What are hearing tests?

Indications and Procedures

Hearing tests are done to establish the presence, type, and severity of hearing impairment in children and adults. Such tests are conducted by an audiologist, although screening tests can also be done by a technician under the supervision of an audiologist. The severity of hearing loss is classified as mild, moderate, moderately severe, severe, and profound. It is also classified according to the anatomic region affected: conductive, sensorineural, or mixed hearing loss.

The selection of tests to evaluate hearing will depend on the patient’s age and ability to follow directions and the ability of the audiologist to elicit responses from the patient. When a patient cannot follow instructions such as lifting a hand or pressing a button, a test that does not require the patient’s cooperation is used. Two tests that do not require the patient’s cooperation are the auditory brainstem potential (ABR) test and the evoked otoacoustic emissions (EOAE) test. Both tests require only that the patient be quiet. For this purpose, the patient may need sedation if normal sleep cannot be induced.

The ABR test requires the placement of four electrodes on the patient’s head: in both mastoid regions and in the mid forehead and upper center of the head. A stimulus is sent through a small microphone placed in the patient’s external ear canal or via headphones. The instrument records the average of the electrical discharges generated by the auditory nerve in response to sound stimuli and produces a tracing of waves that correspond to the different electrical potentials generated in response to the stimuli. Analysis of the waves can determine the presence of hearing loss and measure its severity. The ABR test may be used for screening, to determine whether the subject can hear, or for the clinical evaluation of hearing loss. It can be done at any age. An automated method of ABR testing is available for screening newborn infants for hearing loss; it automatically determines if the patient has passed or failed. The clinical ABR test requires specially trained personnel and takes from forty-five to fifty minutes to perform. The automated method can be applied by a technician.

The EOAE test involves recording the sound produced by hair
cells within the cochlea by way of a microphone placed in the outer ear canal. Normally, when sound enters the cochlea, the hair cells produce a sound that bounces backward and can be recorded. This sound correlates with the sound sent to the auditory nerve. If there is damage to the hair cells in the cochlea, then no sound is elicited. The EOAE test can be performed without sedation if the patient cooperates by staying quiet. It can be done by a technician and takes approximately ten minutes or less. The EOAE test is used for universal screening of newborn infants. It can be done at all ages to help determine the integrity of the cochlea and thus whether an observed hearing defect is within the cochlea.

Behavioral techniques are the most practical, cost-effective, and time-efficient methods for the accurate assessment of hearing. They give more complete information on the child’s hearing as well as functional information about how the child uses his or her hearing. The simplest test is behavioral observation audiometry, in which the audiologist records the behavioral response to an applied sound stimuli of a known frequency. This test can be done with infants up to six months of age, toddlers, and uncooperative patients, such as children or adults with developmental delays. Visual reinforcement audiometry (VRA) is done with infants and toddlers from six months to twenty-four months of age. It is also used with uncooperative patients. In this test, the patient is submitted to sounds of different intensity and trained to respond to the sound stimuli by means of an attractive stimulus. Every time that the sound appears, the stimulus illuminates. When the patient hears the sound, he or she will look for the reinforcement. Play audiometry is a test that can be used in children over two
years of age. The child is taught to move a block or place a puzzle piece every time he or she hears a sound.

In 2002, Ruth Litovsky, an University of Wisconsin–Madison communicative disorders professor, introduced a binaural hearing test to evaluate how people respond to sounds in a noisy environment resembling public areas and schools. Using computers showing images related to words being broadcasted on loudspeaker, her test assesses which sounds people ignore and which sounds secure their attention.

In 2003, the Ear, Nose, and Throat Journal provided information describing the Otogram from Tympany, a Sonic Innovation subsidiary. This device enables patients to test their hearing at sites using automated technology. During the twenty-minute testing period, patients undergo an audiogram that thoroughly evaluates their acoustic capabilities with tympanometry and other standard diagnostic tests, responding to the tests via touchscreens with results recorded by computer.

In 2005, Bio-Logic Systems Corporation and House Ear Institute researchers introduced the hearing in noise test (HINT), which assesses how hearing functions in police and emergency personnel whose hearing is vital to their work. The test involves subjects repeating sentences while exposed to a variation of noise and quiet. The source azimuth identification in noise test (SAINT) evaluates subjects’ ability to detect where sounds are located.

Perspective and Prospects

Early detection of hearing loss has become a priority among intervention services because it has devastating effects on language development and consequently on social adaptation. It has been found that the mean age at which deafness is diagnosed is around three, which is after speech development should have occurred. Thus, children with hearing loss are placed at a disadvantage with their peers.

In 1993, the National Institutes of Health (NIH) developed a consensus statement by which all newborn infants in the United States were to be screened for hearing loss. The aim was that by the year 2000, all newborns would have been screened before being discharged from the hospital. By 1999, many US states had passed legislation requiring hearing screening of newborns, but a study described in the July, 1999, issue of American Journal of Otology recommended screening only babies with a risk for impaired hearing, stating that pediatricians and child care providers would detect deafness in infants and toddlers.

The October, 2001, the Journal of the American Medical Association
evaluated nineteen studies, emphasizing that screening newborns was not superior to tests by pediatricians when infants were several months old and stressing that determining the value of newborn screening required additional study. In October, 2005, the Archives of Pediatrics & Adolescent Medicine estimated that more than half of children whose hearing test results revealed that they needed additional tests never underwent such testing.

The role of otitis media (middle-ear infections
) in producing hearing impairment is an area of great concern and controversy. Special attention to the hearing evaluation of children with recurrent and chronic otitis media is indicated.

Bibliography

"Audiometry." MedlinePlus, August 30, 2012.

Bess, Fred H., and Judith S. Gravel, eds. Foundations of Pediatric Audiology. San Diego, Calif.: Plural, 2006.

