What is gum disease?

Causes and Symptoms

Bacterial infection is the most common cause of gum disease. In the early stages of the disease, only the soft tissues—the gums, or gingiva—are affected, but in later stages bacteria also attack the hard tissues underlying the gums.

The bacteria responsible for gum disease accumulate in plaque,
which is a sticky biofilm of bacteria that forms on the teeth above and below the gum line. Plaque that remains on the teeth for more than about seventy-two hours may harden into tartar, which cannot be removed completely except by a professional. Plaque accumulation is usually the result of inadequate tooth brushing and flossing.

Plaque contains many different kinds of bacteria. Bacteria that live below the gum line, where oxygen is low or lacking, are the main culprits in gingivitis, an inflammation of the soft gum tissues. Toxins produced by the bacteria destroy the collagen fibers that make up the connective tissue between the gum and the tooth, causing the gum to loosen and detach from the tooth. The widening and deepening of the space between tooth and gum produces a pocket. Whereas in healthy gums there is a crevice about 1 to 3 millimeters deep between the gum and tooth, in gingivitis there is a pocket up to 4 millimeters deep. The gum becomes movable instead of clinging to the tooth. The gum also swells, is red rather than a healthy pink, and bleeds when brushed or probed. At this early stage, there is little or no pain.

From a gum pocket, bacteria can advance to the bone and to the other hard tissues that support the tooth: the cementum, which covers the roots of the tooth, and the periodontal ligament, which anchors the tooth to the jawbone. Gum disease that has progressed to the bone is referred to as periodontitis. It usually results from a long-term accumulation of plaque and tartar.

In early periodontitis, the crests or peaks of the bone between the teeth have begun to erode. The patient may as yet be unaware of the problem because there is no pain. As the inflammation destroys the fibers of the periodontal ligament and further dissolves the bone, the pocket often deepens to between 4 and 8 millimeters. In advanced stages, most of the bone surrounding the tooth is destroyed and the tooth loosens. Abscesses and pain are common at this point. Advanced periodontitis can cause teeth to fall out or require extraction and is one of the main causes of tooth loss in adults.

In both gingivitis and periodontitis, the damage may be localized. Furthermore, the disease does not progress at a uniform rate but instead advances episodically, with periods of remission. Most adults have had gingivitis at one time or another, but some individuals are especially susceptible, including those who smoke, have certain medical conditions, or take particular medications.

Treatment and Therapy

Gum disease is treatable. To diagnose the disease, the dentist may use x-rays to determine the extent of bone loss and a dental probe to measure the depth of pockets. The dentist removes plaque and tartar by scaling the surfaces of the teeth and planing the surfaces of the roots. An ultrasonic scaler, which cleans the teeth with high-frequency vibrations, may also be used. Once the bacterial biofilm has been removed, the gums are able to heal and reattach to the teeth, thereby shrinking the pockets.

Oral antibiotics are also useful in fighting periodontitis, though they are not effective for gingivitis. In addition, antibiotics inserted directly into deep gum pockets can deliver high concentrations directly to the infected area.

Surgery is performed on some patients, either by a general dentist or by a periodontist. Under local anesthesia, flaps of gum tissue are cut away from the underlying bone, thus allowing better access for scraping and cleaning the tooth roots and for correcting bone defects caused by the infection. Some of the infected gum tissue is also removed, and the remaining gum is sutured back in place.

An important tool in the fight against gum disease is good oral hygiene. Individuals should brush twice a day and use dental floss daily to remove plaque. In addition to toothpastes, effective cleaning agents include baking soda, peroxide, and some mouth rinses. A regular schedule of teeth cleaning by a dental professional is also essential. Depending on how fast a patient accumulates tartar, professional cleaning may be required every three to six months.

Perspective and Prospects

Humans have attempted to clean their teeth since prehistoric times. Early humans fashioned implements out of twigs and bone splinters to remove bits of food trapped between their teeth. Later, the toothpick became the main tooth-cleaning tool. The Chinese are credited with inventing the toothbrush around 1000 CE. It was not until the late 1930s, however, that an inexpensive toothbrush became available.

Research on the causes, prevention, and treatment of gum disease is being conducted at dental schools and at the National Institute of Dental and Cranio-Facial Research. Research areas include attempts to regenerate periodontal tissues. Bone grafting can help restore lost bone, and guided tissue regeneration may help re-create periodontal ligament.

Bibliography

Amyes, Sebastian G. B. Bacteria: A Very Short Introduction. Oxford: Oxford University Press, 2013.

Anand, Vishal, and Minkle Gulati. Current Trends in Periodontics and Implant Dentistry. Hauppauge, New York: Nova Science Publishers, 2013.

Blayden, Jessica, and Angie Mott. Soft-Tissue Lasers in Dental Hygiene. Oxford: Wiley-Blackwell, 2013.

Christensen, Gordon J. A Consumer’s Guide to Dentistry. 2d ed. St. Louis, Mo.: Mosby, 2002.

Marsh, P. D. “Dental Plaque.” In Microbial Biofilms, edited by Hilary Lappin-Scott and J. William Costerton. New York: Cambridge University Press, 1995.

National Institute of Dental and Craniofacial Research. Periodontal (Gum) Disease: Causes, Symptoms, and Treatments. Bethesda, Md.: U.S. Department of Health and Human Services, 2012.

Porter, Robert S., et al., eds. The Merck Manual Home Health Handbook. Whitehouse Station, N.J.: Merck Research Laboratories, 2009.

Purkait, Swapan Kumar. Essentials of Oral Pathology. New Delhi: Jaypee, 2011.

Serio, Francis G. Understanding Dental Health. Jackson: University of Mississippi Press, 1998.

Smith, Rebecca W. The Columbia University School of Dental and Oral Surgery’s Guide to Family Dental Care. New York: W. W. Norton, 1997.

Wood, Debra. "Gingivitis (Gum Disease)." Health Library, September 12, 2012.

To what extent did the American Civil Rights movement influence Australia's Freedom Rides and how are they similar and different?

The US Civil Rights movement had a very large influence on the Freedom Rides program in Australia, and it's quite possible that Freedom Rides would not have existed otherwise.

In 1964, a protest at the University in Sydney against racial discrimination in the US was held in solidarity with similar protests going on in the US. But one of the most common critical responses to that protest was that Australian protesters should "look to their own backyard"---that is, that racial discrimination in Australia against Aborigine people was just as bad as racial discrimination against African-American people in the US.

A group of University of Sydney students who were at that protest took it upon themselves to determine whether this was really true, and if so, what could be done about it; so they went on a fact-finding mission across New South Wales, documenting the treatment of Aborigine people in several cities both in writing, in photographs, and on video. This ultimately became the Freedom Rides.

The Freedom Rises raised a great deal of awareness of discrimination against Aborigines and helped expand a new civil rights movement in Australia, which modeled itself quite explicitly after the civil rights movement in the US.

One difference between the two is that it took Australia longer to make major headway in their civil rights movement; while the Civil Rights Act was passed in the US in 1964, the Racial Discrimination Act was not passed in Australia until 1975, over a decade later.

There is another major difference that I think is worth pointing out: Aborigine people are indigenous to Australia. In this respect they are more like Native Americans in the US, who to this day are treated a good deal worse than other racial minorities. While the US civil rights movement did include them in theory, in practice this was not always the case, and the focus was often quite strongly on rights for African-Americans as opposed to other racial minorities such as Asians and Native Americans. Conversely, African-Americans were brought to the US from Africa by the Atlantic slave trade. While slavery did exist in Australia, there was never a very large slave population in Australia the way there was in the US. These different historical causes of racial injustice led to different kinds of oppression and different responses to that oppression.

What are the similarities between capitalism and communism?

Both capitalism and communism are economic philosophies that concern how surplus might be allocated in a particular society. From there on out, the two are quite different. 

Capitalism is an economic philosophy that aims to foster the growth of individual economic pursuits. In a capitalist society, individuals are free to choose where to invest their money based on what they think is valuable, and the state protects this right. Unfortunately, this can result in great economic disparities, especially when some people are systematically prevented from having equal opportunities to propose and develop their ideas as marketable. 

In a communist society, the economy is controlled by the state. Ideally, the state is able to provide for all people so their needs are met. One of the drawbacks of communism is that it can inhibit a person's ability to propose and develop new ideas because everyone is held to the same standard. While all people are offered the same liberties and access to healthcare and education under communism, it also means that people who might have profitable ideas can't develop them. All surplus money in a communist society—that is, money that doesn't go to maintaining survival—goes right back into development of the state, rather than investing in individual business opportunities. 

There are positive and negative implications of both philosophies, so I suppose you could say they have that in common, too!

In what way does Lennie resemble Candy's dog? Use evidence from the text for support.

In John Steinbeck's novella Of Mice and Men, Candy's dog and Lennie share several similarities: their relationships with other characters, their defining characteristics, and their fates. 

Relationships: 

Both Lennie and Candy's dog are cared for by men in circumstances that are difficult, demanding, and depressing. However, each of these men feels a sense of obligation, and more importantly, or loyalty to continue to care for and protect their respective wards. 

