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By M. Thorek. William Woods University.

Elevated levels of carbon dioxide in the blood result from inadequate ventilation or from massive mismatches between ventilation and perfusion and the blood order 40mg cialis extra dosage overnight delivery. Some of the common symptoms are: dizziness 200mg cialis extra dosage with amex, drowsiness, confusion, tremors, and twitching Hyperchloremia – an increase in the chloride content of the blood. Chloride is the major extracellular anion and contributes too many body functions including the maintenance of osmotic pressure, acid-base balance, muscular activity and the movement of water between fluid compartments. It is a frequent finding in many disease processes such as asthma, metabolic acidosis, pulmonary embolism, and pulmonary 415 edema, and also in anxiety-induced states. One way to do this is to have the patient breathe through only one nostril, with the mouth closed. Having the patient breathe in and out of a paper bag is discouraged, as it leads to hypoxemia. After the acute phase of the hyperventilation has been managed, the underlying cause of the problem must be determined. Hypnotic – pertaining to sleep or hypnosis, an agent which induces sleep or which dulls the senses, drugs which cause insensibility to pain by inhibiting afferent impulses or the central centers of the brain receiving sensory impressions, and thus causing partial or complete unconsciousness Hypochondriac – affected with a morbid interest in health and disease Hypoglycemia – deficiency of sugar in the blood, a condition in which there is a level less than 80, hyper function of the pancreas may cause it or injection of an excessive amount of insulin Hypokalemia – an abnormally low concentration of potassium in the blood Hypokinesia – decreased motor reactions to stimulus Hypomania – hypomania and excitement, with a moderate change in behavior Hyponatremia – a decreased concentration of sodium (salt) in the blood Hypophysis – the pituitary body or gland Hypotension – decrease of systolic and diastolic blood pressure below normal, deficiency in tone or tension, below a blood pressure of 90/50 is pathologic, if increased pressure is followed by decreased pressure can be a serious condition, if the systolic and the diastolic drops proportionately – the patient will respond to the administration of stimulants, hypotension causes an accumulation of blood in the veins and slows down the arterial current Hypothalamic – a portion of the diencephalons compromising the ventral wall of the third ventricle below the hypothalamic sulcus, source of the hormones vasopressin and oxytocin stored and released by the neural lobe of the hypophysis Hypothermia – having a body temperature below normal, an art of lowered body temperature, usually between 78 - 90 degrees, to reduce oxygen need during surgery (especially cardiovascular and neurological procedures) and in hypoxia, to reduce blood pressure and to remedy Hypothyroid – marked by insufficient thyroid secretions in the body resulting in diminished basal metabolism, intolerance of cold temperatures, fatigue, mental apathy, physical sluggishness, constipation, muscle aches, dry skin and hair, and coarsening of features. These symptoms are called myxedema 416 Hypotonia – reduced tension, relaxation of arteries, loss of tone of the muscles or intra-ocular pressure Hypoventilation – reduced rate and depth of breathing Hypovolemia– diminished blood supply Hypoxemia – decreased oxygen tension (concentration) in arterial blood, measured by arterial oxygen partial pressure (PaO2) values. Symptoms may include memory issues, balance, ambulation, depending which area of the brain is affected Infiltrates – to pass into or through a substance or a space. A shadow seen on a chest xray, and assumed to represent blood, pus, or other body fluids in the lung Influenza – an acute contagious respiratory infection marked by fevers, muscle aches, headaches, prostration, cough, and sore throat. The disease usually strikes during the winter Influx – a flowing in 417 Insomnia – chronic inability to sleep or sleep prematurely ended or interrupted by periods of wakefulness, may be caused by a heavy late meal, with some coffee or other stimulants, including sugar in any form, overtiredness, mental fatigue, worry, excitement, and principally the fear of being unable to sleep Interstitial – placed or lying between; pertaining to interstices or spaces within an organ or tissue Intestinal atony – lack of muscle tone in the intestine and failure to contract normally, causing a delay in movement of fecal debris to exit the intestine Intracellular – within the cell Intracerebral – within the cerebellum of the brain. It consists of two lateral hemispheres and a narrow middle portion called the vermis. The cerebellum is involved in synergic control of skeletal muscles and plays an important role in the coordination of voluntary movements. It receives afferent impulses but is not a reflex center in the usual sense; however, it may reinforce some reflexes and inhibit others. Although the cerebellum does not initiate movements, it interrelates with many brainstem structures in executing various movements, including maintaining proper posture and balance; walking and running; fine involuntary movements as required in writing, dressing, eating, and playing musical instruments; and smooth tracking movements of the eyes. The cerebellum controls the property of movement such as speed, acceleration, and trajectory Intra ocular pressure – pressure with in the eyeball Intrathecal – within the spinal canal; within a sheath Involutional - a rolling or turning inward – associated with senile, pre-senile types, and manic-depressive groups Iritis – inflammation of the iris of the eye associated with pain, lacrimation, photophobia, diminution of vision, the iris appears swollen, dull and muddy, and pupil is contracted, irregular and sluggish in reaction Irritable bowel – the way the bowel responds excessively to a stimulus – diarrhea may be increased Ischemia – a temporary deficiency of blood flow to any organ or tissue. The deficiency may be caused by diminished blood flow either through a regional artery or throughout the circulation 418 J Jaundice – a condition characterized by yellowness of the skin, white of eyes, mucous membranes and body fluids, due to deposition of bile pigments resulting from excess bilirubin in the blood, it may result from obstruction of bile passageways, excessive destruction of red blood cells, or disturbances in functioning of the liver cells K Keratitis – inflammation and ulceration of the cornea, which is usually associated with decreased visual acuity, Eye pain, tearing, and light sensitivity are the most common symptoms Ketogenic diet – diet is high in fat, adequate in protein, and has negligible amounts of carbohydrate. It was created to stimulate some of the metabolic effects of fasting, a state known to decrease seizures in some individuals. They seem to do well for 2 or 3 months, then the seizures begin to start in again. Ketones – normal metabolic products, B-hydroxylbutyric acid and aminoacetic acid, from which acetone may arise spontaneously. The two acids are products of lipid pyruvate metabolism, and are oxidized by the muscles. It is metabolized by bacteria in the colon with the production of organic acids and is used to treat constipation and the encephalopathy that develops in patients with advanced cirrhosis of the liver. The unabsorbed sugar produces diarrhea and the acid pH helps to contain ammonia in the feces Laryngeal edema – swelling of the larynx in the throat Laryngospasm - spasm of the larynx in the throat Lavage – washing out of a cavity, example the eye or the abdomen abdomen Lecithin – any of a group of phospholipids common in plants and animals. They are found in the liver, nerve tissue, semen, and in smaller amounts in bile and blood. They are essential in the metabolism of fats and are used in the processing of foods, pharmaceuticals products, cosmetics, and inks. Deficiency leads to hepatic and renal disorders, high serum cholesterol levels, atherosclerosis, and arteriosclerosis Lennox-Gestaut - blanket term covering a variety of seizures (atonic drop attacks, complex partial, absence, and occasional tonic clonic) associated with significant delay in motor and intellectual development and does not respond well to drugs Lens – a transparent refractory as in the lens of the eye Lethargy – a condition of functional sluggishness, stupor, a state similar to hypnosis, or the first stage of hypnotism Leukocytosis – an increase in the number of leukocytes in the blood. It occurs most commonly in disease processes involving infection, inflammation, trauma, or stress, but it also can result occasionally from the use of some medications Leukopenia – abnormal decrease of white blood cells usually below 5000. A great number of drugs may cause leucopenia, as can failure of the bone marrow Leukorrhea – a white estrogen related scant/moderate odorless physiological vaginal discharge, normally preceding menarche and occurring during ovulation, during pregnancy, and in response to sexual excitement. Some women note an increased discharge related to oral contraceptive or hormone replacement therapy. Chronic cervicitis and vaginal infections are the most common causes of abnormal genital discharge. Signs of infection include increased discharge, change in color and consistency, odor, vulvar irritation, dysuria, and itching Limbic – the edge or border of a part, the margin Lipase – a fat splitting enzyme found in the blood, pancreatic secretion and tissues 420 Liposome – the recycling center of the cell where large molecules are broken down into small molecules to be reused kidney shaped organs of lymphoid tissues that lie at intervals along the lymphatic vessels Lupus Erythematous - tubercular skin disease, acute or subacute circulatory disorders and trauma predispose, reddish brown soft patches, circumscribed with raised edges and depressed centers which are white and scar like when scales drop off, disease spreads slowly, middle life females are predisposing factors. A chronic autoimmune inflammatory disease involving multiple organ systems and marked by periodic acute episodes. The disease is more prevalent is women of childbearing ages Lymphadenopathy – disease of the lymph nodes Lymphocyte – a white blood cell responsible for much of the body’s immune protection. Fewer than 1% are present in the circulating blood; the rest lie in the lymph nodes, spleen, and other lymphoid organs, where they can maximize contact with foreign antigens Lymph nodes – one of thousands of small kidneyed shaped organs of lymphoid tissue that lie at intervals along the lymphatic vessels Lysis – the gradual decline of a fever or disease; the opposite of crisis. The death of cells or microorganisms, caused by antibodies, complement, enzymes, or other substances M Macrocythemia – condition in which erythrocytes are larger than larger, example in folate or vitamin B12 deficiencies Malaise – discomfort, uneasiness, indisposition, often indicative of infection Malassezia – a genus of fungi that infects animals and humans. In hospitals, the infection tends to occur in patients receiving lipid (fat) infusions.