Dobie, Robert A. and Susan B. Van Hemel, eds. Hearing Loss: Determining Eligibility for Social Security Benefits. Washington, D.C.: National Academies Press, 2005

de la Rocha, Kelly. "Audiometry." Health Library, November 11, 2012.

Elder, Nina. “Now Hear This—Check Your Baby’s Hearing.” Better Homes and Gardens 78, no. 5 (May, 2000): 264.

Glaser, Gabrielle. “Pediatricians Urge Hearing Tests at Birth.” The New York Times, April 6, 1999, p. 7.

Hall, James W., III. New Handbook of Auditory Evoked Responses. Boston: Pearson Education, 2006.

Hearing Exchange. http://www.hearingexchange.com.

Koike, Kazunari J. Everyday Audiology: A Practical Guide for Health Care Professionals. San Diego, Calif.: Plural, 2006.

Montemayor-Quellenberg, Marjorie. "Newborn Hearing Test." Health Library, March 15, 2013.

McCormick, Barry, ed. The Medical Practitioner’s Guide to Paediatric Audiology. New York: Cambridge University Press, 1995.

Martin, Frederick N., and John Greer Clark. Introduction to Audiology. 10th ed. Boston: Pearson, 2010.

Northern, Jerry L., and Marion P. Downs. Hearing in Children. San Diego, Calif.: Plural, 2011.

Roush, Jackson, ed. Screening for Hearing Loss and Otitis Media in Children. San Diego, Calif.: Singular, 2001.

Sataloff, Robert T., and Joseph Sataloff. Hearing Loss. 4th ed. New York: Taylor & Francis, 2005.

What theme is illustrated by Désirée's acceptance of blame for the baby's skin color?

Kate Chopin leaves many ambiguities in her short story "Desiree's Baby." Whether Desiree does or does not accept that she is the reason her baby has African features is unclear. In fact, initially she protests vehemently when Armand says, "It means that the child is not white. It means that you are not white." She shows Armand her hand and declares that it is whiter than his. She writes to her mother urging her to "tell them it's not true." Madame Valmonde writes back, telling her to come back home to her with the baby. There is no indication that Desiree ever believes she herself is of mixed race. On the contrary, Chopin's word choice seems to reinforce that Desiree continues to believe in her whiteness. When she lays the letter before Armand, she stands there "silent, white, motionless." When she leaves the house with the baby, "Desiree had not changed the thin white garment" that she wore, and presumably had not changed her conviction about her racial heritage. 

The only indication that suggests Desiree accepts Armand's explanation of their child's looks is that Desiree leaves the plantation when Armand says he wants her to go. However, Desiree no doubt has enough pride to not stay with a husband who expressly wants her to leave. In addition, she realizes that if she is not of mixed race, that Armand must be, and that he will never tolerate such a fact to be made known. She will need to be sacrificed for his secret.

Whether Desiree accepts Armand's explanation or whether she merely acquiesces to it, the theme her actions support is the same. The theme Chopin presents is that in a patriarchal society, a woman is powerless even if she is in the right, and she is at the complete mercy of her husband's whims, beliefs, and desires. 

What major themes and comments on life are evident in the poem "Song of Myself"?

This long poem, a piece of Leaves of Grass, is a spontaneous self-portrait in prose form, celebrating Whitman’s individuality while acknowledging how all humanity is alike (like “leaves of grass”). 

“I harbor for good or bad, I permit to speak at every hazard,/
Nature without check with original energy.”

Whitman’s consistent and unequivocal comment on life is to live it, every day, every moment, to savor and enjoy and be ultra-conscious of your own facticity:

 “My respiration and inspiration, the beating of my heart, the
     passing of blood and air through my lungs,
The sniff of green leaves and dry leaves, and of the shore and
     dark-color'd sea-rocks, and of hay in the barn,”

A second, related theme is that the universe is infinite, that our immediate existence is but a fraction of all that is:

     “You shall possess the good of the earth and sun, (there are
     millions of suns left,)”

Whitman’s “song” is that there is no limit to our experience as living creatures, as spirits given the blessing of our existence.  While it is difficult for us as common men to see the grandeur, Whitman manages to point to it and invite our souls to celebrate the fact of being.

These themes are so large in concept, so vital to our understanding of Whitman's life-message, that paraphrasing or condensing them is "murdering to dissect,"  that is the "life" of the poem itself is diminished; reading the poem is all the "analysis" you need in order to understand his connection to the reader.

What process causes volcanoes to form along the mid-ocean ridge?

The mid-ocean ridge is a continuous underwater range of mountains which virtually encircle the globe. These mountains are formed along the boundaries of tectonic plates where new ocean floor is created when tectonic plates move apart.

Tectonic plates are moved apart by convection in the upper mantle. As the tectonic plates move apart, molten rock ascends, right through to the sea floor, producing huge volcanic eruptions of lava, called basalt. The enormous force of the lava eruption further aggravates the divergence of the tectonic plates.

Tectonic plates spread apart at varying rates. Plates with slow spreading rates of about 2 to 5 cm per year develop deep rift valleys along their crest but fast spreading ones with rates of about 6 to 16 cm per year develop a smooth volcanic summit with only a crack along their crests.

What are the differences between Banquo and Macbeth with relation to the witches' prophecies?

Macbeth is prophesied to be king, while Banquo will be the father of kings. At the beginning of the play, these two soldiers had been friends, fighting together in the battle. With the prophecy, however, things begin to change. Macbeth, believing wholeheartedly in the prophecy, immediately sees murder as the means by which he can get rid of Duncan, as well as Duncan’s sons, Malcolm and Donalbain. When he contemplates the witches’ prophecy of Banquo’s sons becoming kings, he puts two and two together: his own sons will not inherit the crown. Instead, it will go to the offspring of Banquo (a historical note: Banquo’s descendant was James I, the king of England when Shakespeare wrote the play). Therefore, Banquo must die (even though he is not prophesied to be king himself). His sons also must be killed.