Beyond the men who take care of them, both Candy's dog and Lennie are mistreated and mistrusted by a world that sees them as worthless.

Characteristics:

Both Candy's dog and Lennie are disabled; Candy's dog is physically disabled, mostly due to his old age, whereas Lennie is intellectually disabled. These disabilities render them dependent on their caretakers. 

Fates:

Both Lennie and Candy's dog are shot, and both their caretakers feel that this execution was their own responsibility. One significant difference is that Candy, who faces this situation first, cannot bring himself to shoot his dog, whereas George does end up shooting Lennie himself. 

During the trial in Harper Lee's To Kill a Mockingbird, how does Tom Robinson place his hand on the Bible?

The method in which Tom Robinson places his hand on the Bible is seemingly trivial, but it actually turns out to be one of the most important details in the famous trial scene. As such, it's not surprising that Harper Lee describes the method with which Tom places his hand on the Bible in great detail:

Thomas Robinson reached around, ran his fingers under his left arm and lifted it. He guided his arm to the Bible and his rubber-like left hand sought contact with the black binding. As he raised his right hand, the useless one slipped off the Bible and hit the clerk's table. (192) 

Lee's description makes it clear that Robinson's left arm and hand are completely useless, crippled and unable to function. This fact is a key detail in the case, as Atticus earlier established that Mayella Ewell was beaten by a man who was left-handed. Obviously, Robinson couldn't have done it, as his left arm is completely mangled. Mr. Ewell, Mayella's father, however, is ambidextrous, meaning he can use his left hand equally as well as his right. As such, Lee's attention to Robinson's left arm becomes a crucial detail in proving his innocence and Mr. Ewell's guilt. 

Why is Hamlet mad at Ophelia?

In the third act of Shakespeare's Hamlet, Ophelia goes to Hamlet to return "remembrances" that he had given her when he was wooing her. He becomes upset with her because she is completely rejecting him by returning his gifts, but he also knows that she is acting under the direction of her father to spy on him. He asks her if she is honest, as if to also ask if she is being deceitful at that very moment. This so happens to be the case because she knows that Claudius and Polonius are watching the couple as the scene plays out. The uncle and father want to see how Hamlet reacts to Ophelia and to find out if he is really going crazy.

Hamlet becomes emotionally charged because he truly loves Ophelia, but he can't do anything about that at the moment because he is pledged to avenge his father's death. He becomes very frustrated that on top of having to decide what to do about his murderous uncle, he now has to deal with Polonius manipulating his love to go against him. He responds angrily by saying the following:

"I have heard of your paintings, too, well enough. God hath given you one face, and you make yourselves another. You jig, you amble, and you lisp, and nickname God's creatures, and make your wantonness your ignorance. Go to, I'll no more on't. It hath made me mad. I say we will have no more marriages. Those that are married already—all but one—shall live. The rest shall keep as they are. To a nunnery, go" (III.i.142-148).

The above passage also shows that Hamlet has lost faith in the sanctity of marriage, due to the fact that his mother betrayed his father to marry his uncle. And now, the woman he would have married has betrayed him by listening to her father rather than staying true to him. (This should be no surprise, though, for daughters were supposed to obey their fathers completely until they were married. Ophelia acts as the dutiful daughter at her father's bidding during this scene and by rejecting Hamlet.) Unfortunately, the conflict intensifies at this point because Hamlet realizes that he has lost his trust in Ophelia along with the trust he has already lost in his mother.

In chapter 7 in To Kill a Mockingbird, what connections can you make concerning the weather and culture in Maycomb?

Here's the passage from Chapter 7 where the narrator mentions the weather:

"There are no clearly defined seasons in South Alabama; summer drifts into autumn, and autumn is sometimes never followed by winter, but turns to a days-old spring that melts into summer again. That fall was a long one, hardly cool enough for a light jacket."

We know that Maycomb culture moves slowly and is old-fashioned, to the extent where you'd say, "Yeah, nothing EVER changes in Maycomb." Folks have been doing the same thing there, generation after generation. The same traditions, the expectations just continue there as if time is standing still in the town.

That's exactly the feeling that we get when we read this weather description from Chapter 7. Time drifts by without any clear, regular changes that we expect in most other places. Perhaps the rest of the country has moved into a chilly winter (or, pushing that idea of change further, perhaps the rest of the country is making technological and social advances) while Maycomb isn't.

Even though it might seem boring when the narrator starts talking about the weather, it's always a good idea to pay attention to those descriptions instead of skipping past them to get to the action and dialogue of the story. Those descriptions of the weather can play an important role in establishing theme, tone, mood, setting, symbolism, and more. For a full discussion of this concept, with examples, check out Thomas C. Foster's book How to Read Literature Like a Professor, specifically "Chapter 10: It's More Than Just Rain or Snow."

In Seedfolks, how did Curtis affect the garden and his community?

Curtis, known throughout the community for his massive muscles, begins to plant tomatoes in the garden on Gibb Street as a way to apologize to his ex-girlfriend for cheating on her. Curtis's ex-girlfriend, Lateesha, "had a serious thing for tomatoes" and Curtis plants the tomatoes next to the sidewalk where she can see them from across the road. As the tomatoes start to grow, Curtis notices people began stealing them from the garden. Curtis then meets Royce, a fifteen-year-old boy who sleeps in the garden at night to avoid going home to an abusive father. Curtis befriends Royce, buys him breakfast and a new sleeping bag, then makes a deal with him. Curtis gives Royce a pitchfork to protect his tomatoes from people trying to steal them. As the novel progresses, other gardeners begin talking to Royce and trust him with weeding and watering their plants. As Royce's popularity grows, the families in the community hear about his situation and begin to bring him food. Curtis not only plants beautiful tomatoes in the garden, but also improves Royce's life by helping and trusting him. The community gardeners also benefit from Royce's hard work in the garden and his friendship.

Do you think modern tools of communication, such as the Internet, have hindered or improved the development of relationships? Does this vary for...

Modern forms of communication, including the Internet, have had a mixed effect on relationships in general. The Internet, including the use of various forms of social media, has allowed people to stay in contact with each other much easier. With various social media sites, such as Facebook, it is very easy to keep track of what your acquaintances are doing. Without the Internet, many of these connections would very likely be lost. The Internet has also made it easier for people to find and to develop intimate relationships with people whom they very likely wouldn’t have ever met. Internet dating sites have become very popular. It allows people to have a greater opportunity to find a lifelong partner. Studies have shown that Internet dating has increased marriage rates. Thus, there is evidence to suggest that the Internet can enhance both casual and intimate relationships.

The Internet also can have a negative impact on relationships. The Internet can be a very impersonal tool. People develop friendships without ever really knowing the people they have met online. People have used the Internet to say harmful things about other people. Some people have used the Internet to avoid confrontations. Some people have used the Internet to end an intimate relationship. There is no substitute for seeing a facial expression, looking at body language, or feeling the gentle touch or a hug from a person. You can’t get these images or feelings from the Internet.

The Internet can also make it hard to get to know a person. I am answering your question, yet I know nothing about you. You know nothing about me. I answer your question, and we both move on with our lives. If we were face to face in the classroom, we would have a better understanding of each other. We often deal with people in a virtual world. This creates a very impersonal environment. People who work online without ever seeing the people with whom they interact, miss out on a dynamic that exists in the workplace. The connections are casual at best. There is a big difference between working directly with people that you see and know compared to working with somebody that you have never met. People may have 1,500 Facebook friends, but how many real friendships do they really have?

The Internet has had both positive and negative impacts on relationships.

In Book 1 of Homer's The Odyssey, find a quote that supports how the Greeks value family. What does it suggests that Homer starts his story with...

The ancient Greeks valued family as is clear when Athena speaks to her father, Zeus, about bringing Odysseus home.  She says that she will go to Ithaca "'to rouse his son yet more and to put vigor in his breast [...].  To Sparta will [she] send him and to sandy Pylos, to try to learn of his dear father's coming, and so to win a good report among mankind.'"  Although Odysseus is somewhat of a favorite of Athena's, it is notable how strongly she believes that he should be allowed to go home and rejoin his loyal wife, Penelope, and faithful son, Telemachus.  It is worth it, to her, to take this responsibility on herself, to help them all be reunited.  Moreover, she claims that his "vigor" in attempting to locate his father will strengthen his reputation.

Further, filial piety is of such cultural importance that Telemachus, though he is only a very young man, must be brave enough to leave his home and embark on what could be a very perilous sea journey to search for news of his long-missed father.  We know that Telemachus has a strong desire of his own to find Odysseus, and, yet, Athena says that she will rouse him "more" than the extent to which he already feels compelled.  As she speaks with him, later in the Book One, she "turn[ed] his thoughts upon his father more even than before."  The extent to which she feels the need to increase his already strong sense of family honor and loyalty to his father shows us just how championed these feelings are in ancient Greek culture.

What character sketch of Mr. Merton S. Keith is found in Helen Keller's autobiography The Story of My Life?