Synthetic polymers Carbomers are poly (acrylic acid) polymers widely used in the pharmaceutical and cosmetic industries order cialis extra dosage 200mg on line. They have several advantages safe cialis extra dosage 40 mg, including high viscosities at low concentrations, strong adhesion to mucosa without irritation, thickening properties, compatibility with many active ingredients, good patient acceptability and low toxicity profiles. These properties have made carbomers very valuable in the field of ophthalmic formulations. Artificial tear products and novel drug delivery systems based on carbomers have been extensively formulated. A recent scintigraphic study on Geltears (a Carbopol 940 based product) showed that the precorneal residence is significantly prolonged by carbomer gel when compared to the saline control. Phase transition systems The introduction in the early 1980s of the concept of in situ gel systems demonstrated that a considerable prolongation in duration of action could be obtained. In situ gelling systems have unique properties, which can make a liquid change phase to a gel or solid phase in the culde-sac upon its instillation into the eye. Three methods have been employed to induce phase transition on the eye surface: change in pH and temperature as well as activation by ions. Cellulose acetate phthalate forms a pH-triggered phase transition system, which shows a very low viscosity up to pH 5. The half-life of residence on the rabbit corneal surface was approximately 400 seconds compared to 40 seconds for saline. However, such systems are characterized by a high polymer concentration, and the low pH of the instilled solution may cause discomfort to the patient. When the solution is instilled onto the eye surface (34 °C) the elevated temperature causes the solution to become a gel, thereby prolonging its contact with the ocular surface. One of the disadvantages of such a system is that it is characterized by a high polymer concentration (25% poloxamer), and the surfactant properties of poloxamer may be detrimental to ocular tolerability. Gellan gum is an anionic polysaccharide formulated in aqueous solution, which forms clear gels under the influence of an increase in ionic strength. The gellation increases proportionally to the amount of either monovalent or divalent cations. The reflex tearing, which often leads to a dilution of ophthalmic solutions, further enhances the viscosity of the gellan gum by increasing the tear volume and thus the increased cation concentration. It is also possible to develop systems which undergo both temperature and pH dependent changes in structure. Carbomers form acidic, low viscosity, aqueous dispersions that transform into stiff gels when the pH is raised. Although these aqueous materials can form gels in situ in the conjunctival sac upon instillation, they often cause irritation to the eye due to their high acidity and sometimes the dispersions are not easily neutralized by the buffering action of the tear fluid. Various polymer combinations have been investigated in attempts to improve the gelling properties and reduce the total polymer content of formulations, thereby improving their tolerability. Dispersed systems These can be grouped into suspensions, particulates, liposomes and emulsions. Suspensions 311 Suspensions are commonly formulated by dispersing micronized drug powder (< 10 μm in diameter) in a suitable aqueous vehicle. Ophthalmic suspensions, particularly for the steroids, are thought to be acceptable as delivery systems since it is assumed that drug particles persist in the conjunctival sac giving rise to a sustained release effect. However, suspensions have a disadvantage that the concentration of dissolved drugs cannot be manipulated due to their relative insolubility in the vehicle. Several investigators have shown the importance of particle size of the suspension in ocular drug delivery. Unfortunately, a particle size above 10 μm in diameter may result in a foreign body sensation in the eye following ocular application causing reflex tearing. A reduction in particle size generally improves the patient comfort and acceptability of suspension formulations. Particulates Although the suspension technique may be useful in extending drug release under certain conditions, it is only applicable to drugs that are practically insoluble in water, such as corticosteroids. For drugs that are somewhat water-soluble, the particulate approach may be considered. Particulates are commonly classified into micro- and nanoparticles based on the size of the particles. Nanoparticles are colloidal particles ranging from 10 to 1,000 nm, in which drug may be entrapped, encapsulated, and/or absorbed. Microparticulates are drug-containing small polymeric particles (erodible, non-erodible or ion-exchange resins) within the size of 1–10 μm, which are suspended in a liquid carrier medium. Several distinct approaches have been used to formulate drugs in a microparticulate dosage form suitable for topical application. These include erodible microparticulates, swelling mucoadhesive particulates, pH responsive microparticulates, latex systems, ion-exchange resins, etc. Upon administration of particle suspension to the eye, the particles reside at the delivery site (cul-de-sac, sub conjunctiva or vitreous humor) and the drug is released from the particles through diffusion, chemical reaction, polymer degradation, or ion-exchange mechanism, resulting in increased ocular absorption. Piloplex was one of the first commercial exploration of nanoparticle formulations in ocular drug delivery. The formulation consists of pilocarpine-loaded nanospheres of poly(methylmethacrylate-acrylic acid) copolymer.