Macbeth’s hubris (pride) easily twists his soul, seeing murder as a requirement to achieve his destiny. He had momentarily thought that he should do nothing, and that his fate would happen without his own effort. Then he decides that he cannot take that risk. Previously a loyal subject and friend, his relationship with Duncan as well as Banquo is twisted.

Banquo, understanding the prophecy as well, does not see it as “fate.” He believes it is the work of the devil, in order to get Macbeth and himself to commit evil. He rejects this, and begins to distance himself from Macbeth, at least emotionally.

The difference between the two men, therefore, is the nature of the souls. Macbeth is easily corrupted, while Banquo is strong in character. In the end, it is this difference that brings about the result of the prophecy. Macbeth does not live long enough to pass the crown onto his son, which the witches didn’t prophesy. Banquo, who chooses righteousness, does nothing to help the prophecy along; as a result, it comes true.

Why is the world we live in today interested in not only the quality of goods we buy but in how those goods and services are produced?

Have you ever seen references to the internet meme “first world problems?”  I believe that we care not only about the quality of the products we buy, but about how they are produced, because we are so rich that we have the ability to do so.

In the past, we were not nearly as rich as we are now.  Before WWII, the average American did not live the sort of affluent lifestyle that we now have.  Even in the boom years after the war, the typical American did not live as well (in material terms) as we do now.  Most people did not have two cars.  Houses were much smaller than they are now.  People did not go out to eat all the time or spend their money on fancy cups of coffee products.  It is only in the last few decades (no matter how much we complain about the weak economy or rising inequality) that the vast majority of Americans have come to have so much material wealth.

The psychologist Abraham Maslow said that human beings have to have their basic needs fulfilled before they can care about other things.  Speaking of individual people, he said that a person has to have food and shelter, for example, before they can worry about things like morality. I think that the same sort of thing applies to our society as a whole.  When we were worried about having enough material goods, we were not able to care about other things.  Now, we have enough material goods.  We have the luxury of worrying about how they are made.  We have the luxury of wondering if they were made in ways that harmed the environment or exploited workers in other countries.  When we were poorer, we did not care about these things because we just wanted to fulfill our more basic needs.  Now that our basic needs are amply provided for (and have been for at least a couple of decades), we have been able to move on to thinking about things like the morality of how our goods and services are made.

What is the proper chemical formula and model for water?

The chemical formula of water is H2O. One molecule of water contains 2 atoms of hydrogen and one atom of oxygen. It is a covalent molecule and has a definite geometry. The central atom is oxygen.   The electronic configuration of Oxygen in the ground state is

1s2 2s2 2p4. (atomic number of oxygen is 8).

The 2s orbital containing 2 electrons and the three 2p orbitals containing a total of 4 electrons of oxygen undergo  sp3 hybridization. Hybridization is the process of mixing up of orbitals of slightly different energies of an atom to give same number of equivalent orbitals. The hybrid orbitals will have the same energy and shape. In this case 4  sp3 hybrid orbitals are formed. According to VSEPR theory these hybrid orbitals will get themselves arranged around the central atom in such a way that repulsion between them is minimum. Here the orbitals are arranged tetrahedrally around the central oxygen atom. The angle between the orbitals in the tetrahedral arrangement is 109028’. As an orbital can accommodate only two electrons, the 6 electrons are distributed among the 4 hybrid orbitals such that two orbitals contain two electrons each (paired electrons) and the remaining two contain one electron each (unpaired electron). Only half filled orbitals containing one electron (unpaired electron) can form covalent bond. Hence the two half-filled sp3 hybrid orbitals of oxygen form covalent bonds with two hydrogen atoms.

The electronic c configuration of Hydrogen atom is   1s1. (atomic number of hydrogen is 1).

The 1s orbital of hydrogen is half-filled (contains only 1 electron).

According to Valence Bond theory, a covalent bond is formed by the overlap of two half-filled orbitals containing electrons of opposite spin of two atoms. Thus in water, the two half-filled sp3 hybrid orbitals of oxygen  overlap with the half-filled 1s orbitals of 2 hydrogen atoms to form covalent bonds. The overlap of the orbitals takes place along the inter-nuclear axis resulting in the formation of sigma type covalent bonds. (if the overlap takes place sideways, a pi bond is formed). In water the two O-H bonds are of sigma type.

In water, the central oxygen atom has two bond pair electrons (from two covalent bonds) and two lone-pair of electrons (from two completely filled orbitals not involved in bond formation) .According to VSEPR theory the repulsion between the orbitals are in the order

Lone pair-lone pair> lone pair- bond pair > bond pair-bond pair.

As there are 2 lone pair electrons, the bond pairs get repelled and the H-O-H bond angle decreases from the normal tetrahedral angle of 109028’ to 104.50. Water is thus a bent molecule. It is a V-shaped molecule.

The atomic radius of Oxygen is greater than that of hydrogen. Hence oxygen is bigger in size than hydrogen.

Oxygen is more electronegative than hydrogen.Electronegativity is a measure of the tendency of an atom to attract the shared pair of electron s (bonded pair of electrons) of a covalent bond towards itself in a molecule. Since oxygen is more electronegative than hydrogen the shared pair of electrons in the O-H bond is displaced towards oxygen atom. As a result a partial negative charge develops at the oxygen atom and a partial positive charge at each hydrogen atom. The O-H bond is thus polar. Each O-H bond has a dipole moment. Dipole moment is a vector quantity, having both magnitude and direction. Since H2O is a bent molecule, the bond moments do not cancel each other and the molecule has a net dipole moment. Water is thus a polar molecule.

The image at ‘b’ represents the water molecule.

Why does the narrator of "The Cask of Amontillado" by Edgar Allan Poe want revenge?