In 1896, Helen began studying at the Cambridge School for Young Ladies in preparation for admittance into Radcliffe and was soon accompanied by her younger sister Mildred. But when Helen grew ill and could not attend classes one day during her second year, Mr. Gilman, the school's principal, argued that she was "breaking down" from the stress and insisted he change her schedule. Helen reports in Chapter XIX that the change in her schedule "would have rendered it impossible for [her] to take [her] final examinations with [her] class." When Miss Sullivan tried to battle Mr. Gilman on Helen's behalf but was unable to reach an agreement, Mrs. Keller, Helen's mother, had both Helen and Mildred withdrawn from the school. Instead, Helen continued her studies under a tutor of the Cambridge school by the name of Mr. Merton S. Keith.

Helen studied "algebra, geometry, Greek and Latin" under Mr. Keith twice a week while she was staying at Wrentham then five times a week once she was back in Boston. Miss Sullivan interpreted all of his instructions for Helen.

Helen describes her tutor as always having a very "gentle and forbearing," meaning tolerant, nature no matter how long it took her to grasp a subject of study. Though Helen found languages and literature easy subjects, she struggled to learn algebra and geometry; however, he was able to make mathematics interesting and patiently continued to help her, no matter how long it took her to grasp a concept. Helen was so grateful for his patience and teaching style that she notes her "stupidity would often have exhausted the patience of Job."

All in all, through her descriptions of Mr. Keith, we develop the understanding that he was a very well-educated, patient, kind, and level-headed man, whom she learned a great deal from, much more than she would have learned in the classroom.

What happened the night the narrator hung Pluto? Was this a coincidence?

The night the narrator hung Pluto, his house and everything he owned went up in flames. He, his wife, and a servant barely made it out of the house with their lives, but everything else was destroyed. Poe never gives an explanation for how the fire started, so the readers are left to wonder; he does, however, describe a certain event after the fire that certainly hints that it had something to do with the cat. Only one wall survived the fire, and upon this wall, there was the image of a cat. The narrator gives a scientific explanation for the surprising image, saying that someone had thrown the cat, which had still been hanging in the tree, through his bedroom window to alert him about the fire; then, due to a combination of the lime from the wall plaster, the flames, and the ammonia from the cat's dead body, its image was burned onto the wall. But that information is given to us as the narrator's supposition, not as an actual explanation.

In the end, the question of whether it was a coincidence or not depends on what kind of person you are. If you are a superstitious person by nature, then the fire was not a coincidence; it was retribution for what the narrator did to Pluto. However, if you are a more logical, scientifically minded person, then the fire was just a coincidence, and the image of the cat was exactly what the narrator supposed it was.

What signs are found in Jeanne DuPrau's The City of Ember?

Signs are certainly a very frequent recurring motif author Jeanne DuPrau uses in The City of Ember. One of the most important signs is the "E drawn with curving lines" on the surface of a stone in a cluster of stones along the river in the Pipeworks, right where the "river disappeared into a great hole in the Pipeworks wall" (Ch. 14). Lina and Doon have figured out that this E stands for egress and leads to the way out of Ember.

In chapter 15, after Lina and Doon find the door leading into the boat room, the candles, and matches, they discover other important signs. The one boat in the first room and the metal box is labeled with signs, and Lina assesses that the signs are teaching tools to help the citizens understand the directions on the piece of paper Lina found:

We learn what's what on the one that has signs. "Boat." "Paddles." "Candles." "Matches."

Lina and Doon then fully understand that the river is the way out of Ember and must be traversed using the boat and paddles.

In chapter 19, after they follow the river in the boat, Lina and Doon find the entrance to a path on a rock shelf. On one of the rocks, Doon finds another very important and encouraging sign:

Welcome, Refugees from Ember!
This is the final stage of your journey.
Be prepared for a climb
that will take several hours.
Fill your bottles with water from the river.
We wish you good fortune,
The Builders. (Ch. 19)

Other signs mentioned throughout the book are the date sign that hangs in Harken Square, mentioned in chapter 2; signs in store windows that, as Lina observes in chapter 11, read "'Closed' or 'Open Mon. Tues. Only'"; and signs protestors are using to picket the mayor, which read, "WHAT solutions, Mayor Cole," as mentioned in chapter 12.

How did Ms. Emily change after her father's passing?

Emily Grierson’s father was a domineering man who controlled his daughter’s life. The narrator says, “We had long thought of them as a tableau, Miss Emily a slender figure in white in the background, her father a spraddled silhouette in the foreground, his back to her and clutching a horsewhip, the two of them framed by the back-flung front door.” Emily’s mother was dead and her father turned away any young men who wanted to court Emily with the excuse they were not good enough. Emily remained fairly isolated in the house with her father.

When the townspeople somehow discerned that Emily’s father died, they went to offer their help and sympathy. They also indulged their avid curiosity about Emily and the life she lived behind those mysterious walls. However, Emily will not let go of her father:

“She told them that her father was not dead. She did that for three days… We did not say she was crazy then. We believed she had to do that. We remembered all the young men her father had driven away, and we knew that with nothing left, she would have to cling to that which had robbed her, as people will.”

Emily retreated into lonely isolation, rarely leaving the house. Nevertheless, she did go out enough to meet Homer Baron, the Northerner whom the town believed was too low class for Emily. When she bought a men’s toiletry set, they believed she and Homer would be married. But Homer disappeared and Emily withdrew into complete isolation. The narrator comments, “After her father's death she went out very little; after her sweetheart went away, people hardly saw her at all.” No one entered the house except Tobe, the servant who had been with her family for years.  The pattern she practiced of isolation and refusing to let go of those she loved, even when they died, continued until her own death.

How is Paris in Romeo and Juliet like the other Paris in the Iliad?

The short answer? He isn't much like him at all. In both texts, the two men known as Paris are most known for how they court and seduce the women they are interested in. In this, they couldn't go about it more differently. While Paris in the Iliad comes as a guest to Menelaus's court and then steals away with his wife Helen in the dead of night, Paris in Romeo and Juliet follows all of the proper customs for courtship and marriage, approaching Juliet's father to state his intentions and receive permission before even speaking to Juliet herself. Romeo and Juliet Paris is the epitome of respectability and etiquette, while Iliad Paris is far more impetuous and self-interested.

However, there is a strong character comparison between Iliad Paris (who I'll just call Paris from now on) and Romeo. Romeo's courtship methods are much more similar to Paris's sneaky methods. Romeo sneaks into the garden beneath Juliet's balcony after they meet at the Capulet party and tries to seduce her there, later marrying her (not to mention consummating the marriage) in secret. Both Romeo and Paris eschew social customs to pursue their beloved.

Additionally, both Romeo and Paris are known for their "lover, not a fighter" attitudes. Even before meeting Juliet, Romeo doesn't seem that active in the feud between Montague and Capulet, and he is especially peaceful after, stepping between Mercutio and Tybalt as they fight. Likewise, Paris is constantly chastised for lying around with Helen while his brothers and the other men of Troy go out and fight his war for him. Even when he does fight, he uses the cowardly weapon of a bow and is more concerned with looking cool than actual strategy and combat.

Finally, as both of the men's wooing proves, they are both of a reckless nature, often acting before they think. Consider Romeo drinking poison immediately upon seeing Juliet's body and Paris choosing a goddess to give the golden apple to in the first place, knowing that he'll be angering two others.

What is pelvic inflammatory disease (PID)?

Causes and Symptoms

Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper genital tract. The microbes involved may be sexually transmitted organisms (such as Neisseria gonorrhea

or
Chlamydia trachomatis) and/or endogenous
bacteria found in the vagina (for example Staphylococcus, Streptococcus, or Bacteroides species). These microorganisms can travel from the lower genital tract (vagina, cervix) into the upper genital tract (uterus, Fallopian tubes, ovaries, and pelvic cavity) and establish infection there. Occasionally, PID can occur via another mechanism, such as infection and rupture of the appendix or lower gastrointestinal tract leading to spillage of bacteria into the pelvic cavity.

Most cases of PID are asymptomatic. In cases where symptoms occur, the patient has lower abdominal or pelvic pain. The Centers for Disease Control and Prevention (CDC) stipulates the diagnostic criteria for PID, noting that the diagnosis is made on clinical findings rather than on laboratory evidence. On abdominal examination, the lower abdomen is tender to palpation. Upon pelvic examination, either the cervix is tender upon movement by the examiner or one or both ovaries or Fallopian tubes is tender to palpation; both of these symptoms can be present as well. Other symptoms and signs include fever and abnormal cervical discharge.

Laboratory tests can be helpful in establishing a diagnosis when clinical symptoms are ambiguous and in emphasizing the need for partner treatment. The tests include blood tests that suggest systemic
inflammation (such as the erythrocyte
sedimentation rate) and cultures for N. gonorrhea or C. trachomatis. With ultrasound or other imaging techniques, fluid collections associated with the Fallopian tubes, ovaries, or elsewhere in the pelvic cavity can be consistent with PID.

On rare occasions, PID can spread to the upper abdomen, leading to pain and tenderness there. In particular, the infection can affect the region surrounding the liver, leading to Fitz-Hugh Curtis syndrome.

