By Y. Gunock. Nazarene Bible College.
What is the most for positive interference from Hgb buy sildenafil 25mg, the results may likely explanation of these results? A commonly used approach is to direct bilirubin measure absorbance at 454 nm and 540 nm buy cheap sildenafil 50 mg line. Physiological variation owing to premature absorbance contributed by Hgb at 540 nm is equal hepatic microsomal enzymes to the absorbance contributed by Hgb at 454 nm order sildenafil 75mg visa. Therefore purchase sildenafil 100 mg on-line, the absorbance diﬀerence will correct for Chemistry/Apply knowledge to recognize sources of free Hgb. In the enzymatic assay of bilirubin, how is could interfere with the direct spectrophotometric measurement of both total and direct bilirubin measurement of bilirubin. Using diﬀerent pH for total and direct assays bilirubin back to biliverdin, and measure the decrease B. At pH 8, both conjugated, reductase unconjugated, and delta bilirubin react with the C. Using diﬀerent polarity modiﬁers enzyme, but at pH 4 only the conjugated form reacts. C Measurement of bilirubin concentration through Chemistry/Apply principles of basic laboratory the skin requires the use of multiple wavelengths procedures/Bilirubin/2 to correct for absorbance by melanin and other light-absorbing constituents of skin and blood. What is the principle of the transcutaneous than 100 wavelengths and multiple reﬂectance bilirubin assay? Multiwavelength reﬂectance photometry They can be used to identify neonates with D. To Clinical chemistry/Calculate/Solutions/2 calculate, multiply the percentage (as mL) by the 3. A biuret reagent requires preparation of a stock volume required (mL), then divide by 100 (mL). C To convert from milliequivalent per liter to milligrams stock solution are needed to prepare 100. B To calculate the volume of stock solution needed, divide the concentration of working standard by the concentration of stock standard, then multiply by the volume of working standard that is needed. C1 × V1 = C2 × V2, where C1 = concentration of stock standard V1 = volume of stock standard C2 = concentration of working standard V2 = volume of working standard 2000. B When zeros appear by themselves to the left of Clinical chemistry/Calculate/pH/2 the decimal point, they are not significant. How many signiﬁcant ﬁgures should be reported they are to the left of the decimal point and are when the pH of a 0. In laboratory practice, most analytes are reported Clinical chemistry/Calculate/Signiﬁcant ﬁgures/2 with two significant figures. B The Henderson–Hasselbalch equation can be used to determine the pH of a buﬀer containing a weak acid and a salt of the acid. A glycerol kinase method for triglyceride calls for a result for the patient’s serum before applying the serum blank in which normal saline is substituted ratiometric formula to calculate concentration. A The acceptable range for quality control results is deviations usually set at the 95% conﬁdence interval. This is Chemistry/Evaluate laboratory data to assess deﬁned as the range between –1. Chemistry/Evaluate laboratory data to assess validity/ If a control is assayed 100 times, 68 out of 100 results Accuracy of procedures/Quality control/1 would fall within +1 s and –1 s of the mean. Two consecutive controls greater than 2 s above 100 results fall within ±3 s of the mean. A Rejecting a run when three consecutive controls fall the mean between 1 and 2 s or when a trend of four increasing C. Four controls steadily increasing in value but less or decreasing control results occurs would lead to than ±1 s from the mean frequent rejection of valid analytical runs. One control above +1 s and the other below –1 s control limits are four consecutive controls above or from the mean below 1 s (41s) to detect a signiﬁcant shift, and a cusum result exceeding the ±2. When controls deviate in opposite directions, the diﬀerence should exceed 4s before the run is rejected. One of two controls within a run is above +2s Answers to Questions 20–24 and the other control is below –2s from the mean. The R4S rule is applied only to controls within a run Chemistry/Evaluate laboratory data to recognize (Level 1 – Level 2), never across runs or days. Two consecutive controls are both beyond –2s Ninety-ﬁve percent of the results fall within ±2s of the from the mean. B The R4s rule is applied to two control levels within Accuracy of procedures/Quality control/2 the same run. The R4s rule detects random error standard deviation from the mean (error due to poor precision). Two consecutive controls in the same run are control results either increase or decrease in the same each greater than ±4s from the mean direction; however, this is not cause for rejection until D. Trends are systematic errors consecutive controls (aﬀecting accuracy) linked to an unstable reagent, calibrator, or instrument condition. For example, loss Chemistry/Evaluate laboratory data to assess of volatile acid from a reagent causes a steady pH validity/Accuracy of procedures/Quality control/2 increase, preventing separation of analyte from 23. Recalibrate, then repeat