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Once an adequate airway has been assured and the primary trauma survey has been completed purchase cialis extra dosage 60mg mastercard, the burn wound must be assessed buy cialis extra dosage 100mg amex. In the case presented above, the patient, who was burned in an enclosed space, has facial burns and hoarseness sug- gestive of early onset of upper airway edema. The Language of Burn Care What sets burns apart from other forms of trauma is the damage to and loss of the protective shell that keeps the outside out. Skin is more than a passive envelope, however; it is a dynamic organ that has active biologic and immunologic functions. An accurate assessment of burn size is critical to the selec- tion of an appropriate fluid resuscitation regimen, nutritional support calculations, decisions on transfer to tertiary facilities, and prognosis for survival. Dermatopathologists divide the skin into more than a dozen layers, but, for practical purposes, skin is composed of three zones: epidermis, superficial dermis, and deep dermis. These are of importance in burn care since the depth of burn determines the potential for primary skin regeneration versus scarification (the need for surgical coverage by skin grafting or flap rotation). Hammond Second-degree burns involve the superficial dermis and produce a painful and moist or blistered wound. Note that a closed wound is not the same as a healed burn wound, since a burn wound may require 3 to 18 months to mature. Third-degree burns involve the deep dermal layer and may pene- trate into the subcutaneous fat. These wounds usually are painless, because of the destruction of dermal pain corpuscles, but sensation to touch may be preserved. Because the skin appendages, such as hair follicles and sweat glands from which skin regeneration occurs, are destroyed, these wounds close only with scar tissue produced by epithe- lial migration from wound edges. For the best cosmetic and functional results, third-degree burns require skin grafting or flap closure. So-called fourth-degree burns, involving bone or periosteum, are the result of charring or high-voltage electrical injury. Factors that are significant predictors of depth include location of the burn, patient age, preexisiting medical condi- tions, and etiology of the burn injury. Hot water scalds usually are second-degree wounds, while immersion burns, due to the longer contact time, are third degree. Flame burns generally are third degree, and grease or tar burns can be deceptively deep. The burn is a dynamic rather than a static wound, and serial inspection over several days may reveal that the burn wound has “progressed” in depth as marginally viable skin tissues in the zone of injury die. The head, for example, is 9%, while both the anterior and posterior torso are 18% each. The problem with this methodology is that it is highly inaccurate and frequently leads to overestimation of burn size by factors of 100%. A more formal and accurate method of burn size calculation is to use standard body nomograms, such as the Lund-Browder chart. Since adult proportions are reached at about age 12, separate nomograms exist for adults and chil- dren. For burns that are highly irregular in shape, such as tar injuries or grease splatters, a “hand count” method may be helpful. Inhalation Injury The presence or absence of inhalation injury is a major determinant of survival in burns. Hammond tract are rare, generally occurring only with the inhalation of super- heated steam. What commonly is thought of as a respiratory “burn” is a response to inhalation of the products of combustion, or carbon monoxide toxicity. Incomplete products of combustion, such as alde- hydes, nitrogen dioxide, and hydrochloric acid, can cause direct parenchymal lung damage. Carbon monoxide, with an affinity for oxygen more than 200 times that of hemoglobin, seriously can impair oxygen delivery to tissues. Early diagnosis of inhalation injury can be difficult, and it usually is a clinical diagnosis supported by an index of suspicion. The strongest correlation for a pulmonary injury is a history of being burned in an enclosed space coupled with the presence of facial burns or the history of patient incapacitation from drugs or alcohol. The serum carbon monoxide level may be used to tailor therapy, but it may be unreliable if supplemental oxygen already has been administered. The concen- tration of carboxyhemoglobin is reduced by 50% for each 40-minute period of treatment with high-flow oxygen. Bronchoscopy has been advocated as a diagnostic tool, but it adds little to the accuracy of the history and the physical examination. Since signs and symptoms of inhalation injury may appear over an 18- to 36-hour period, patients at risk or patients suspected of being at risk should be admitted for a 24-hour period of observation. Steroid therapy is not beneficial and carries a risk of superimposed infection; bronchodilator therapy and aggressive chest physiotherapy are advantageous. Prophylactic antibiotics are not recommended due to the risk of selection pressure for the emergence of resistant organ- isms.