Long-term consequences of PID can be significant and can occur in asymptomatic as well as symptomatic patients. PID can cause scarring of the reproductive tract leading to infertility. PID increases the risk for ectopic pregnancy,
a potentially life-threatening condition. If the infection spreads beyond the reproductive tract, then organs such as the bowels may become involved in the infection as well. Any organs involved in the infection run the risk of becoming damaged and scarred. In addition to the acute pain of PID, the disease can also lead to chronic pelvic pain, which can be difficult to treat.

Treatment and Therapy

Pelvic inflammatory disease is usually treated in an outpatient setting, although severe cases require hospitalization with intravenous medications. Antibiotics are the first-line treatment for PID, which is most commonly treated empirically based on clinical suspicion. Because PID is polymicrobial, combinations of antibiotics, each targeted at different bacteria, are given simultaneously. One common regimen involves cefotetan plus doxycycline. Metronidazole is now added to many regimens as a third drug to cover for anaerobic organisms.

Since PID is usually sexually transmitted, therapy involves counseling regarding the prevention of sexually transmitted infections (STIs) and safer sexual techniques. Condoms and other barrier techniques decrease the spread of STIs. Anal penetration followed by vaginal penetration during intercourse may increase the risk of infection of the female reproductive tract. Testing for other STIs, such as hepatitis B and C and syphilis; wet prep testing for bacterial vaginosis and trichomonas; and screening for human immunodeficiency virus (HIV) is encouraged, since the risk factors for PID are similar to those for other STIs. Contact tracing is offered to notify sexual partners of their possible exposure to STIs and to encourage them to seek medical attention. Treatment of these partners can decrease reinfection of the patient from subsequent sexual encounters and prevent the partners from spreading infection to others.

Perspective and Prospects

One of the first reports of PID was from ancient Greece and involved a case in which pus from the pelvis was drained through the vagina. It was not until the 1880s, however, that the sequence of events starting from lower genital tract infection ascending to cause upper tract disease was recognized. With the widespread use of laparoscopy in the 1960s, a more accurate diagnosis of PID could be made, allowing clinicians to recognize that PID has many clinical presentations.

Future prospects focus primarily on the prevention of PID, since treatment does not prevent many of the long-term effects. Prevention involves continued widespread screening of asymptomatic men and women at risk for STDs, as well as partner referral and safer-sex education. Studies have shown that the screening and treatment of asymptomatic women for STDs has reduced the prevalence of these infections in the general population in the United States, thus translating into a reduction in the incidence of PID. With these prevention techniques, there is hope that the morbidity and serious sequelae of PID will be reduced.

Bibliography

Holmes, King K., et al., eds. Sexually Transmitted Diseases. 4th ed. New York: McGraw-Hill Medical, 2008.

Kasper, Dennis L., et al., eds. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005.

"Pelvic Inflammatory Disease (PID) Treatment." Centers for Disease Control and Prevention, March 1, 2013.

Schuiling, Kerri Durnell, and Frances E. Likis. Women's Gynecologic Health, 2d ed. Sudbury, Mass.: Jones and Bartlett Learning, 2013.

Sutton, Amy L. Sexually Transmitted Diseases Sourcebook. Detroit, Mich.: 2013.

Sweet, Richard L., and Harold C. Wiesenfeld, eds. Pelvic Inflammatory Disease. New York: Taylor & Francis, 2006.

Vorvick, Linda J. "Pelvic Inflammatory Disease (PID)." MedlinePlus, September 12, 2011.

Workowski, Kimberly A. “Sexually Transmitted Diseases Treatment Guidelines 2010.” Centers for Disease Control and Prevention, December 17, 2010.

Identify and explain three literary devices used in Katherine Mansfield's short story "Miss Brill."

Katherine Mansfield is renowned for her stories of lonely women, and Miss Brill is probably one of the most well-known. This is a story of little action but of deep character development; Mansfield thus relies heavily on descriptive words and phrases to help the reader see and feel what the protagonist experiences.

This descriptive language begins right away with the use of several metaphors, similes in particular. Miss Brill describes the sky as 

"like white wine splashed over the Jardins Publiques"

and the night air as 

"like a chill from a glass of iced water before you sip"

and the conductor of the band as behaving

"like a rooster about to crow."

Similes are the most common, easily recognized literary devices; they compare two dissimilar things with a single connecting word. This story is told in the third person limited from Miss Brill's cheerful and optimistic point of view. Given that she is an English teacher, it is interesting that she would see life through a series of simple comparisons. This tells the reader that perhaps she has a simple and somewhat narrow idea of what the world is and should be. These first similes at the beginning of the story are bright and positive; they contrast sharply with the final one Miss Brill uses in the last paragraph:

". . . went into the little dark room—her room like a cupboard . . ."

This, of course, is after her outlook has been dramatically changed by the rude young couple in the park.

The second dominant literary device that shouts to the reader immediately is the personification in the opening paragraph. Miss Brill remembers taking out her fox-fur stole that afternoon:

"What has been happening to me?" said the sad little eyes.

She seems to see her fur as an extension of herself. She takes extravagant care of it and believes it to be a point of pride. This question, though, that she projects on this object that she cherishes can tell the reader much about the protagonist. Is it the fur enclosed in its box that Miss Brill believes has been "sad," or Miss Brill herself, who is so often enclosed in her room alone? Again in the final paragraph, Miss Brill projects her own feelings onto the fur when she puts it away after coming home from the park:

"But when she put the lid on she thought she heard something crying."

Finally, the transformation of Miss Brill hinges on Mansfield's use of symbolism. The entire parade of humanity at the park, from the band to the passersby, all symbolize a surrogate family for Miss Brill. She joined with the crowd for what she believed was a singular purpose—enjoying the music and the company—much the way a congregation joins together for worship. For this reason, the young couple who bitterly reject her presence shatter the world Miss Brill has created.

What are some different literary theories?

Literary theories are frameworks used by critics to analyze various works of literature. They each operate on different assumptions, and focus on distinct aspects of a text. Though a variety of literary theories exist, the most popular literary theories are Formalism, Psychoanalytic Criticism, Marxist Criticism, and Reader-Response Criticism.

Formalists view a text as distinct from its author and historical background; they instead assume that a text's meaning is derived from the text itself. Formalists analyze how a work's various components, such as its symbols, characters, conflicts, and ironies, contribute to the overall meaning.

Psychoanalytic critics use Sigmund Freud's psychological theories to explain characters' behaviors. Some Freudian concepts they employ are the unconscious, ego, desire, repression, and the Oedipal complex.

Marxist critics examine how a text depicts socioeconomic systems. They explore how a work represents class distinctions, and ask who the principle character or characters' efforts ultimately benefit.

Reader-Response critics primarily concern themselves with how readers respond to a work. Critics of this school assume that a text's meaning is found in the interaction between the reader and the text.

How do clouds form, starting from the absorption of heat by the earth to rainfall?

The process that covers cloud formation starting from the earth absorbing heat and culminating in rainfall is known as the water or hydrologic cycle. The water cycle refers to the continuous motion of water below the earth’s surface, on the earth’s surface and in its surrounding atmosphere. Water moves from below the earth and on its surface into the atmosphere; it then goes back to earth in the form of rainfall. For this to occur, water goes through a variety of processes which change its state. Water changes state into liquid, vapor, and ice as it goes through different processes. The processes include evaporation, condensation, precipitation, infiltration, and runoff.

Clouds form after water from the earth is exposed to heat and evaporates into the atmosphere. The rising water vapor then begins to condense at high altitudes because of the drop in temperature (the higher you go, the cooler it becomes). When a large body of the vapor condenses and concentrates in the atmosphere, it forms visible clouds. When the clouds become dense enough, the water droplets collide and fall as precipitation (rain, snow and hail among others).

What is hormone replacement therapy (HRT)?

Related cancers:

Breast and uterine cancers; possibly ovarian, testicular, and prostate gland cancers

Definition:
Hormone replacement therapy (HRT) most often involves the administration of estrogen alone or estrogen in combination with progesterone. Estrogen is a general term for any number of sex hormones, including estradiol, the main estrogen produced by the body, and estriol and estrone, which are products of estradiol metabolism. Progesterone is another sex hormone, which often opposes estrogen in action. Progestin is a general term for progesterone or other substances that have the same effect as progesterone. Alternatively, HRT may involve the administration of androgens, either for transgender men or for men suffering from hypogonadism; however, there is little confirmed evidence to suggest that androgen therapy is carcinogenic in humans.

Exposure routes: Estrogen and progesterone, whether naturally occurring in the body or inhaled, ingested, injected, or absorbed through the skin, travel through the bloodstream. They are then absorbed by estrogen-dependent cells or metabolized by the liver for final excretion in urine and stool.

Where found: Estrogen and progesterone are found in many animal fluids and tissues, including milk and meat, as well as many plants, including palm kernel oil. The estrogen most often used in HRT is extracted from the urine of pregnant mares. Estrogens and progesterones are also used commercially in skin and hair products in low concentrations. The most likely route of excessive exposure is use of prescribed HRT in oral, dermal, or vaginal preparations.

