topics to answer the case study as required.All the instructions are mentioned in the attached word document. No references needed but used the attached powerpoints to

North Carolina State University Creation of List Type Data Project

online dissertation writing North Carolina State University Creation of List Type Data Project.

Set up your project with the given starting templates. The files should compile and run, but either no tests willbe run, or tests will run but be failing.2. For this project, start by uncommenting the first TEST_CASE in the assg07-tests.cpp file. These are the unittests to test the functionality of getSize() member function.3. Add the correct function prototype for the getSize() member function to the ListType class in theListType.hpp header file. The prototype consists of the name of the function, its input parameters and theirtypes, and the return value of the function.4. Add a implementation of the getSize() member function to the ListType.cpp implementation file. Thefunction should have the same signature as the prototype you gave in the header file. Documentation for the1function has not been given for you this time, so add documentation of your function first. Don’t forget toindicate that this function is a member of the ListType class.5. Your code should compile and run now. Make sure after adding the function prototype and stub your codecompiles and runs. However, your unit tests might be failing initially.6. Incrementally implement the functionality of your getSize() function (if needed). You should try to add nomore than 2 or 3 lines of code, and then make sure your program still compiles and runs. Start by adding codeto get the first failing test to pass. Then once that test passes, move on to the next failing tests until you haveall tests passing. If you write something that causes a previously passing test to fail, you should stop and figureout why, and either fix it so that the original test still passes, or remove what you did and try a new approach.7. Once you have the getSize() function implemented and all unit tests passing, you should then move on to theother functions in the order suggested. Some member functions use previous ones in this assignment, so dothem in the order given for you in the tasks below.
North Carolina State University Creation of List Type Data Project