The narrator of "The Cask of Amontillado" wants revenge against his friend and fellow nobleman, Fortunato, because Fortunato has insulted him in some fashion. The exact details of this transgression are never named within the text; rather, the narrator only asserts, "The thousand injuries of Fortunato I had borne as I best could, but when he ventured upon insult I vowed revenge." With a soon-to-be murderer acting as our sole perspective in this story, it is hard to discern whether or not this insult was as grave as is implied. Is this a matter of actual slander? Or is the narrator simply paranoid, bloodthirsty, or mad? We are never given any definitive answer... That being said, Fortunato certainly does not seem to think he has committed any wrongdoings, as he greets the narrator "with excessive warmth." 

Nonetheless, the narrator assures us that "[a]t length [he] would be avenged," and proclaims proudly, "I must not only punish but punish with impunity" for "[a] wrong is unredressed when retribution overtakes its redresser... It is equally unredressed when the avenger fails to make himself felt as such to him who has done the wrong." 

When does Lady Macbeth use flattery on Macbeth whilst persuading him to kill Duncan in Act 1, Scene 7?

In this particular scene, Lady Macbeth uses a great deal more insult that she does flattery to sway her husband.  However, after calling him a coward and saying that he's not really acting "like a man" at this point -- now that he's ambivalent about committing the murder of Duncan -- she does say, "When you durst do it, then you were a man; / And to be more than what you were, you would / Be so much more the man.  Nor time nor place / Did then adhere, and yet you would make both" (1.7.56-59).  In other words, she says that the decision Macbeth had made earlier, to kill the king, was a really manly decision, and he will be even more manly if he goes through with that decision now.  At the time, when he'd initially conceived of the plot to murder Duncan, nothing was ready -- it wasn't the time or the place -- and yet he still thought of and determined to enact this plan.  She seems to admire this and think it courageous and masculine.

Further, Lady Macbeth claims that if Macbeth can just pluck up the courage to move forward, there is no way that they will fail to succeed.  She says, "screw your courage to the sticking place / And we'll not fail" (1.7.70-71).  She makes it sound as though the whole plan hinges on him: if he can muster his courage then there is no possible way for things to go wrong.  This is relatively complimentary.

Why does water contract while increasing temperature from 0 to 4 degree C?

Water molecules are composed of one oxygen bound to two hydrogen atoms through a single covalent bond with each. These bonds are not evenly shared; oxygen has more positive charges in its nucleus and is able to exert a stronger pull on the electrons in the bond. Therefore, the electrons spend more of their time closer to the oxygen, which gives the oxygen a partial negative charge. The hydrogens, having less time around the electrons, do not have their single positive charge completely cancelled out, so they have a partial positive charge. We call this type of condition polarity. Water is one of the most polar molecules, and this explains a great deal about its properties.

The reason for the phenomenon observed when water is at 4 and 0 degrees is due both to the nature of this polarity, and to the behavior of molecules in their different phases. Liquids are typically higher in energy than their solid counterparts of the same substance under the same conditions. This means the liquid molecules are moving around more, and therefore will have a lower density. So, it shouldn't surprise us that as water cools, the trend is, on average, for the density to increase.

The polarity of water factors into the cooling as well. When water cools, the decreased motion of the molecules allows the molecules to "lock" themselves into the arrangement that best satisfies their polar charges; oxygens are near hydrogens, and vice versa. Due to the geometric shape of the water molecule, this results in a specific hexagonal crystal shape. These shapes are less dense, on average, than the liquid form of water because they don't have the energy to squeeze themselves into the less-favorable spaces.

When the water reaches 4 degrees, these shapes are beginning to take form, and the water is both increasing in density (as it cools) and decreasing in density (as the crystal shapes form and lock the molecules into a particular arrangement). By the time the water has reached 0 degrees Celsius, the locking effect is complete, and there's actually "wasted" space in the crystal that was once occupied by the slightly more energetic 4 degree water.

The molality of a 1L Solution with x percent H2SO4 is 9. The weight of solvent present in the solution is 910 grams. What is the value of x?

Molality is a measure of concentration defined as moles of solute per kg of solvent.  So if the molality of the sulfuric acid solution is 9, then that means that there are 9 moles of sulfuric acid per 1 kg of solvent.  So we have a solution that is 9 molal in concentration and the amount of solvent in it is 910 g which is the same as 0.910 kg.  So we multiply the two to get the moles of sulfuric acid in the solution.

(9 mole / kg) * 0.910 kg = 8.19 moles sulfuric acid

Multiply this by the molecular weight of sulfuric acid (98.079 g/mole) to convert into grams.

8.19 moles * (98.079 g / mole) =  803.3 g sulfuric acid

Now divide by the density of sulfuric acid (1.84 g/mL) to convert the grams into mL's.

803.3 g * (1 mL / 1.84 g) = 436.6 mL sulfuric acid

So we have 436.6 mL of sulfuric acid total.  Since we know that we have 1 L (the same as 1,000 mL) of total solution, we know that means that the percentage of the sulfuric acid in the solution can be calculated as shown below.

436.6 mL H2SO4 / 1,000 mL total solution = 0.437 = 43.7%

So we know that the value of x in the original question (percentage of H2SO4 in the solution) is 43.7%

I need to know who Hamlet really trusts. Who is loyal to Hamlet?

Hamlet really trusts Horatio and no one else. And Horatio is completely loyal to Hamlet. Hamlet confides everything to Horatio. Horatio is the only one to whom Hamlet has confided the substance of his meeting with the Ghost on the battlements and who knows that Claudius murdered Hamlet's father to seize the throne. In one scene Hamlet expresses his confidence in Horatio.