At risk: Women who use HRT are at greatest risk. Workers in facilities where prescription estrogen and progesterone products are made can be also exposed through inhalation or skin contact.

Etiology and symptoms of associated cancers:
Prolonged or excessive estrogen exposure causes estrogen-dependent cells to divide more rapidly than normal. Overexposure to estrogen can damage chromosomes or alter gene expression in estrogen receptor cells. Estrogen receptors are proteins within cells that bind to estrogen and stimulate production of certain tissue cells, including breast, ovarian, and uterine lining cells. Overexpression of estrogen receptors causes increased cell division and deoxyribonucleic acid (DNA) replication, which increases the chance for mutations and causes tumor growth. The mechanism by which progesterone is associated with cancer is not known, but many studies have shown that injection of progesterone in animals causes tissue overgrowth and tumor formation in the uterine lining, the breast, and other reproductive tissues.

The cancers that are known to result from HRT include breast cancer (lobular more than ductal) and endometrial, or uterine, cancer. At least one study has shown a causal relationship between HRT and ovarian cancer, but other studies have had conflicting results. The most common symptom of breast cancer is a lump or mass in the breast. Some breast cancers present as calcifications in breast ducts, with no mass. These are usually discovered on mammography. Uterine cancer is slow growing and is often found on imaging studies of the abdomen ordered for vaginal bleeding in a postmenopausal woman or for other symptoms not related to the cancer.

History: Estrogen is a hormone naturally produced by the ovaries, placenta, testes, and adrenal glands. It regulates development of secondary sex characteristics, such as breast development and body hair distribution, and is important in the growth and functioning of all reproductive organs as well as bones. It regulates brain processes associated with reproduction, including mood and interest in sex. One of its most important functions is maintaining the lining of the uterus and preparing the body for pregnancy.

Progesterone is produced by the ovaries in adult women and by the placenta during pregnancy. It is also produced by the adrenal glands and, like estrogen, is found in many body tissues and fluids. Progesterone is essential in the thickening and vascularity of the uterine lining that allow the fertilized ovum to implant and grow during pregnancy. Both hormones are used in oral contraceptives.

Estrogen, alone or with progestin, has been prescribed for menopausal women to relieve unpleasant side effects of menopause and was once thought to prevent heart attacks and retard aging. Progestins are prescribed, among other reasons, to regulate the menstrual cycle and prevent miscarriage.

HRT use flourished in the 1960s and 1970s until researchers started noticing a marked increase in the incidence of endometrial cancer in women treated with estrogen replacement therapy. The results of one of the first studies to make the connection were published in 1975 in the New England Journal of Medicine by D. C. Smith and colleagues, who found a 4.5 times greater risk of endometrial adenocarcinoma in postmenopausal women being treated with estrogen alone. Many other studies followed, and conjugated estrogen, a mixture of naturally occurring estrogens, was listed as a known carcinogen in 1985. Other studies, including a Swedish study by I. Persson and colleagues published in the British Medical Journal in 1989, found that estrogen therapy in combination with progestins did not increase the risk of endometrial cancer, so combination therapy came into common use, with an estimated 40 million prescriptions in the United States in 1992. By 1999, studies were showing an increased risk for breast cancer in patients using estrogen alone or combination (estrogen-progestin) therapy.

The definitive study for the association of breast cancer and HRT was the 1991 Women’s Health Initiative, a US government–sponsored research study consisting of clinical trials and an observational study, which included trials on more than 16,000 postmenopausal women using estrogen alone or combination therapy. The combination therapy part of the study was stopped in 2002, after nearly six years of research, because the findings showed the risks of combined HRT to be greater than the benefits. The study found that the incidence of breast cancer increased and that the risk increased with the duration of HRT. The estrogen-alone part of the study was stopped in 2004 because data indicated an increased risk of stroke in patients taking estrogen supplements. Estrogen-alone therapy did not increase the risk of breast cancer in the study population.

Use of HRT dropped significantly after the Women’s Health Initiative results were published, as did the incidence of breast cancer. Some researchers thought the drop was a direct result of less use of HRT. Other studies concluded that the decrease in the incidence of breast cancer began four years before the Women’s Health Initiative results were announced and that it was more likely to be a result of fewer women getting mammograms. Mammograms were part of the required follow-up for women getting HRT, and it is ironic that many women may have stopped getting mammograms because of decreased medical care that resulted from stopping HRT, which could have delayed detection of breast cancers.

Studies of HRT continue, but the consensus seems to be that women who need HRT for relief of menopausal symptoms should receive therapy in the lowest effective dose for the shortest period of time needed. Estrogen therapy was shown in the Women’s Health Initiative to be effective in treatment of osteoporosis, or thinning of bone tissue, but its use is recommended only for patients who are not candidates for other treatments. HRT is no longer recommended for prevention of coronary artery disease. The benefits of HRT include a decreased risk of colorectal cancer and osteoporosis and relief of troublesome menopausal symptoms. Patients in need of HRT should discuss options with their physicians, who will weigh the benefits and risks of treatment for each patient.

Antoine, Caroline, et al. "Systematic Review about Breast Cancer Incidence in Relation to Hormone Replacement Therapy Use." Climacteric 17.2 (2014): 116–32. Print.

Hein, Alexander, et al. "Hormone Replacement Therapy and Prognosis in Ovarian Cancer Patients." European Journal of Cancer Prevention 22.1 (2013): 52–58. Print.

Hou, Ningqi, et al. "Hormone Replacement Therapy and Breast Cancer: Heterogeneous Risks by Race, Weight, and Breast Density." Journal of the National Cancer Institute 105.18 (2013): 1365–72. Print.

Lacey, James V., Jr., et al. “Menopausal Hormone Therapy and Ovarian Cancer Risk in the National Institutes of Health–AARP Diet and Health Study Cohort.” Journal of the National Cancer Institute 98.19 (2006): 1397–1405. Print.

Li, Christopher I., et al. “Changing Incidence Rate of Invasive Lobular Breast Carcinoma among Older Women.” Cancer 88.11 (2000): 2561–69. Print.

"Menopausal Hormone Therapy and Cancer Risk." American Cancer Society. Amer. Cancer Soc., 1 Aug. 2013. Web. 7 Nov. 2014.

Persson, Ingemar, et al. “Risk of Endometrial Cancer after Treatment with Oestrogens Alone or in Conjunction with Progestogens: Results of a Prospective Study.” British Medical Journal 298.6667 (1989): 147–51. Print.

Stefanick, Marcia L., et al. “Effects of Conjugated Equine Estrogens on Breast Cancer and Mammography Screening in Postmenopausal Women with Hysterectomy.” Journal of the American Medical Association 295.14 (2006): 1647–57. Print.

United States. Dept. of Health and Human Services. Public Health Service. Natl. Toxicology Program. 13th Report on Carcinogens. Research Triangle Park: Author, 2014. National Toxicology Program. Web. 17 Oct. 2014.

Yang, Hannah P., et al. "Ovarian Cancer Incidence Trends in Relation to Changing Patterns of Menopausal Hormone Therapy Use in the United States." Journal of Clinical Oncology 31.17 (2013): 2146–51. Print.

What two things did the kidnappers not anticipate?

In addition to the obvious fact that the young kidnap victim turned out to be a hellcat, there were two main things the kidnappers Bill and Sam did not anticipate. Both of their mistakes might be attributed to the fact that these men are "out of the loop," so to speak, when it comes to domestic matters. They are both obviously bachelors. Their profession as confidence men keeps them perpetually on the lam. They are outsiders. They only know men as potential suckers for their scams, nothing about kids or family life.

One of the two things Bill and Sam did not anticipate was that their "victim" would enjoy being kidnapped. He has never had so much fun in his life. He is wild enough at home, but being kidnapped and living outdoors brings out previously hidden depths of wildness. He calls himself Red Chief, and he behaves like his idea of a wild savage. Bill and Sam have a tiger by the tail. They can't frighten him because he frightens them. They have no moral authority as adults because the boy knows they are outlaws.

The other thing the kidnappers do not anticipate is that the boy's father, Ebenezer Dorset, does not show any concern about his abducted son. The father is an exceptionally calm, complacent man. He may be glad to get the boy off his hands for a few days. He assumes the kidnappers are in more danger from the victim than the victim is from them. Bill and Sam know nothing about parenthood. They assumed that Ebenezer would be terribly distraught and willing to pay anything to get his darling little boy back into his arms. When he does get Red Chief back into his arms, after forcing Bill and Sam to pay him a sort of reverse-ransom, he can only promise to hold on to the boy for ten minutes, which is just time enough for the two erstwhile kidnappers to make their frantic escape out of town.

Why do you think Tybalt approaches Meructio and Benvolio and has a word with them in Act 3, Scene 1 of Romeo and Juliet?

Tybalt approaches the Montagues because he is angry at them for going to the Capulet party.

There is a feud between the Montagues and Capulets that has been going on for quite some time.  They are willing to kill each other on sight for the smallest insult, or just because.  When Romeo goes to Juliet’s party with his Montague friends, Tybalt Capulet recognizes them.  He is very angry, and tells Lord Capulet so.  Capulet scolds him and warns him not to cause trouble at the party, but Tybalt will not let it go.