controls followed by can be evaluated by repeating abnormal patient selected patient samples if quality control is samples. If the average diﬀerence between results acceptable before and after recalibration is > 2s, then all samples B. Prepare fresh standards and recalibrate Chemistry/Evaluate laboratory data to take corrective action according to predetermined criteria/Quality control/3 228 Chapter 5 | Clinical Chemistry 25. B Data between ±2 and ±3s must be included in current target limits calculations of the next month’s acceptable range. Using control results from all shifts on which the “out-of-control” situations a frequent occurrence. A Although calcium has the lowest s, it represents the Chemistry/Apply principles of laboratory assay with poorest precision. Relative precision operations/Quality control/2 between diﬀerent analytes or diﬀerent levels of the same analyte must be evaluated by the coeﬃcient 26. For example, when comparing the precision of the level 1 control to the level 2 control, A. The method mean for comparison of precision and accuracy among level 1 is at the center of the y axis and mean for level laboratories? Which plot will give the earliest indication of a Answers to Questions 30–31 shift or trend? Results are out problems/Quality control/2 of control when the slope exceeds 45° or a decision 31. Te matrix is similar to the specimens being dynamic linear range of the assay, and can be used tested for multiple analytes. Te concentration of analytes reﬂects the clinical is determined from replicate assays by the user‘s range method, not the “true” concentration of the analyte. Analyte concentration must be independent of Out-of-control results are linked to analytic the method of assay performance rather than to the inherent accuracy Chemistry/Apply principles of basic laboratory of the method. Kurtosis temperature, evaporation, light exposure, and Chemistry/Evaluate laboratory data to recognize bacterial contamination. Day 9 plotting control data is that trends can be identiﬁed Chemistry/Evaluate laboratory data to recognize before results are out of control and patient data problems/Quality control/3 must be rejected. In this case, corrective steps should have been implemented by day 7 to avoid the delay 34. Referring to the Levy–Jennings chart, what and expense associated with having to repeat the analytical error is present during the second analysis of patient samples. Kurtosis in the assay conditions that aﬀect the accuracy of all results, such as a change in the concentration of the Chemistry/Evaluate laboratory data to recognize calibrator; change in reagent; a new lot of reagent problems/Quality control/3 that diﬀers in composition; or improper temperature 35. What is the ﬁrst day in the second half of the setting, wavelength, or sample volume. Day 19 This means that four consecutive controls are greater Chemistry/Evaluate laboratory data to recognize than ±1s from the mean. D An R4s error is deﬁned as the algebraic diﬀerence +2s between two controls within the same run. C The minimum requirement for frequency of quality control for a general chemistry analyte (based upon +2s the Clinical Laboratory Improvement Act, 1988) is two levels of control assayed every 24 hours. Two controls every 8 hours are required for blood gases, automated hematology, and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 point-of-care glucose testing to comply with College of American Pathology requirements. A Student’s t test is the ratio of mean difference to the standard error of the mean difference 37.
Alterations of osmotic pressure and pH beyond a certain range might be expected to result in damage to the epithelium and hence increase its permeability to xenobiotics buy sildenafil 50 mg free shipping. Delivering the drug as a dry powder 243 A further approach has been to deliver drugs in the form of a powder (but without a bioadhesive carrier) buy cheap sildenafil 25 mg on-line. For example order 50 mg sildenafil amex, freeze-dried insulin has been shown to be better absorbed as a powder than in solution 75 mg sildenafil otc, although the absorption of glucagon and dihydroergotamine, when delivered from liquid or powder formulations, was equivalent. However, problems which require resolving include developing absorption promoters with minimal toxicity and overcoming adverse nasal pathology to ensure accurate and reproducible dosing. List the mechanisms by which the permeability of the nasal epithelium may be increased to improve the efficacy of nasal drug delivery. Delivery of anti-asthmatic and other locally acting drugs directly 245 to their site of action reduces the dose needed to produce a pharmacological effect, while the low concentrations in the systemic circulation may also reduce side-effects. The lung may additionally be employed as a route for delivery of drugs into the systemic circulation, and onward to an effect site located elsewhere in the body. A product containing ergotamine tartrate is available as an aerosolized dosage inhaler for the treatment of migraine. Volatile anesthetics, including, for