Causes and Effects of Child Poverty in Britain

TAQ 1: TOPIC: CHILD POVERTY IN BRITAIN: THE CAUSES AND THE EFFECTS. WHAT IS THE PURPOSE OF THIS SOURCE? IS IT FACT, OPINION OR BOTH? GIVE EXAMPLES TO SUPPORT YOUR ANSWERS: HOW APPROPRIATE IS THIS SOURCE? GIVE EXAMPLES TO SUPPORT YOUR ANSWERS: To communicate, enlighten, inform the reader about child poverty. Also encourage the reader to get involved in helping those affected. Both. The CPAG blog write up has used both to cover this topic. Facts have been based on various surveys, data and statistics. This is to further help the reader understand the extreme importance of this issue and how it can be effectively tackled. The newstateman’s blog has used opinion based on some personal experiences. The objective of both write ups is to incline and motivate the reader to do something tangible to help children living in poverty thereby tackling the menace. The CPAG blog write up gives facts and figures aimed at making the reader fully understand the causes and effects of child poverty and how the reader can contribute to managing this issue. The newstateman’s blog used opinion based on personal experience thereby prone to be partial. TAQ 2: TOPIC: CHILD POVERTY IN BRITAIN: AN ANALYSIS OF THE CAUSES AND THE EFFECTS. The aim of this essay is to discuss and analyse the causes and effects of child poverty in Britain. It will start by giving a definition of child poverty, explaining and analysing the causes and effects of child poverty distinguishing between fact and opinion, looking into the severity of the effects of child poverty and lastly, suggesting ways with which this menace can be dealt with. According to According to the United Nations Children’s Fund (UNICEF 2006) “children living in poverty are those who experience deprivation of the material, spiritual and emotional resources needed to survive, develop and thrive, leaving them unable to enjoy their rights, achieve their full potential or participate as full and equal members of society”. The Christian Children Fund (CCF) definition is based on Deprivation (lack of essential conditions and services needed for the development of a child’s full potential), exclusion (denial of rights, dignity and voice as a result of prejudiced processes) and vulnerability (incapability of society to handle deal with threats to children in their environment). Children living in poverty are as a result of being born to poor parent(s) who are poor as a result of various reasons such as unemployment or low paid jobs, lack of education, government policies, disabilities and discrimination. When a parent lacks the required resources such as a regular disposable income to bring up a child, that child’s well-being is restricted. Other causes of child poverty includes teen pregnancy, unplanned pregnancy, increase in number of single parents (a child raised by a single parent is more likely to live in poverty than that raised by a couple) and insufficient benefits (CPAG 2015). In United Kingdom, the benefits system is in place to act as a safety barrier for people who are out of work or earn insufficient amount of money. The reality is that these benefits are hardly ever enough to cater for the needs of these people thereby affecting their families, leaving them to live below the poverty line (CPAG 2015). The effects of child poverty are not far fetching. This menace damages a child in all aspects- physically, socially, emotionally. A child living in poverty is prone to ill-health, low attainment in life, low morale and a feeling of rejection. These can give rise to anti-social behaviours which will in turn affect the society. According to Child Poverty Action Group (CPAG 2015), it was reported that child poverty costs the United Kingdom at least £29 billion pounds each year, £20. 5 billion of which is a direct cost to the government due to the additional demands for services and benefits. To effectively curb this issue, there has to be a collective effort from both the government and her people. The government has to provide profitable jobs with excellent incentives to motivate people to work; better benefits structure, where benefits received is not too much to discourage work and at the same time not too low in which case they are found living below the poverty line. REFERENCES AND BIBLOGRAPHY Child Poverty Action Group. 2015. Child poverty facts and figures. [Online] Child Poverty Action Group. Available at: [Assessed 16 February 2015]. Enrique, et al. 2006. Children living in poverty: Overview of definitions, measurements and policy. [Pdf] New York: United Nations Children’s Fund. Available at: [Assessed 16 February 2015]. TAQ 3: CHILD POVERTY IN BRITAIN: WHY YOU SHOULD ACT. Child poverty in Britain is a phenomenon that should be addressed by everyone whether an individual is being classed as middle class citizen or not as it affects the whole society in the long run. Having read through a few articles on child poverty, interesting facts and figures has made me both curious and emotional. According to the Child Poverty Action Group’s write up (CPAG 2015) which I read online, there are currently 3.5 million children living in poverty in the United Kingdom, that’s a ratio of more than one in four. These kids live in deplorable conditions, often left cold and hungry, unable to play and have fun with friends or even go on school trips. All these situations affect them in the long term. The CPAG blog also reported that by the age of sixteen, children receiving free meals at school achieve 1.7 grades lower at GCSE than their wealthier peers; they leave school with lower qualifications which in turn lead to lower earnings over the course of a working life time and it has also been projected that 4.7 million children will be living in poverty by 2020. I personally find these figures appalling and saddening and I believe that while the government has a responsibility to her people, companies and individual members of the society all have a role to play if we are to tackle this issue effectively. Increases in the number of single mothers or parent, unplanned pregnancies, teenage pregnancies are some of the underlying causes of child poverty. Teenagers (kids who think they are adults and matured enough to make major decisions, feel it is their God- given right to be rebellious and can hardly take care of themselves) should not be having children. These teenagers need to be sexually educated, encouraged to get involved in profitable activities that will open their minds and expand their horizons so they can tap into their full potential. This is not to say that sometimes these kids would not derail from the right path. This is where having a strong family unit comes into play. If and when they do, they need to be supported emotionally, physically, financially especially by family. Companies (minor, major, multi- national) should also be involved. These companies should have a social responsibility to the community in which they are operating. Having support groups, organising campaigns, making regular donations in cash and in kind and creating awareness will suffice. The government should not be less concerned. She has a duty to provide basic amenities, profitable jobs and benefits structure that will motivate and inspire her people. Children are gifts that should be cherished. They should not be born to suffer and live in poverty. They need to be nurtured in love because they are after all- OUR future.