Patience perforce with wilful choler meeting
Makes my flesh tremble in their different greeting.
I will withdraw: but this intrusion shall
Now seeming sweet convert to bitter gall. (Act 1, Scene 5)

Lord Capulet tells Tybalt that Romeo has a good reputation for a Montague.  Tybalt doesn’t care.  He is annoyed with Romeo for being at the party, and wants revenge.  Tybalt apparently has a reputation too.  Mercutio believes that Tybalt has a temper.  He calls him “prince of cats.”  When Tybalt shows up and says he wants a “word” with them, Mercutio counters that it will likely be “a word and a blow.”

Tybalt wants to fight Romeo for having been at the party, but Mercutio intervenes.  Of course, this turns bad quickly.  Mercutio knows that Romeo is not inclined to fight and will try to talk to Tybalt.  He sees him as family and not an enemy, since Juliet is his wife.  Mercutio knows that it won’t work, because Tybalt is spoiling for a fight.  He doesn't know about the wedding, but he knows Romeo is a Montague.

TYBALT

Romeo, the hate I bear thee can afford
No better term than this,--thou art a villain.

ROMEO

Tybalt, the reason that I have to love thee
Doth much excuse the appertaining rage
To such a greeting: villain am I none;
Therefore farewell; I see thou know'st me not. (Act 3, Scene 1)

This fight ends in Mercutio's death.  Tybalt kills him trying to fight Romeo, and Romeo tries to intervene.  Then Romeo kills Tybalt.  It's a big mess just for who went to a party, but that's the point.  Feuds are silly and harmful and people end up dead for no reason.  This unfortunately is not the last death, as we know.

Who are the Radleys? What do their house and yard look like?

The Radley family lived in Maycomb on the same street as Jem and Scout. Mr. and Mrs. Radley had two sons and were not sociable around town. Scout wondered what Mr. Radley did for a job. Their oldest son moved to Pensacola. Their other son, Arthur, got into trouble as a young man. Over the years, a string of rumors developed about him. He never seemed to leave the house. The Radley house stood out on a street full of well-maintained homes. It also stood in a unique location on the street:

The Radley Place jutted into a sharp curve beyond our house (Chapter 1).

The house used to be cared for well. It was a low house. It used to have a whitewashed front porch, but time and neglect turned the paint on the porch gray. The shutters on the house were green, and they always stayed closed. The Radleys never left their front door open on Sundays. This was an oddity in friendly Maycomb. Atticus could remember a time, long ago, when they had screen doors. The house itself looked almost abandoned:

Rain-rotted shingles drooped over the eaves of the veranda; oak trees kept the sun away.  The remains of a picket drunkenly guarded the front yard—a "swept" yard that was never swept—where johnson grass and rabbit-tobacco grew in abundance.

The backyard of the house bordered the school property. The Radleys kept chickens and had pecan trees. They also had a vegetable garden full of collards and other foods.

What are 2 details about Mad Dog Craddock in Out of the Dust?

In Out of the Dust, Mad Dog Craddock is an incredibly talented (and handsome) musician and singer. One important detail to remember about him is that, after Billy Jo's accident, he is one of the few people to treat Billy Jo with the same courtesy and friendliness as he did before when she tries to begin her piano playing again. Unlike those who pity her and stare at her, Mad Dog treats her with dignity.

Another detail to keep in mind is that Mad Dog is one of many people who leave Oklahoma in search of a better life. In his case, this better life consists of trying to make it in the radio business. Like when her other friends and neighbors leave the area, Billy Jo has mixed feelings about this; she understands and appreciates his talents and potential for success, but she also feels some resentment, as she is still stuck in the Dust Bowl.

What questions did Anti-Federalists ask Federalists?

Federalists and Anti-Federalists had different opinions on many topics. Federalists believed the federal government should have an active and strong role. They believed in having a national bank. They wanted the federal government to have significant power. They tended to support Great Britain in foreign policy matters. They believed in a loose view of the Constitution.

The Anti-Federalists had opposite views. They were against the national bank. They wanted the state governments to have more power than the federal government. They wanted the federal government to have a limited role in our society. They tended to support France in foreign policy issues. They believed in a strict interpretation of the Constitution.

Anti-Federalists would likely ask the Federalists the following questions:

Why do you want a strong federal government when we fought against the rule of the strong British government?

Why should we be friendlier with Great Britain when it was France that helped us in the Revolutionary War?

Why should we try to interpret what the writers of the Constitution meant? Why can’t we follow what is directly written in the Constitution?

Why do we want to have an extensive system of taxes when we were opposed to the taxes the British placed on us?

Why were the Federalists willing to pass laws such as the Alien and Sedition Acts that limited our freedoms when we fought so hard to gain the freedoms we had?

The Anti-Federalists would have had a lot of questions for the Federalists because they different views on many significant issues.

What is idiopathic thrombocytopenic purpura?

Definition

Idiopathic thrombocytopenic purpura (ITP) is a treatable blood disorder.
Antibodies that are produced in the spleen attack and
destroy the body’s own blood-clotting cells (platelets), which help stop bleeding.
Normally, platelets move to damaged areas of the body and stick together, forming
a sort of barrier against germs. If there are not enough platelets in the body,
bleeding injuries are difficult to stop. Although people with ITP have a lower
than normal number of platelets in their blood, all other blood cell counts are normal.

There are two types of ITP. Acute ITP, which lasts less than six months and usually occurs in children, is the most common. Chronic ITP lasts more than six months and usually occurs in adults.

Causes

The cause of most cases of ITP is unknown. In children, the disorder has been
linked to viral
infections. It is believed that in these cases the immune
system becomes confused and begins attacking healthy platelet cells. When too many
platelets are destroyed, ITP can result. The disorder in adults has not been
linked to viral infections. Some cases of ITP are thought to be caused by drugs,
infection, or other immune disorders. Pregnant women too sometimes develop the
disorder.

Risk Factors

Persons with an increased chance of developing ITP include children who have had a recent viral infection or have had a live-virus vaccination (which may sometimes put a child at a higher risk); women, usually younger than age forty years; and women in general, who are two to three times more likely to get ITP than are men.

Symptoms

Both adults and children may notice the following symptoms of ITP: easy
bruising, dark urine or stools, bleeding for longer than normal following an
injury, unexplained nosebleeds, bleeding from the gums, heavier-than-normal
menstrual periods (in adult women), red dots called petechiae on the skin
(petechiae may occur in groups and resemble a rash), and, in rare cases, bleeding
within the intestinal tract or brain.

Screening and Diagnosis

A doctor will ask about symptoms and medical history and will perform a
physical exam. Tests may include a complete blood count (CBC), in which a
blood sample is tested to see if the numbers of different blood cells are normal;
and a bone marrow test, in which a needle is inserted into the skin and into the
bone and a small amount of bone marrow is removed. The sample is tested to ensure
the marrow contains normal numbers of platelet-producing cells. This test is done
to rule out other disorders. Another test is a computed tomography (CT)
scan (in rare cases). The CT scan is done if there is a
concern about bleeding in the brain.

Treatment and Therapy

Treatment for ITP is different for children and for adults. Most children
recover from ITP without any treatment. However, a doctor may recommend the
following: medications to increase platelet counts in the blood, such as
steroids (for example, prednisone), which lowers the
activity of the immune system and keeps it from destroying platelets; and gamma
globulin infusions (an antibody-containing protein that slows down platelet
destruction). An infusion means that the injection is given by IV (intravenously)
or through a shot. It usually works more quickly than steroids. Both of these
treatments work but both can have side effects. Eighty-five percent of children
who have ITP recover within a year and do not experience the problem again.

Two newer drugs stimulate platelet production: eltrombopag (Promacta) and
romiplostim (Nplate). Using these drugs and also using the targeted monoclonal
antibody rituximab (Rituxan) may prevent the need for a splenectomy. A
splenectomy is the surgical removal of the spleen. This
procedure stops the destruction of platelets because the antibodies are made in
the spleen. In adults, if drug intervention does not do enough to raise platelet
counts, the doctor may recommend a splenectomy.

A splenectomy leaves the body more vulnerable to infection from other sources. This surgery is usually not performed until medications have proven ineffective. Doctors also sometimes recommend lifestyle changes when platelet counts are low, including avoiding contact sports; patients also are recommended to wear a helmet during sports activities.

Prevention and Outcomes

Because the cause of ITP is unknown, there are no specific ways to prevent the disease. However, because bleeding and injury can be serious for people with ITP, one should take precautions to avoid injury, such as using padding on an infant’s crib or around a play area and ensuring that older children wear helmets and protective gear when playing sports (to help reduce bruising injuries). Persons with low platelet counts should stop playing contact sports.

People who have ITP should also avoid medications that contain aspirin or
ibuprofen. These medicines can reduce platelet function. To help stay healthy, one
should eat a healthful diet, low in saturated fat and rich in whole grains,
fruits, and vegetables; get regular exercise; lose weight if overweight; stop
smoking; and drink alcohol, if desired, only in moderation (two drinks per day for
men and onedrink per day for women).