example, halothane, are also given via the pulmonary route. In recent years, the possibility of utilizing the pulmonary route for the systemic delivery of peptides and other molecules which are not absorbed through the gastrointestinal tract has also been explored. Pulmonary drug delivery for both local and systemic effects will be discussed in this chapter. There are a number of schemes for categorizing the different regions of the respiratory tract. With respect to pulmonary drug delivery, division into the following three regions is useful (Figure 10. Every branching of the tracheobronchial tree leads to a new “generation” of airways; for example, the trachea (“generation 0”) bifurcates into two main bronchi (“generation 1”) and then follows sequential branching into lobar bronchi (“generation 2”), segmental bronchi (“generation 3”), intrasegmental bronchi, bronchioles, secondary bronchioles and ultimately the terminal bronchioles (“generation 16”). The terminal bronchioles mark the limit of the tracheobronchial region, beyond which lies the alveolar region (“generations 17 to 23”). Progression from the trachea to the extremities of the tracheobronchial tree is characterized by decreases in both the diameter and length of the tubules with each branching, but the geometrically increasing number of airways results in dramatic increases in surface area. It should be borne in mind, however, that in humans, the left and right lungs are not identical and each contains irregular dichotomous and trichotomous branching patterns. Additionally, while the average path length from trachea to terminal bronchioles is 16 branches, short paths of only 8 to 10 branches may also exist. The alveolar region begins at the respiratory bronchioles, where alveoli begin to appear in the airway walls. Further branching of the respiratory bronchioles is associated with increasing frequency of alveoli appearing until the airway terminates at a respiratory unit, which contains alveolar ducts, atria and about 20 alveoli. The alveoli are packed tightly with adjacent alveoli separated by a common alveolar septum. The diversity of pulmonary epithelia can be illustrated by examining its structure at three principal levels (Figure 10. Some serous cells, brush cells and Clara cells are also present with few Kulchitsky cells. The frequency of goblet and serous cells decreases with progression along the airways while the number of Clara cells increases. The alveolar region This is devoid of mucus and has a much flatter epithelium, which becomes the simple squamous type, 0. Two principal epithelial cell types are present: • Type-I pneumocytes: thin cells offering a very short airways-blood path length for the diffusion of gases and drug molecules. These phagocytic cells scavenge and transport particulate matter to the lymph nodes and the mucociliary escalator (see below). The ciliated cells each have about 200 cilia with numerous interspersed microvilli, of about 1–2 μm in length. They are bathed in an epithelial lining fluid, secreted mainly from the serous cells in the submucosal glands. The tips of the cilia project through the epithelial lining fluid into a layer of mucus secreted from goblet cells. The cilia beat in an organized fashion to propel mucus along the airways to the throat, as discussed below (see Section 10. The mucus largely originates from the vagally innervated submucosal glands, with a smaller contribution from goblet cells. It consists of lipid-rich lipoproteins with the lipid composition dominated by phosphatidylcholine with a high dipalmitoyl content. About 85–90% of isolated surfactant is lipid of which 95% is phosphoglycerols with cholesterol as the main neutral component. Lung surfactant decreases the surface tension and thereby maintains the morphology and function critical for respiration. Thus with each intake of air, the lung receives a high burden of dusts, fumes, pollens, microbes and other contaminants. Efficient defense mechanisms have evolved to minimize the burden of foreign particles entering the airways, and clearing those that succeed in being deposited. All devices employed for drug delivery to the airways of the lung generate an aerosol. Therapeutic aerosols are two-phase colloidal systems in which the drug is contained in a dispersed phase which may be a liquid, solid or combination of the two, depending upon the formulation and method of aerosol generation (see Section 10. Clearly for successful therapy, the drug must be presented to the lung in aerosol droplets or particles that deposit in the appropriate lung region and in sufficient quantity to be effective. Once the aerosol particle or droplet has deposited in the lung, there are a number of further barriers which must be overcome before the drug exerts its pharmacological effect. The respiratory defense mechanisms of mucociliary clearance and phagocytosis by macrophages may act upon undissolved particles. Aerosol particle dissolution may be slow and the drug may then subsequently be subject to enzymatic degradation before it reaches its site of pharmacological action. The factors influencing the