Horatio, thou art e'en as just a man
As e'er my conversation cop'd withal.
....................................................
Nay, do not think I flatter;
For what advancement may I hope from thee,
That no revenue hast but thy good spirits
To feed and clothe thee? Why should the poor be flatter'd?
No, let the candied tongue lick absurd pomp,
And crook the pregnant hinges of the knee
Where thrift may follow fawning. Dost thou hear?
Since my dear soul was mistress of her choice,
And could of men distinguish her election,
Sh'hath seal'd thee for herself. For thou hast been
As one, in suff'ring all, that suffers nothing;
A man that Fortune's buffets and rewards
Hast ta'en with equal thanks; and blest are those
Whose blood and judgment are so well commeddled
That they are not a pipe for Fortune's finger
To sound what stop she please. Give me that man
That is not passion's slave, and I will wear him
In my heart's core, ay, in my heart of heart,
As I do thee.       (Act III, Scene 2)

Hamlet expresses these sentiments to Horatio just before asking him to help observe the King during the course of the play-within-a-play. Hamlet wants to have a witness to verify his own observations of Claudius when it comes to the place where the actor playing the villain pours poison in the ear of the actor playing the sleeping King. It turns out that Hamlet hardly needs a witness, since Claudius makes such a scene that he brings the play-within-a-play to a halt as he flees the room. Horatio is convinced that the Ghost who appeared to Hamlet on the battlements was indeed the ghost of Hamlet's father and was telling him the exact truth.

Horatio acts like a true friend to Hamlet throughout the remainder of the play, and he proves his complete loyalty when he endeavors to commit suicide and join Hamlet in death at the very end. But Hamlet wrests the poisoned goblet out of his friend's hand and asks him to "absent himself from felicity" for a while in order to tell his story to the members of the court. Horatio is necessary for this function, since he is the only person still alive who knows the whole truth. Without him, everyone in the Danish court would assume that Hamlet had committed a wilful murder in an attempt to usurp the throne from Claudius. Horatio could not have been more loyal to Hamlet.

How are the themes of kindness and trust communicated in the story?

The themes of a piece of literature are implied messages the author conveys to the reader. In “Thank You, M’am” by Langston Hughes, the themes of kindness and trust are evident throughout the story.

The theme of trust is developed from the beginning of the story when Roger attempts to steal Mrs. Luella Bates Washington Jones’ “kitchen sink” pocketbook. Although, she has him in her grasp, she trusts him to pick up the purse and not run away. After she drags him back to her rooming house, the pair carry on a conversation during which Mrs. Jones reveals things from her past. She trusts Roger to understand her reasons for divulging her own desperate times.

The door to her room remains open while she instructs Roger to wash up, and when she goes behind the curtain to cook their meal. Her purse sits in plain sight so that if Roger chose to, he could grab it and run. He does not because at this point he wants to be trusted.

In another corner of the room behind a screen was a gas plate and an icebox. Mrs. Jones got up and went behind the screen. The woman did not watch the boy to see if he was going to run now, nor did she watch her purse which she left behind her on the day-bed. But the boy took care to sit on the far side of the room where he thought she could easily see him out of the corner of her eye, if she wanted to. He did not trust the woman not to trust him. And he did not want to be mistrusted now.

In addition, the theme of kindness runs throughout the story. Mrs. Jones decides not to call the authorities when Roger tries to steal her purse, instead she takes him home to teach him a lesson with her actions. She notices he is a hungry, neglected young man, which prompts her to encourage him to look presentable, and share her meager supper with him. This includes splitting a ten cent dessert. While she is preparing the meal, Roger offers to run to the store for anything she might need as he tries to reciprocate for her kindness towards him.

Her greatest kindness may have been the respect she shows him by not asking him questions about his home life so as not to embarrass him. Others would argue the utmost kindness occurred at the end of the story when Mrs. Luella Bates Washington Jones hands him money so he can buy the blue suede shoes he so desperately wants.

When they were finished eating she got up and said, “Now, here, take this ten dollars and buy yourself some blue suede shoes.  

He is rendered practically speechless by this act of kindness towards him.

The boy wanted to say something else other than “Thank you, m’am” to Mrs. Luella Bates Washington Jones, but he couldn’t do so as he turned at the barren stoop and looked back at the large woman in the door. He barely managed to say “Thank you” before she shut the door. And he never saw her again.

Explain why Amir's task is to not only atone for his own sins but for his father's as well in the novel The Kite Runner.

The protagonist in Khaled Hosseini's novel The Kite Runner, Amir, is motivated by guilt for most of his adult life for an act he committed in childhood. More specifically, it was an act he did not commit: he witnessed the rape of his best friend, Hassan, but did nothing to intervene. In fact, Amir violently rejected Hassan, desperately ashamed and discomfited by interacting with him. 

Later, Amir's guilt leads him to return to Afghanistan and rescue Hassan's son. However, it is not solely Amir's guilt that pushes him to this, some might say courageous, decision. As is revealed later in the text, Hassan is in fact Amir's half brother, fathered by Baba. In returning to Afghanistan for Sohrab, Amir recognizes Hassan's relationship with Baba as legitimate, complete with the responsibilities due to a family member in need. 

What is a good thesis statement for the nature of sin and grace in "A Good Man Is Hard to Find" that can lead me into a discussion of the...

Thesis Statement: In Flannery O'Connor's "A Good Man Is Hard to Find," violence is a means to redeeming grace.

Miss O'Connor once wrote,

Redemption is meaningless unless there is a cause for it in the actual life we live.

In "A Good Man Is Hard to Find," when the grandmother is confronted with death as she faces the Misfit and hears the report of pistols firing as the other men execute her family, she tries to tell the Misfit that he is really a good man, a superficial assessment of hers used earlier in the story. In this previous incident, she speaks to Red Sammy and he tells her that he let three men charge their gas, but then asks, "Now why did I do that?" She instantly replies, "Because you're a good man," without really knowing what kind of person Red Sammy truly is.

So, it is not until the family car turns over on the dirt road and they are confronted by the Misfit and his companions that the grandmother becomes truly compassionate.

Faced with death in the person of the Misfit, who has no interest in her false compassion—

"I just know you're a good man" she said desperately. "You're not a bit common!"
"Nome [No ma'am], I ain't a good man...."—

the grandmother's shallow emotion has no effect on her salvation. The Misfit's only goal is survival, and the family and the grandmother are threats to this survival since they can identify the three men.