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It is important to remember that each reproductive eventis statistically independent of all previous events 100mg cialis extra dosage sale. Therefore buy cialis extra dosage 100 mg without a prescription, the recur- rence risk remains the same regardless of the number of previously affected or unaffected offspring. The first affected individual to be identified in the family is termed the proband. Skipped generations are not typically seen because two Unaffected parents cannot transmit a disease-causing allele to their offspring (an exception occurs when there is reduced penetrance, discussed below). Autosomal dominant alleles are relatively rare in populations, so the typical mating pattern is a heterozygous affected individual (Aa genotype) mating with a homozygous normal individual (aa genotype), as shown in Figure I1-1-3. Note that, by convention, the dominant allele is shown in uppercase (A) and the recessive allele is shown inlowercase (a). The recurrence risk is thus 50%, and half the children, on average, will be affected with the disease. Autosomal Dominant Inheritance • Neurofibromatosis type 1 • Marfan syndrome Acute intermittent porphyria A a a aa a aa Attected offspring (Aa) are shaded. Recurrence Risk for the Mating of Affected Individual (Aa) with a Homozygous Unaffected Individual (aa) Autosomal Recessive Inheritance Important features that distinguish autosomal recessive inheritance: • Because autosomal recessive alleles are clinically expressed only in the homozygous state, the offspring must inherit one copy of the disease-causing allele from each parent. In contrast to autosomal dominant diseases, autosomal recessive diseases are typically. This mechanism, termed X inactivation, occurs in the i" chromosomes but one are blastocyst (-100 cells) during the development of female embryos. X inactivation has several important characteristics: o It is random-in some cells of the female embryo, the X chromosome inherited from Note the father is inactivated, and in others the X chromosome inherited from the mother is inactivated. Thus, as a condition in which cells • females are said to be mosaics with respect to the active X chromosome. For example, females with three X chromosomes in each cell (see Chapter 3) have two X chromosomes inacti- vated in each cell (thus, two Barr bodies can be visualized in an interphase cell). Inactivation of the X Chromosome During Embryogenesis Is a Random Process,I I I Properties of X-linked recessive inheritance! Skipped generations are commonly seen because an affected male can transmit the disease-causing mutation to a heterozygous daughter, who is unaffected but who can transmit the disease-causing allele to her sons. Male-to-male transmission is not seen in X-linked inheritance; this helps distinguish it from autosomal inheritance. Affected male-homozygous normal female: All of the daughters will be heterozygous carriers; all of the sons will be homozygous normal. Normal male-carrier female: On average, half of the sons will be affected and half of the daughters will be carriers. Affected male-homozygous normal female (X chromosome with mutation is in lower case) B. However, because X inactivation is a random process, a het- erozygous female will occasionally express an X-linked recessive mutation because; by random chance, most of the X chromosomes carrying the normal allele have been inactivated. Single-Gene Disorders X-Linked Dominant Inheritance Clinical Correlate There are relatively few diseases whose inheritance is classified as X-linked dominant. In this condition, females are differently affected than Males: 100% penetrance males, and whereas penetrance in males is 100%, that in females is approximately 60% (see margin note). Because females have two X chromosomes (and • Macro-orchidism (usually il thus two chances to inherit an X-linked disease-causing mutation) and males have only postpubertal) one, X-linked dominant diseases are seen about twice as often in females as in males. None of his sons will I be affected, but all of his daughters have the disease (assuming complete penetrance). X-Linked Dominant Inheritance Recurrence Risks Figure 11-1-10 shows the recurrence risks for X-linked dominant inheritance. Affected male-homozygous normal female (the mutation-carrying chromosome is upper case) B. X-linked Autosomal Autosomal May be X- recessive recessive dominant dominant Are all daughters of an affected male also affected? Note: If transmission occurs only through affected mothers and never through affected sons, the pedigree is likelyto reflect mitochondrial inheritance. Sometimes a specific muta- tion is seen in only some of the mitochondria, a condition known as heteroplasmy. She takes no prescription drugs although she does use tu:1; ill aspirin for the hip pain. A liver biopsy revealed stainable iron in all hepatocytes and initial indications of hepatic I,,I I cirrhosis. Subsequently Mary was tested and also proved to be homozygous for the I,I Q82Y mutation. The autosomal recessive disease xeroderma pigmentosum will be expressed more severely in individuals who are exposed more frequently to ultraviolet radiation. Different mutations in the disease-causing locus may cause more- or less-severe expression. Allelic heterogeneity usually results in phenotypic variation between families, not within a single family. Generally the same mutation is responsible for all cases of the disease within a family.