deposition and fate of pulmonary delivered drugs will be discussed in this section. Three principal deposition mechanisms operate within the lower respiratory tract (Figure 10. A particle with a large momentum may be unable to follow the changing direction of the inspired air as it passes the bifurcations and as a result will collide with the airway walls as it continues on its original course. The probability of inertial impaction will be dependent upon particle momentum (the product of mass and velocity), thus particles with larger diameters or higher densities and those travelling in airstreams of higher velocity will show greater impaction. Airflow velocities in the main bronchi are estimated to be 100-fold higher than in the terminal bronchioles and 1,000-fold higher than in the A region (Figure 10. It becomes increasingly important for particles that reach airways where the airstream velocity is relatively low, e. The fraction of particles depositing by this mechanism will be dependent upon the time the particles spend in these regions. Particles below this size are displaced by a random bombardment of gas molecules, which results in particle collision with the airway walls. The probability of particle deposition by diffusion increases as the particle size decreases. Brownian diffusion is also more prevalent in regions where airflow is very low or absent, e. Another method of deposition, that of interception, is of importance for fibers but is not of importance for drug delivery. As a consequence of these physical forces acting on the aerosol particle, its deposition in the lung is highly dependent on diameter. Generally: • Particles larger than 10 μm will impact in the upper airways and are rapidly removed by coughing, swallowing and mucociliary processes. An 8 μm particle inhaled at 30 L min−1 has approximately a 50% chance of impacting on the throat. If the particles are less than about 3 μm then appreciable deposition in the A region is likely to occur. The “respirable fraction” of a therapeutic aerosol is often quoted as the percentage of drug present in aerosol particles less than 5 μm in size.
The collecting tubule transports newly formed urine to the renal pelvis for excretion by the kidneys order 50mg sildenafil. Urine leaves the collecting tubule and enters the The nephron performs three physiological renal pelvis cheap 25 mg sildenafil amex. From here it passes to the bladder functions as it produces urine: until urination takes place order 25 mg sildenafil otc. The union of the vas deferens with the duct from Male Reproductive System the seminal vesicle forms the (7) ejaculatory The purpose of the male reproductive system is to duct order sildenafil 75mg without a prescription. The seminal vesicle contains nutrients that produce, maintain, and transport sperm, the male support sperm viability and produces approxi- sex cell required for fertilization of the female egg. The prostate gland The primary male reproductive organ consists secretes a thin, alkaline substance that accounts of two (1) testes (singular, testis) located in an for about 30% of seminal fluid. Within the protect sperm from the acidic environments of testes are numerous small tubes that twist and the male urethra and the female vagina. Two pea- coil to form (3) seminiferous tubules, which shaped structures, the (9) bulbourethral (Cowper) produce sperm. The testes also secrete testos- glands, are located below the prostate and are terone, a hormone that develops and maintains connected by a small duct to the urethra. Lying over the bulbourethral glands provide the alkaline fluid superior surface of each testis is a single, tightly necessary for sperm viability. It is cylindrical stores sperm after it leaves the seminiferous and composed of erectile tissue that encloses the tubules. The urethra expels semen and urine which sperm passes after its production in the from the body. Tracing the duct upward, the epididymis at the base of the bladder closes, which not only forms the (5) vas deferens (also called the semi- stops the urine from being expelled with the nal duct or ductus deferens), a narrow tube that semen, but also prevents semen from entering passes through the inguinal canal into the the bladder. The vas deferens extends over (12) glans penis, contains the (13) urethral ori- the top and down the posterior surface of the fice (meatus). A movable hood of skin, called the bladder, where it joins the (6) seminal vesicle. Midsagittal section of male reproductive structures shown through the pelvic cavity. Connecting Body Systems–Genitourinary System The main function of the genitourinary system is to enable sexual reproduction and to regulate extracellular fluids of the body. Specific functional relationships between the genitourinary system and other body systems are summarized below. Blood, lymph, and immune Endocrine • Male reproductive system transports • Kidneys regulate sodium and water bal- testosterone throughout the body in ance, which is essential for hormone trans- blood and lymph. Cardiovascular Female reproductive • Kidneys help regulate essential