Then, as the Misfit talks about how Jesus threw everything off balance by supposedly dying on the cross for people, the "old lady" mumbles and sinks down into the nearby ditch with her legs twisted beneath her. Ignoring her, the Misfit says he is not certain of this salvation offered by Jesus because he was not there. He says that if he were there, he would know for certain what is right.

...the grandmother's head cleared for an instant. She saw the man's face twisted close to her own as if he were going to cry and she murmured, "Why you're one of my babies. You're one of my own children!"

Now, with real compassion, her sincere words touch the Misfit, who is repelled "as if a snake had bitten him," and he shoots her three times in the chest. Indeed, the grandmother's real compassion has made her a victim of his violence. But with this violence the grandmother has received grace by means of her maternal compassion. She has her moment of redemption:

...the grandmother...half sat and half lay in a puddle of blood with her legs crossed under her like a child's and her face smiling up at the cloudless sky.

The violent catastrophe that the grandmother has experienced becomes a redemptive catastrophe as it affects her conversion and grace, symbolized by her "legs crossed under her" much as Christ's were when taken down from the cross after He, according to Christian belief, redeemed mankind by dying. Her grace, too, comes only at the moment of grisly death.

Miss O'Connor describes this story as well as her other works in this way:

I have found, in short, from reading my own writing, that my subject in fiction is the action of grace in territory held largely by the devil.

How does O. Henry widen the vision of the reader in addition to telling interesting stories?

O. Henry's short but powerful short stories are masterpieces of irony, as the outcome of the stories often involves an unexpected twist. For example, in "Heart and Hands," the man who the reader thinks is the marshal winds up being the prisoner. 

O. Henry's stories also widen our vision because they challenge our prejudices and preconceived notions. For example, in "Heart and Hands," the reader might assume that the attractive character, Mr. Easton, is the representative of the law. However, although he is young and handsome, he is the prisoner. At the end of the story, the reader learns that his or her prejudices have been wrong and that the less attractive, older member of the pair on the train is the marshal and that Easton is the prisoner. In "Gifts of the Magi," a young couple named Jim and Della buy Christmas gifts for each other that don't work out. Jim buys Della combs for her hair, but she has cut off her hair to buy him a chain for the watch he sold to buy her the combs. This story expands our vision because it makes us realize that our preconceived notions of what we need to buy on Christmas--that is, material goods--are often flawed. Instead, as Jim and Della realize, the ultimate gift they can give each other is love. 

What are stomach, intestinal, and pancreatic cancers?

Causes and Symptoms

The section of the gut from the esophageal sphincter in the upper stomach to the ileocecal valve at the end of the small intestine digests food taken into the body and absorbs its nutrients. This vital function also exposes the gut and its organs, the liver and pancreas, to ingested toxins that can initiate cancer and to materials that damage the gut lining, also potentially leading to cancer. Because diet greatly influences the chances for contracting these cancers, it is understandable that stomach cancer is the world’s most common type. Surprisingly, however, cancers of the small bowel are rare. Pancreatic cancer is the most lethal of these cancers and one of the most difficult to detect before irreversible damage has been done: Few patients live long after diagnosis. These facts and the large number of suspected carcinogens make the stomach and pancreatic cancers a pressing challenge for physicians and public health.

Broad similarities characterize the types of cancers throughout the upper gastrointestinal (GI) tract. The majority, adenocarcinomas, grow in and mimic gland tissue, but possible as well are cancers of the lymph tissue (lymphoma), hormone-secreting cells (carcinoid tumors), and the muscle wall of the bowel (sarcoma). Early symptoms tend to be vague and do not necessarily point specifically to cancer: abdominal pain, loss of appetite, weight loss, and perhaps diarrhea or vomiting.

While diet is a major factor in stomach cancer, its role in pancreatic and intestinal cancers is not as clear. A diet consisting mainly of pickled, smoked, or salted food with few fruits and vegetables, especially those containing vitamins A and C, is thought to be risky. In fact, countries with the highest rates of gastric cancer, such as Japan, are those that have long relied on such chemical preservation techniques rather than on refrigeration. It is probably no coincidence that the stomach cancer rate in the United States declined sharply after refrigeration became widespread in the 1930s; moreover, Japanese immigrants to the United States have sharply fewer gastric cancers than do their relatives in the homeland.

The presence of nitrites in the diet, alcohol consumption, radiation exposure, chronic gastritis (inflammation of the stomach lining), and cigarette smoking have also been suspected as gastric carcinogens. Hereditary susceptibility may sometimes play a role, although it is also possible that family members, living under the same conditions, are simply exposed to the same carcinogens and that no genetic susceptibility is involved. Finally, chronic stomach infection with the bacterium Helicobacter pylori has been linked to gastric cancer development.

Risk factors for the
pancreas and
small intestine are much less clear. Chronic pancreatitis, gallstones, and cirrhosis (scarring) of the liver pose some danger of initiating pancreatic cancer, and smokers and diabetics are twice as likely to develop it than are others. In March 2013, scientists at the Institute of Social and Preventive Medicine at the University of Zurich published a study of 450,000 subjects that found that consumption of processed meats increased the risk of premature death by cancer and other health problems. Chemists and others who work with organic solvents and petrochemicals also run a slightly higher risk. Intestinal cancer becomes more likely after the immune system has been damaged or late in the course of chronic intestinal diseases, such as Crohn’s disease and sprue.