Bibliography

Bick, Roger L. Disorders of Thrombosis and Hemostasis: Clinical and Laboratory Practice. 3d ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Bussel, J. B., et al. “Eltrombopag for the Treatment of Chronic Idiopathic Thrombocytopenic Purpura.” New England Journal of Medicine 357, no. 22 (November 29, 2007): 2237-2247.

George, J. N. “Platelets.” The Lancet 355 (April 29, 2000): 1531-1539.

George, J. N., et al. “Update on Idiopathic Thrombocytopenic Purpura.” Available at http://www.hematology.org/publications/hematologist/ 2010/4965.aspx.

Karpatkin, S. “Autoimmune (Idiopathic) Thrombocytopenic Purpura.” The Lancet 349 (1997): 1531-1536.

Lichtman, Marshall A., et al., eds. Williams Hematology. 7th ed. New York: McGraw-Hill, 2006.

McCrae, Keith R., ed. Thrombocytopenia. New York: Taylor & Francis, 2006.

Newland, A., et al. “An Open-Label, Unit Dose-Finding Study of AMG 531, a Novel Thrombopoiesis-Stimulating Peptibody, in Patients with Immune Thrombocytopenic Purpura.” British Journal of Haematology 135, no. 4 (2006): 547-553.

What is homeopathy?

Science and Profession

In conventional medicine, diseases—or changes from the normal physiological state—are diagnosed on the basis of symptoms and physical signs. This enables the physician to find a cause for which there is a specific treatment and to treat the patient’s symptoms. There are few treatments, however, that cure or even address the whole patient. Sometimes, symptoms are assumed to be the disease, and the traditional method of action is to address and fix the symptoms and not the disease. Suppressing or removing symptoms does not necessarily constitute a cure. Curing patients means restoring them to a holistic sense of well-being that focuses on all facets of a patient: the physical, emotional, and mental. Homeopathic medicine is a form of treatment that studies the person as a whole, with particular interest in the patient as an individual. Homeopathy is a therapeutic method that consists of prescribing for a patient weak or infinitesimal doses of a substance that, when administered to a healthy person, causes symptoms similar to those exhibited by the ill patient. Homeopathic remedies stimulate the defense mechanisms of the body, causing them to work more effectively and making them capable of curing the individual. While controversial and still considered alternative medicine in much of the medical community, homeopathy is not intended as a substitute for conventional medicine. Rather, it is a system of therapeutics that is meant to enlarge and broaden the physician’s outlook and in some cases might about a potential cure that would not be possible with conventional medication and medical treatment alone.

The word “homeopathy” is derived from the Greek words homoios, meaning “like” or “similar,” and pathos, meaning “suffering.” A symptom is defined as the changes felt by the patient or observed by another individual that may be associated with a particular disease. When a homeopathic drug, or remedy, is administered in repeated doses to a group of healthy persons, certain symptoms and signs of toxicity are produced. These symptoms are carefully annotated in what is called the proving of a remedy. In some cases, there are accidental provings—cases in which the symptoms produced by a drug in a healthy person are observed because of an accident, such as being bitten by a snake. Other sources for the proving of a remedy are the cases in which, after a remedy has been successfully prescribed, symptoms cured by it that were not present in the provings are noted. Some of these symptoms are common to many drugs, and a few are characteristic of particular ones. It is then possible to build a symptom-complex picture that is unique to each drug or remedy. In many cases, when the symptom-complex presented by the patient is compared to the symptom-complex produced by a certain remedy, there will be a resemblance—often a close one—between the patient’s symptom picture and the effects of a given drug on healthy persons.

The first and fundamental principle of homeopathy is the selection and use of the similar remedy based on the patient’s symptoms and characteristics and the drug’s toxicology and provings. A second principle is the use of remedies in extremely small quantities. The most successful remedy for any given occasion will be the one whose symptomatology presents the clearest and closest resemblance to the symptom-complex of the sick person in question. This concept is formally presented as the Law of Similars, which expresses the similarity between the toxicological action of a substance and its therapeutic action; in other words, the same things that cause the disease can cure it. For example, the effects of peeling an onion are very similar to the symptoms of acute coryza (the common cold). The remedy prepared from Allium cepa (red onion) is used to treat the type of cold in which the symptoms resemble those caused by peeling onions. In the same way, the herb white hellebore, which toxicologically produces cholera-like diarrhea, is used to treat cholera.

The homeopathic principle is being applied whenever a sick person is treated using a method or drug that can cause similar symptoms in healthy persons. For example, conventional medicine uses radiation therapy, which causes cancer, to treat this disease. Orthodox medicine, however, does not follow other fundamental principles of homeopathy, such as the use of infinitesimal doses.

Homeopathy stimulates the defense mechanism to make it work more effectively and works on the concept of healing instead of simply treating a disease, combating illness, or suppressing symptoms. Individualization plays a crucial role in homeopathic treatment. Even when two individuals have the same ailment, their symptoms can be different. Remedies are therefore selected on an individual basis, depending on the specific, complete symptom picture of the individual. Homeopathic physicians must develop a different approach to their patients, which involves a diagnosis as well as a study of the whole individual. The way in which some homeopathic remedies work is still unknown, but the persistence of homeopathy since the mid-nineteenth century would seem to suggest its effectiveness in helping sick people.

Some conditions do not respond well to homeopathy, such as those requiring surgery, immediately life-threatening situations such as severe asthma attacks, or situations for which an improvement requires a change in diet (such as iron deficiency) or reduced exposure to environmental stress (a change in lifestyle). Nevertheless, homeopathy appears to help in these cases. For example, it can be useful for faster, complete healing after surgery or after the necessary change in lifestyle has been made. In the United States, both the Food and Drug Administration (FDA) and traditional homeopaths have been concerned about the use of homeopathic remedies to treat serious problems, such as cancer, and their use by unlicensed practitioners. In some cases, the ability to prescribe homeopathic remedies has been restricted to osteopaths, naturopaths, and medical doctors. In some cases, homeopathy does not work; the reason is unknown.

Individuals who have benefited from these remedies may not care whether homeopathy can be scientifically explained or whether research has proven its effectiveness. Nevertheless, some facts suggest that homeopathic medicines are not placebos and that the infinitesimal doses produce true biological action. For example, homeopathic medicines work on animals and are also commonly and successfully used on infants; it is doubtful that psychological suggestion can explain their success in these cases. Moreover, homeopathic microdoses have the capacity to cause symptoms in healthy individuals, and the experience of what is called a healing crisis—temporary exacerbation of symptoms that is sometimes observed during the healing process—cannot be produced by placebos or psychological suggestion. The major drawback to most homeopathic research, however, is that it is rarely published in respected scientific journals, and whatever little has been published has been received with much skepticism from the medical community.

The action of homeopathic medicines supports the theory that each organism expresses symptoms in an effort to heal itself. This homeopathic action can augment, complement, and sometimes replace present medical technologies. For example, abuse of strong medications can lead to resistance to the drugs themselves, allergies, and other unpleasant side effects. In homeopathy, small drug doses have been shown to be more effective than larger ones, which in itself can reduce the undesired side effects associated with the use of common medications.

Diagnostic and Treatment Techniques

The first step in treating an illness using homeopathy is taking the case history or symptom picture (the detailed account of what is wrong with the patient as a whole). This is carried out in a similar way by classical doctors and homeopathic practitioners, since most homeopaths are doctors or have some conventional medical training. The symptoms are divided into three categories: general, mental/emotional, and physical.

The homeopath then consults the Materia Medica
(the encyclopedia of drug effects) and/or the Repertory
(an index of symptoms from the Materia Medica listed in alphabetical order, used as a cross-reference between symptoms and remedies) to decide on the remedy to be used. The professional homeopath works with a number of Materia Medica texts compiled by different homeopaths.

The classical homeopath will give only one remedy at a time in order to gauge its effect more efficiently. The best-known unconventional usage of homeopathic medicines is of combination medicines or complexes, normally a mixture of between three and eight low-potency remedies. This approach is useful when the correct remedy is not available or when the practitioner is unsure as to which one to use. These mixtures are commonly sold in health food stores and are named for the disease or symptom that they are supposed to cure. Another unconventional use is what is called pluralism, which is the application of two or more medicines at a time, each of which is taken at a different time of day. This approach is most commonly used in Europe.

Homeopathy is a natural pharmaceutical system that utilizes microdoses of substances to arouse a healing response by stimulating the patient’s immune system. Homeopathic remedies are always nontoxic because of the small concentrations used. They do not act chemically but rather according to a particular physical state linked to the way in which they are prepared. They have the capacity of making the ill subject react to his or her disease, and in this way they are considered specific stimulants.

Homeopathic remedies come from the plant, mineral, and animal kingdoms. Plants are the source of more than half of the remedies with a popular product being Bach flower remedies. The plants are harvested in their natural state according to strict norms by qualified specialists and are used fresh after thorough botanical inspection. Mineral remedies include natural salts and metals, always in their purest state. Animal remedies may contain venoms, poisonous insects, hormones, or physiological secretions such as musk or squid ink.