electrolytes • Male organs of reproduction work in con- needed for contraction of the heart. Digestive • Kidneys aid in removing waste products • Kidneys aid in removing glucose from the produced by the fetus in the pregnant blood when excessive amounts are con- woman. Anatomy and Physiology 315 Connecting Body Systems–Genitourinary System Integumentary Nervous • Kidneys compensate for extracellular fluid • Kidneys regulate sodium, potassium, and loss due to hyperhidrosis. Respiratory Musculoskeletal • Kidneys and lungs assist in regulating acid- • Kidneys work in conjunction with bone base balance of the body. It is time to review male reproductive anatomy by completing Learning Activity 11–2. Medical Word Elements This section introduces combining forms, suffixes, and prefixes related to the genitourinary system. The onset of the disease is usually acute, with Pathology of the urinary system includes a range of symptoms including pain around the kidney, disorders from those that are asymptomatic to dysuria, fatigue, urinary urgency and frequency, those that manifest an array of signs and symp- chills, fever, nausea, and vomiting. However, in some anomalies, infectious diseases, trauma, or condi- cases, organisms may have developed a resistance tions that secondarily involve the urinary struc- and alternative antibiotics may be required. Many times, asymptomatic urinary diseases are first diagnosed when a routine urinalysis shows Glomerulonephritis abnormalities. Forms of glomerulonephritis and chronic urinary tract infection are two such dis- Any condition that causes the glomerular walls orders. Symptoms specific to urinary disorders to become inflamed is referred to as glomeru- include changes in urination pattern, output, or lonephritis. Endoscopic tests, radiological evaluations, glomerular inflammation is a reaction to the toxins and laboratory tests that evaluate renal function are given off by pathogenic bacteria, especially strepto- typically employed to diagnose disorders of the uri- cocci that have recently infected another part of nary system. Glomerulonephritis Signs and symptoms of male reproductive dis- is also associated with diabetes and autoimmune orders include pain, swelling, erectile dysfunction, diseases such as systemic lupus erythematosus, and loss of normal sexual drive (libido). Red blood cells and include pain, discharge, or lesions as well as a vague protein pass through the glomerulus and enter the feeling of fullness or discomfort in the perineal or tubule.. A complete evaluation of the genitalia, nephron tubules and forms solid masses that take reproductive history, and past and present geni- the shape of the tubules in which they develop. They commonly pass identify disorders associated with male reproduc- out of the kidney by way of the urine and may be tive structures. For diagnosis, treatment, and management of The clinical picture for glomerulonephritis genitourinary disorders, the medical services of a includes blood and protein in the urine (hema- specialist may be warranted. The physician who specializes in diagnoses and with acute glomerulonephritis associated with a treatment of genitourinary disorders is known as a streptococcal infection recover with no lasting kid- urologist. Stones (calculi) may form in any part of the uri- nary tract (urolithiasis), but most arise in the kid- Pyelonephritis ney, a condition called nephrolithiasis. These stones may is pyelonephritis, (also called kidney infection or increase in size and obstruct urinary structures. In this disor- they lodge in the ureters, they cause intense throb- der, bacteria invade the renal pelvis and kidney tis- bing pain called colic. Because urine is hindered sue, commonly as a result of a bladder infection that from passing into the bladder, it flows backward has ascended to the kidney via the ureters. When (refluxes) into the renal pelvis and the tubules, the infection is severe, lesions form in the renal causing them to dilate. If the stone is large, an ultrason- ic or electrohydraulic probe is used to break the stone into smaller fragments, which are then more easily removed. For stones that have descended into the ureters, it may be pos- Kidney stones sible to remove them using a specialized uretero- scope fitted with a small basket. The ureteroscope is passed through the urethra and bladder and into the ureter where the basket collects the stone. For larger stones, it may be necessary to break them into smaller pieces using an endoscope fitted with a laser beam before the fragments are removed. This procedure is called ureteroscopic stone removal, and no incision is required. Bladder infection (cystitis) and, ultimate- this procedure, a small incision is made in the skin, ly, kidney infection (nephritis) may result. Pathology 321 the entire prostate may be done through the per- disorder involves surgical suspension of the testes ineum (perineal prostatectomy) or an abdominal (orchiopexy) in the scrotum. This procedure is opening above the pubis and directly over the usually done before the child reaches age 2. These pro- Because an inguinal hernia