Risky foods, diseases, or occupations do not inevitably lead to cancers. Tumor growth requires at least three factors: some agent that initiates a change in a cell’s genetic structure so that a new type of cell is created, called a
mutation; an agent that enhances the cell’s response to the initiator, encouraging it to reproduce; and the failure of the immune system to destroy the abnormal cells. Most small bowel and gastric cancers probably result from long-term overstimulation of the glands or mucosa. This overstimulation occurs when the body fights chemical irritants that have been ingested with food, drink, or air; the body’s defense mechanisms lead to inflammation in the damaged area. Chronic inflammation and continually stimulated cell division to repair damage eventually is likely to produce a mutated cell. If adapted to the harsh environment that produced it, the cell can multiply unchecked, overwhelm the immune system, and invade normal tissue; eventually, it may metastasize. A potentially lethal cancer can grow for months or years before its victim notices any definite changes in particular body functions or general health.

Eventually, however, danger signs begin. After initially complaining of abdominal pain, loss of appetite, and difficulty keeping food down, stomach cancer patients may have black, digested blood in the stool, weight loss, general weakness, bouts of vomiting blood, a swollen abdomen, a noticeable mass in the stomach, and iron-deficiency anemia. When the disease is well advanced, metastases become increasingly common, invading the lymph nodes, bile ducts, and liver and eventually spreading to the lungs, bones, and brain. The cancer becomes symptomatic relatively quickly. On average, patients go to their doctors about six months after noticing symptoms.

Pancreatic cancer is much less likely to cause early symptoms, and by the time patients seek medical help, the cancer is usually too far advanced to cure. Physicians suspect pancreatic adenocarcinoma when a patient complains of food aversion, progressive weight loss, and abdominal and back pain, especially when accompanied by vomiting, diarrhea, and jaundice. A rare form of pancreatic cancer (less than 5 percent of cancers in the pancreas) develops from the insulin-producing cells of the organ and makes abnormally high amounts of insulin; in this case, the symptoms are attributable to low blood sugar (hypoglycemia) and include weakness, loss of energy, dizziness, chills, muscle spasms, double vision, and, in extreme cases, coma.

Adenocarcinomas, lymphomas, carcinoid tumors, and sarcomas may form in the small bowel, and most of these grow slowly. Intestinal adenocarcinomas show up primarily in the jejunum or duodenum of elderly patients. Often, they first become apparent when they clog the bowel or bleed. Usually appearing in the stomach, lower jejunum, or ileum, lymphomas are suspected when the patient has fever, night sweats, weight loss, and abdominal pain. Intestinal carcinoid tumors may actively secrete hormones. If they metastasize, release of the hormones sometimes causes a bizarre group of symptoms that are collectively known as carcinoid syndrome: diarrhea, flushing, itching, low blood pressure, and heart disease. Intestinal sarcomas can occur anywhere in the small bowel and reveal themselves by bleeding.

Treatment and Therapy

Since other diseases also cause the weight loss, abdominal pain, and nausea common to these cancers—for example, pancreatitis, malabsorption, inflammatory bowel disease, and gastritis—the diagnosis of cancer requires specific evidence from chemical tests, imaging, endoscopic procedures, or surgery. Suspecting stomach cancer, the physician may send the patient for an upper GI barium study. For this procedure, the patient drinks a mixture containing barium sulfate; the radio-opaque barium coats the stomach and under X-ray photography can be seen to outline a tumor if one is present. Tests to check for anemia and blood in the stool may also be ordered. If imaging and tests support a diagnosis of cancer, a gastroenterologist, inserting an endoscope through the patient’s mouth, will obtain biopsies of the tumor so that a pathologist can determine if the tumor is malignant. Since biopsies remove such small samples and can miss a cancerous portion of a tumor (especially a lymphoma or sarcoma), surgical biopsy may be necessary to settle the diagnosis beyond doubt.

Similarly, initial tests for pancreatic and intestinal cancer rely on imaging and chemical assays. A barium X-ray study of the small bowel, a computed tomography (CT) scan, or ultrasonography may locate the tumor. Again, endoscopic or surgical biopsy alone can verify the diagnosis of malignancy. Tumors in the small bowel usually lie beyond the reach of endoscopy, so when a barium study reveals a tumor, surgical biopsy is most often necessary to obtain tissue samples; at the same time, the tumor is usually removed to relieve or prevent obstruction of the bowel.

If a tumor has not spread and is well defined, cutting it out provides the best chance of a cure for cancers throughout the stomach, pancreas, and small bowel. Such surgeries are often technically difficult, however, because the patients are typically malnourished and weak and have difficulty enduring the rigors of surgery. When a stomach tumor is single and small, surgeons remove it and a small margin of tissue around its edges. Larger or multiple tumors force the removal of larger portions of the stomach and adjacent lymph nodes. For pancreatic cancer, if more than a single area of the pancreas is involved, the surgeon may remove the entire organ and, depending on the size and location of the tumor, parts of the duodenum and stomach as well. Cancers of the intestines are cut away along with a section of bowel, whose ends are then reconnected by suturing. Chemotherapy and radiation on their own have not proved reliable for shrinking stomach, pancreatic, and intestinal cancers (except lymphomas) and are usually used in conjunction with surgery, especially when a primary tumor has metastasized.

Sometimes endoscopic maneuvers can stop bleeding or relieve pain by clearing out obstructions or, in the case of an obstructed bile duct, by inserting a small perforated tube called a stent to ensure that bile and pancreatic juices flow freely. Pain management, whether with manipulative procedures or with drugs, becomes the primary focus of treatment when surgical cure for a cancer is unlikely. Surgeons do not attempt curative operations if the cancer has metastasized. At this point, surgery, if possible at all, is for relieving pain, preventing blockage, or minimizing blood loss.