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This remedy is the Baptisia Tinctoria discount cialis extra dosage 40 mg with visa, which may be used in either of the cases named cialis extra dosage 50 mg visa, but is especially valued in the last. The reader will bear in mind that the activity of a zymotic poison is in exact proportion to the departure from normal function. With a rapid pulse, high temperature, and arrest of secretion, its development is rapid and its devitalizing influence marked. Or in the rare opposite case of congestive intermittent and cholera, as the circulation is enfeebled, and the temperature lowered, its progress is rapid. Hence, in order to antagonize a zymotic process, it is necessary, so far as possible, to obtain a normal circulation and temperature. In a given case, the circulation and temperature being favorably influenced by Aconite and Veratrum, Sulphite of Soda exerts an immediate and marked controlling influence over the fever poison. Whilst if it had been given without such preparation it would have had no influence at all, or but slight influence. Some causes of disease are destroyed and removed by remedies that increase waste and excretion. There are some organic remedies that exert a direct influence upon causes of disease, modifying or destroying them, as may be instanced in the action of Phytolacca in diphtheria. Causes of disease acting in and from the blood, are frequently removed by stimulating the excretory organs. Some are removed principally by the skin, others by the bowels, others by the kidneys. The cause of periodic disease, whatever it may be, plays a very important part in the diseases of some localities. Hence in the treatment of the diseases of the West, antiperiodics become the most important remedies. It fails frequently, possibly it is administered nine times where its specific action is obtained once. If the diagnosis is correctly made, and the system is prepared for its administration, it will rarely fail, even when given in a single sufficient dose. I am satisfied that the study of the direct antagonism of remedies to causes of disease, must advance the progress of rational medicine. It is possible, and I deem it probable, that such research will give us remedies controlling all zymotic disease in its early stage. As this exerts a controlling influence, we should expect that its lesions would form a very important element of the study of pathology. This has not been the case, however, and we find pathologists and therapeutists giving it but very little attention. It is a wide field for study, and its cultivation will greatly advance medical science. A few suggestions may not be out of place here: Those functions which we have been accustomed to speak of as vegetative, are associated together, and to some extent governed by the ganglionic or sympathetic nervous system. It comprises digestion, blood-making, the circulation of the blood, nutrition, and secretion and excretion - these are the essentially vital functions, in the performance of which man has life. If they are properly performed, he has healthy life, if there is an aberration in either of them, one or more, he has diseased life. If this be so, then this ganglionic system of nerves must play an important part in every disease. If there are remedies then that influence the ganglionic nerves directly, and through them the vital ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ * See Principles of Medicine, page 306. The sedatives, Aconite, Veratrum, Gelseminum, Lobelia, and others, as Cactus, Belladonna, Eryngium, Phytolacca, Hamamelis, Pulsatilla, etc. The association of the spinal-cord with the sympathetic brings vital functions in relation with our conscious life, and through its superior expansion the brain, adds suffering from disease. Conversely, mal-conditions of conscious life are reflected through this association and influence vital processes. Whilst, therefore, it is very important to reach lesions of vegetative life directly through the ganglionic system of nerves, it is no less important to control any disease producing influence that might be extended from the cerebro-spinal centres. In some they form a principal part, in others in less degree, but in all they require to be estimated in diagnosis and therapeutics. They range themselves under the common classification of excess, defect, and perversion, and usually it is not difficult to determine their character, and select means that exert a direct influence. If the material is broken down and removed to the blood, but not carried out by the excretions, we will have an impairment of life from its presence in the blood. Too rapid waste of tissue is sometimes an important element of disease, requiring care in diagnosis and the application of remedies.

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