commonly accompa- cedures are invasive and are performed when the nies cryptorchidism, the hernia may be sutured entire prostate must be removed, such as when (herniorrhaphy) at the same time. At the conclusion of the surgery, the urethra may occur because of circulatory collapse, severe and bladder are irrigated to remove the small hypotension, hemorrhage, dehydration, or other chips. In many mental apathy, nausea, vomiting, and increased infants born with this condition, the testes blood levels of calcium (hypercalcemia). When descend spontaneously by the end of the first tubular damage is not severe, the disorder is usually year. Urinary bladder Resectocope in urethra Testis Benign prostatic hyperplasia Rectum Figure 11-6. Two The most common form of cancer in men is carci- forms of radiation oncology include brachytherapy noma of the prostate. In brachytherapy ease is rarely found in men younger than age 50; (also called internal radiation therapy), radioactive however, the incidence dramatically increases with “seeds” are placed directly in the malignant tissue. Symptoms include difficulty starting urina- They remain in place for long or short periods of tion (hesitancy) and stopping the urinary stream, time depending on the type of malignancy, its loca- dysuria, urinary frequency, and hematuria. Early pre- directed at the tumor from outside the body to symptomatic tests include a blood test for destroy prostate tissue. Surgery and apy) has been effective in treatment at the early radiation therapy are usual treatment modalities, stages of the disease. Because prostatic cancer is but other forms of treatment may also be em- stimulated by testosterone, surgical removal of the ployed. Surgical treatment includes the removal of testes (bilateral orchiectomy) may be necessary.
It was claimed that the Negro women of the South made common use of it buy cheap sildenafil 25 mg on-line, and that it was so certain and safe that they could rid themselves of the product of conception whenever they wished trusted sildenafil 100mg, and without impairment of health sildenafil 100 mg generic. It was singular what a demand sprung up for cotton root bark; but fortunately for the unborn it had no influence on the gravid uterus buy 100 mg sildenafil visa. Still the reports from the South seemed well authenticated, that, at least in some cases, it was abortive, and was a very certain emmenagogue, and a stimulant diuretic. It is only another example of a fact I have insisted on, that many plants possessing medicinal properties when fresh, lose them when gathered at the wrong season and kept in stock. It also exerts a direct influence upon the urinary apparatus, increasing secretion and acting as a stimulant to the entire urinary tract. The indications for its use are a sense of fullness in the head, dizziness, flushed face, tensive pain as if the head would burst, partial loss of consciousness, or difficulty in drawing conclusions from impressions; throbbing in the whole body or in a particular part, as if the arteries were distended with blood, is deemed a good indication for glonoine. Locke for making a decoction are as follows: Put eight pints of water and eight ounces of prepared bark into a kettle and boil until the liquid is reduced to about four pints, then strain through muslin; press well. Add the contents of the strainer again to the same amount of water (eight pints), and boil until reduced to four pints, and strain as before. The indications for its use are - a feeble circulation of blood, pallid, transparent skin, pale tongue, impairment of the sexual function (irritation without power), irregular and painful menstruation, leucorrhœa. It may be employed in jaundice, dropsy, engorgement of spleen, fullness and oppression of the brain, and some other diseases where there is an obstructed circulation. Glycerine may be used in the prescription to hold the remedy in solution with water. I have employed it with good results in asthma, bronchorrhœa, dilated bronchia, old ulcers, and chronic diseases of the skin, with enfeebled circulation. I have employed it with marked benefit in the treatment of old and indolent ulcers. As we have an abundance of astringent remedies for diarrhœa, it is hardly worth while to import one, so that this may be tried in small dose for other effects. The Guarana of the drug market is the ground seed of the Paullinia Sorbilis, a native of Brazil. It is a stimulant to the cerebro-spinal centers, and its principal use now is to relieve headache. If the face is pallid, the eyes dull, the face expressionless, it may be used with advantage. It may be given in those severe headaches that recur with the menstrual period, the symptoms being as above, with a prospect of relieving the disease of the reproductive function, as well as the headache. It is indicated by vertigo, dizziness, variable appetite, cough, and may prove valuable in the early stages of phthisis. The tincture thus prepared may be occasionally used with advantage in the latter stages of acute, and in chronic rheumatism. It may also be associated with the vegetable alteratives