Misery In Elizabeth Brownings The Cry Of The Children English Literature Essay

The Victorian Age was a period of stark contrasts between, on the one hand, extreme poverty, misery, exploitation, and social unrest, and on the other, the prosperity of the middle and upper classes. Victorians themselves were often characterized by the double moral standards they followed. They were pretending to be following the moral values, but were on the other side, involved in corruption (Buelens 54). When government investigations into child labour revealed the rampant exploitation of children, Browning responded with her poem The Cry of the Children (Browning 6). By an extensive use in symbols, the author portrays a direct indictment of social misery: In a sense of aggressive fury and frustration, she exposes the brutal exploitation of child labour in English coal mines and factories in which children were suffering because of harsh conditions (Greenblatt 1078). The poem’s aim is to get the attention of people no longer to keep silent but to bear witness to all the sufferings. The image, with which the poem opens, is one of pure sadness. Browning introduces the reader to children, who seem not to be happy: “They are leaning their young heads against their mothers, / and that cannot stop their tears” (TCC 3-4). [1] Though the cause of the children’s weeping is not given, it can be assumed that what they have to deal with must be terrible. Browning illustrates that what causes these children to cry is so terrible that even their mothers cannot comfort them. The first hint on child labour is, however, given in the following lines. By contrasting the children to other young offspring, Browning represents the youngsters to be innocent and to play around on wide-open spaces (Lamana 5/6). They do not live their lives how they should – That they were to be out at play in the fields, chasing their shadows, is emphasized by “The young fawns are playing with the shadows” (TCC 7). Children should be happy and enjoy their youth but unfortunately they cannot. Instead, they are “weeping bitterly!” (TCC 10)! The author continues this contrast in the next stanza: One may understand why elderly people weep when they have had a life full of experiences and look back on memories, wishing they had some more time to live their lives over again in a different way. One may also understand that it is in the nature of a tree to lose its leaves as it gets older. But it is behind one’s comprehension to understand why innocent, uncorrupted youngsters are weeping so bitterly, while they, in contrast to the old man, are still young (notice the repetition of the word young) and have a lot to discover. Hence, Browning points the finger of blame in the right direction when she confronts the English government with the children’s conditions, because no one seems to be cared enough to ask why these children are in sorrow (TCC 13-14). In pleading with her ‘brothers’, Browning literally wants to shake the English government up and make them realize how badly they are exploiting the children. A second image of indictment is read in the fourth stanza. Although the children still have to work long before leaving this world, they acknowledge that “it may happen/ that they die before their time” (TCC 36-37). They know that death is near for them if they continue working in bad conditions. They know this because it happened to little Alice: Not surprisingly, the image of death is drawn rather positive. It is obvious that although this little girl named Alice is dead, she is happier. She is no longer troubled because of these ordeals. Experiencing this, the children explicitly say they would be happier if they would die. It is disturbing to read how small children desire their death but even more disturbing to read how they at the same time, do not pin much hope on it because the “grave-rest is very far to seek” (TCC 32), as the child still has a long time to work before it gets to rest. The children in the poem also go on to describe Alice’s grave: “Little Alice died last year, her grave is shapen/ Like a snowball, in the rime (TCC 39-40). This part of the stanza illustrates how children witnessed other children like themselves die before their eyes. The description of the grave even illustrates that when children pass away; their bodies are not taken away for proper burial. Instead, these are being left behind and from time, as the skin gets hard, it gets covered by dust and dirt, looking like a snowball. The children pray for help but nothing is done. They conclude that if the people they meet everyday do not respond to their weeping, why God, who is so even further away, would be anymore likely to do so. This image also occurs in the next following stanza. The children explain how when they pray they know no other words except “Our Father” (TCC 117). One might argue that the children are, despite their condition, very religious and keep praying to God all the time in the hope that one day, God will make an end to all the misery. Actually, the fact that they only know two words emphasizes that these children were excluded from education and were sent to coal mines instead. They would have faith in God, “but grief has made [them] unbelieving” (TCC 130). Browning notes that this fact is also rendered by her friend R.H. Horne who wrote the commission’s report during the investigation (Browning 10). In the second last stanza, the author again makes effective use of contrasting images to display the children’s health conditions, severely damaged by the labour and the long hours of work in the mines and factories of those industrial times: Although they are only children, their experiences, as bleak and rough as they are, have taught them the grief of man but not its wisdom, as it is with age that one becomes more practical and proficient. The children feel defeated and are well aware that they will not get out of their situation if death does not liberate them. Slaves kept their faith strong in times of weakness. The children are slaves as well, but do not have the confidence in God. Their constant weeping is being ignored, which is hardly the sort of thing one would expect from a loving God. In the closing stanza, Browning makes a final plea to end child labour because “The coal-mine is the scene of a multitude of the most terrifying calamities, and these come directly from the selfishness of the bourgeoisie” (Bloy 13/17). As introduced at the beginning of this essay, Victorians themselves were often characterized by the double moral standards they followed. By writing this poem, Elizabeth Barrett Browning opens people’s eyes to the real life surrounding them. Cleverly, she lends a voice to the youngsters and let them speak up their mind loud and clear. The contrast marked by the young children having a lifetime to go and the harshness of the experiences they utter, may not lose its effect. The children’s cry not to turn a deaf ear on their demands but to bear witness to all their sufferings echoes throughout the whole poem. As the core image of the poem, the mine is described as a dark, ruthless place where children are robbed of a proper childhood and look into the jaws of death.

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