In all cases, the starting remedy is made from a mixture of the substance itself, which has been steeped in alcohol for a period of time and then strained. This starting liquid is called a tincture or mother tincture. In the decimal scale, a mixture of one-tenth tincture and nine-tenths alcohol is shaken vigorously, a process known as succussion; this first dilution is called a 1X. (The number in the remedy reveals the number of times that it has been diluted and succussed; thus, 6X means diluted and succussed six times.) In the centesimal scale, the remedy is diluted using one part tincture in a hundred, and the letter C is used after the number. The number indicates the degree of the dilution, while the letter indicates the technique of preparation (decimal or centesimal). Insoluble substances are diluted by grinding them in a mortar with lactose to the desired dilution. The greater the dilution of a remedy, the greater its potency, the longer it acts, the deeper it heals, and the fewer doses are needed.

A medicine is chosen for its similarity to the person’s symptoms so that the person’s bioenergetic processes are hypersensitive to the substance. One theory used to explain the success of homeopathic remedies, even when they are used in such small concentrations, is that they work through some kind of resonance within the individual’s system. There are other examples of high sensitivity to small amounts of substances in the animal kingdom, such as in the case of pheromones, sex attractants that affect only animals of the same species in very small amounts and at a very long distance.

Constantine Hering (1800–80), one of the early pioneers of American homeopathy, was the first to make note of the specific features of the healing process to create a holistic assessment tool that can be used to evaluate a patient’s progress. His observations are summarized in Hering’s Law of Cure. First, the human body seeks to externalize disease, to dislodge it from more serious, internal levels to more superficial ones. For example, in the healing of asthma the patient may exhibit an external skin rash before complete cure is achieved. Second, the healing progresses from the top of the body to the bottom; someone with arthritis, for example, will feel better in the upper part of the body earlier than in the lower part. Third, the healing proceeds in the reverse order of the appearance of the symptoms; that is, the more recent symptoms will heal first, and old symptoms may reappear before complete healing.

Homeopathic remedies are most commonly available in tablet form, combined with sugar from cow’s milk. The tablets can be soft (so that they dissolve easily under the tongue and are easy to crush) or hard (so that they must be chewed and held in the mouth for a few seconds before being swallowed), or they can be prepared as globules (tiny round pills). The liquid remedies are dissolved in alcohol. Also available are powders that are wrapped individually in small squares of paper (convenient if the remedy is needed for only a few doses or is to be sent by mail), wafers, suppositories, and liniments. Homeopathic tablets will keep their strength for years without deteriorating, but they must be stored in a cool, dark, and dry place with their bottle tops screwed on tightly, away from strong-smelling substances.

The prescribed quantities are the same for babies, children, adults, and older people. The size of a dose is immaterial because it is how often it is taken that counts. The strength (potency) that is needed changes with the circumstances. The greater the similarity between the symptoms and the remedy, the greater the potency to be used (that is, the more dilute the remedy).

The following substances all counteract the effects of a homeopathic remedy to some extent (and as such are considered antidotes): camphor, coffee, menthol/eucalyptus, peppermint, recreational drugs, and any strong-smelling or strong-acting substance.

As with all treatments, there are some dangers associated with homeopathic cures, such as unintentional provings. These take place when, after an initial improvement, the symptoms characteristic of the remedy appear, creating a worse situation for the patient. Sometimes, this reaction takes place because the individual has been taking the remedy for too long, and it can be stopped by discontinuing the remedy or by using an antidote. In other cases, there is a confused symptom picture, the effect being that the remedy is working in a limited way or curing a restricted number of symptoms.

Homeopathy is important in the treatment of bacterial infections (where resistance to antibiotics can develop) and viral conditions. Homeopathic remedies stimulate the person’s resistance to infection without the side effects of antibiotics, and they help the body without suppressing the organism’s self-protective responses. The remedies used are safer than traditional medications because they exhibit minimal side effects, and counterreactions between medicines can be prevented.

Homeopathic remedies are exempt from federal review in the United States. In 1938, any drug listed in the Homeopathic Pharmacopoeia of the United States was accepted by the FDA. Consequently, prescribed homeopathic remedies do not have to undergo the rigorous safety and effectiveness testing the regulating agency requires of drugs used in orthodox medicine. Nonprescription remedies are also exempt and can be purchased in pharmacies and natural and health food stores throughout the United States. The FDA requires that, as with any over-the-counter drug, a remedy be sold only for a self-limiting condition (such as headaches, menstrual cramps, or insomnia) and that the indications be printed on the label. The ingredients and their dilution must also be listed. Nonhomeopathic active ingredients cannot be included in the preparation.

Perspective and Prospects

The Law of Similars was observed twenty-five centuries ago by Hippocrates and was utilized by people of many cultures, including the Mayans, Chinese, Greeks, and American Indians. In the following centuries, other doctors made similar observations, but they did not come to any practical conclusions. It was not until the end of the eighteenth century that a German physician, Christian Friedrich Samuel Hahnemann, studied the matter further, developed it, and gave it a scientific basis.

Hahnemann recruited a group of healthy subjects to take the remedies and report in a diary the symptoms that they caused, a process called proving the substance. He and his subjects proved more than a hundred remedies and produced a very accurate collection for use by other homeopathy practitioners. He also found that the remedies worked better in very small doses. Homeopathy was initially rejected by the medical profession, but its methods became more accepted when Hahnemann obtained astonishing results with his patients. In 1810, he published a book called Organon der rationellen Heilkunde (The Organon of Homœopathic Medicine, 1836), in which he presented the philosophy of homeopathy. He also published Materia Medica pura in six volumes between 1811 and 1821. These volumes contain the compilations of his provings. As new remedies are discovered, they are added to the compilation. By the time of Hahnemann’s death in 1843, homeopathy was established around the world.

In the 1820s, homeopathy arrived in the United States at a time when the state of orthodox medicine was worse than in Europe. Many ordinary people consulted herbalists and bonesetters, so homeopathy was easily accepted and soon flourished. In April 1844, the American Institute of Homeopathy was founded. In 1846, however, the American Medical Association (AMA) was founded, and it adopted a code of ethics that forbade its members to consult homeopaths. Nevertheless, public demand continued. The 1860s through the 1880s saw the heyday of homeopathy in the United States, with the institution of homeopathic training programs, hospitals, and asylums throughout in the country.

Developments in orthodox medicine around the end of the nineteenth century strengthened this camp, however, while the homeopathic establishment was weakened by internal division. In 1911, the AMA moved to close many homeopathic teaching institutions because they were considered to provide a poor standard of education. By 1950, all the homeopathic colleges in the United States were either closed or no longer teaching homeopathy. By the 1990s, it was estimated that only five hundred to one thousand medical doctors used homeopathics in their practices. Although the AMA has no official statement on homeopathy, it is no longer part of the medical school curriculum.

Homeopathy has exhibited a renaissance, and it is popular throughout the world, especially in France. The London-based marketing research firm Mintel reported that natural and homeopathic product sales were $6.4 billion in 2012, which was a 3 percent increase over the previous year. Perhaps the reasons for this revived popularity include both skepticism surrounding conventional medicine and a need for alternatives in the face of challenging health problems: Homeopathy offers a safe alternative as it seeks to improve the general level of health of the whole person, emotionally as well as physically.

Bibliography

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How does Harper Lee use place in To Kill a Mockingbird?

In To Kill a Mockingbird, author Harper Lee often uses place to establish mood. One example of this can be seen in her descriptions of Maycomb's jail just prior to the mob scene.

At the start of Chapter 15, Atticus meets with a group of men, led by Sheriff Heck Tate, who have come to express their concern that members of the community may try to lynch Tom Robinson while he waits in the county jail for his trial. Though the group led by Sheriff Tate does not mean Atticus any harm, Jem can't help but feel concerned about Atticus's safety, and when Atticus leaves the house around 10 o'clock at night, Jem follows him into town, accompanied by Scout and Dill, to find out what Atticus is up to. Once in town, they find Atticus sitting in a chair propped against the jailhouse door; he is reading a newspaper and being illuminated by a light bulb attached to an extension cord he had brought with him.

In her narration, Scout notes what the jailhouse looks like. According to Scout, "The Maycomb jail was the most venerable and hideous of the county's buildings." By venerable, she means both impressive and outdated; by hideous, she means shockingly ugly. She continues to describe it as something an insane person might have concocted in a dream as a "miniature Gothic joke" due to its architectural design. The jailhouse is made of red brick, has steel bars in its windows, and, like all Gothic architecture, it is "complete with tiny battlements and flying buttresses."

It is particularly interesting that the jailhouse is composed of Gothic architecture since Gothic artworks, like Gothic literature, have a tendency to be gloomy and depressing because the artworks deal with subjects of violence and moral decay. Hence, the Gothic jailhouse serves as a perfect setting for the lynch mob, led by Walter Cunningham Sr., to assemble. The Gothic architecture serves to set the gloomy and frightening tone of the scene.