in the treatment of some chronic diseases, where stimulation of the skin is required. Occasionally it will prove useful in functional diseases of the uterine organs, especially in amenorrhœa. An East Indian nut which has been employed in doses of one to ten grains in the treatment of agues, and as a prophylactic against malarial fevers. In doses of from one twenty-fifth of a grain to one grain, it is a remedy in some eruptive diseases, in enlargement of the spleen, hepatic pain, and œdematous swelling; it has also been employed in syphilis. For experiment, a tincture may be made of the bark, beans, or pulp of the seed-pod; the last being regarded as the most active. Herring concluded from his experiments that it might be given with benefit in cases of “cough accompanied or followed by tonsilitis; in erysipelas of the face; in scarlet fever; in so-called hives; in typhoid fever: in remittent or intermittent epidemic fever, with a typhoid character, etc. The ordinary fluid extract may be used as a topical application, as a gargle for the throat, and for the general purposes of an astringent. Where the Witch-Hazel can be readily obtained, I would advise that the leaves be gathered in June or July, and if no apparatus for distilling is at hand, that they be packed in a percolator, and a tincture prepared with a very weak spirit, say 30 per cent. The Hamamelis has a specific action upon the venous system, giving strength to it, and facilitating the passage of venous blood. It may, therefore, be employed with advantage in any case where a part is enfeebled, and there is a sluggish circulation. Thus we use it in cases of catarrh and ozæna; chronic pharyngitis, disease of the tonsils, pillars of the fauces, vellum and uvula, and in chronic laryngitis. The indications for its employment are, thickening of mucous membranes, with enfeebled circulation, and increased secretion, either mucous or muco-purulent. It is especially a valuable remedy in the treatment of hemorrhoids, sometimes effecting a cure in old and very stubborn cases without the use of other remedies. Usually, however, I use the solution of the persulphate of iron as a local application. It is also a very useful remedy in the treatment of diseases of the uterus and vagina. Given, a case with the conditions named, thickening, with relaxation, enfeebled circulation, and increased mucous, or muco-purulent secretion, and its action is very positive. We employ it also in the treatment of various lesions of the lower extremities, both as a local application and an internal remedy, and many times with excellent results. It is an excellent dressing for erysipelas, and for burns, giving that slight stimulation that seems to be required in these cases. I need not name other cases, as the indications for its use first given, will suggest its application. I regard it as one of the most valuable stimulant diaphoretics; very kindly received by the stomach, and quite certain in its action. It is an admirable remedy for amenorrhœa from cold; the safest and most certain we have, I think. It may be given in doses of a teaspoonful every hour or two hours, or two or three times in the evening, with the hot foot bath. Prepare your own tincture in this way: In July, gather a sufficient quantity of the herb, stem it, and at once pack the leaves in a percolator. Let it stand twenty-four hours, and then draw off, putting on water until the tincture measures Oj. It may have other properties, and it would be well to give it a thorough investigation. It has had a reputation as an antidote to the bite of poisonous snakes, and probably possesses some power in this direction. It exerts the general influence of a tonic, and a special tonic action upon the urinary and uterine organs. It is possible that if we can obtain a reliable preparation, it will be found superior to other remedies for these purposes. One of the special indications for its use is in the mental depression and irritability that attends many of these affections. I am of the impression that, in many cases, the relief of this cerebral disturbance is its most important action. The Hepatica exerts a slightly stimulant and tonic influence upon the stomach and small intestines, relieving irritation and promoting functional activity. Culpepper wrote, “It is a singularly good herb for all diseases of the liver, both to cool and cleanse it, and is serviceable in yellow jaundice. It is a singular remedy to stay the spreading of tetters, ringworms, and other fretting and running sores. Probably its best action is upon the bronchial mucous membrane, when enfeebled from inflammation or irritation, attended with profuse secretion. It has been employed as an antispasmodic, and we would judge that it was a spinal stimulant. In poisonous doses it produces great excitation of the nervous system, sometimes with convulsions, followed by coma and difficult respiration. It improves the appetite and facilitates digestion; but beyond this it relieves gastrointestinal irritation. Its topical action, however applied, is that of a tonic, strengthening the circulation and nutrition.