Perspective and Prospects

The frequency of these cancers and their distribution in the world vary considerably. Intestinal cancers make up less than 1 percent of all cancers and less than 5 percent of gastrointestinal cancers; pancreatic cancer accounts for only about 3 percent of all cancers. Yet the incidence of both cancers has been rising. In the United States, for example, pancreatic cancer increased about 25 percent from the 1950s to the 1990s. By 2002, it was the fourth leading cause of cancer death, and more than 30,000 Americans were diagnosed with the disease annually. At the same time, stomach cancer decreased dramatically, dropping from the United States’ most common cancer in the 1930s to about 2 percent of all cancers in the 1990s. Yet in Japan, Iceland, and parts of Central and South America and of Eastern Europe, the stomach cancer rate is very high, accounting for most of the nearly 700,000 new cases yearly. In 2008, the World Cancer Research Fund International listed stomach cancer as the fourth most common cancer in the world. Approximately 990,000 new cases of stomach cancer were diagnosed in 2008. The highest rates of stomach cancer are in Eastern Asia; specifically South Korea, Mongolia, and Japan. Worldwide, incidence of stomach cancer occur in men twice as often as women. In 2013, the American Cancer Society estimated that 21,600 cases of stomach cancer are diagnosed annually in the United States . In the United States, African Americans get these cancers more often than Caucasians. Probably because of their diet, poor people develop intestinal cancer more often than middle-class or upper-class people. The peak age group is fifty to fifty-nine years for stomach cancer and seventy to seventy-nine years for pancreatic and intestinal cancer.

The chances for successfully treating or drastically curtailing small bowel cancer are reasonably good; 20 percent of patients with adenocarcinomas in the small intestine survive for at least five years following diagnosis, and patients with carcinoid tumors have lived ten and even fifteen years after surgery. Treatment of small bowel or stomach lymphomas can result in a cure or prolonged survival in a significant percentage of cases. The prospects for pancreatic and stomach adenocarcinomas, however, are another story entirely. Overall, in the United States about 10 percent of gastric cancer patients are alive five years later. Pancreatic cancer is even deadlier, with 90 percent of patients dying in the first year after diagnosis, regardless of treatment. Of those with cancer of the pancreatic duct, only about 4 percent survive three years. Those with cancer in the insulin-producing cells fare better—a 30 percent survival rate—but this is a very rare type of cancer.

Because gastric cancer is common in Japan, doctors routinely screen patients for it by endoscopy or photofluorography (a type of X ray). Prescreening in Japan increases the overall survival rate of patients in the country. Many more cancers are caught early, while they are still surgically treatable. Endoscopic and chemical screenings for pancreatic cancer are also possible, but since the disease is so much less common, doctors do not perform the tests unless they already have good reason to suspect cancer. Avoidance of carcinogens, especially alcohol, remains the most promising way to escape gut cancers.

Bibliography

American Cancer Society (ACS). http://www.cancer .org.

Daly, John M., Thomas P. J. Hennessy, and John V. Reynolds, eds. Management of Upper Gastrointestinal Cancer. New York: W. B. Saunders, 1999.

Eyre, Harmon J., Dianne Partie Lange, and Lois B. Morris. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2d ed. Atlanta: American Cancer Society, 2002.

Ferlay, J. GLOBOCAN 2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10.  Lyon, France: International Agency for Research on Cancer, 2010.

Kapadia, Cyrus R., James M. Crawford, and Caroline Taylor. An Atlas of Gastroenterology: A Guide to Diagnosis and Differential Diagnosis. Boca Raton, Fla.: Parthenon, 2003.

Levine, Joel S., ed. Decision Making in Gastroenterology. 2d ed. Philadelphia: B. C. Decker, 1992.

O’Reilly, Eileen, and Joanne Frankel Kelvin. One Hundred Questions and Answers About Pancreatic Cancer. 2d ed. Sudbury, Mass.: Jones and Bartlett, 2010.

Parker, James N., and Philip M. Parker, eds. The Official Patient’s Sourcebook on Gastric Cancer. San Diego, Calif.: Icon Health, 2002.

Rustgi, Anil K., and James M. Crawford, eds. Gastrointestinal Cancers. New York: W. B. Saunders, 2003.

Sachar, David B., Jerome D. Waye, and Blair S. Lewis, eds. Pocket Guide to Gastroenterology. Rev. ed. Baltimore: Williams & Wilkins, 1991.

What is an insightful research question about the creation of the Volkswagen and the connection to Hitler's vision?"

Volkswagen is one of the most recognizable brands in the auto industry. Despite the success of the auto maker, most Americans probably do not realize that this company was created by Adolf Hitler with great pride and enthusiasm.  This was a well known fact in the 1950's and the car's association with the Fuhrer resulted in sluggish sales in the United States even in the booming economy of the decade.  

As a teacher, I would focus on how Volkswagen overcame this tremendous public perception problem.  This would require research on the marketing strategies that Volkswagen utilized in the 1950's to make the car one of America's top imports.  An insightful question would be one that asks the students to apply some of the concepts of their research.  This is the prompt that I would assign:

Research the marketing strategies of the Volkswagen and provide a short critique of the company strategy.  Create your own marketing campaign for Volkswagen for the years between 1951-1953.

Another option:

Create a research strategy for Volkswagen that attempts to separate the automaker form Adolf Hitler's vision of the car company.

While traveling in England, you purchase 8.91 gallons of gas (or petrol there). The price posted is €1.98 per liter. How many U.S. dollars...

I suppose the prices in England are listed in pounds £, not in euros €.

To answer this question we need the conversion ratio between pounds and U.S. dollars. I got it from the attached link, and it says  `1 GBP approx 1.328 USD.` 

Also we need to know how many liters are in one gallon, it is about  `3.785.`

Now we can perform the calculations: `8.91` gallons are about  `8.91*3.785` liters, they cost about  `8.91*3.785*1.98` pounds, and in dollars it will be

`8.91*3.785*1.98*1.328,`  which is equal to about  88.68 U.S. dollars.

What is the Earth's crust made of?

The outermost layer of our planet, called the crust, is made up of minerals in the form of solid rock and loose dirt. The crust sits atop the mantle, although the liquid magma of the mantle sometimes breaks through. When this magma cools, it hardens into part of the outer crust. In some places, like the bottom of the ocean, the crust is quite thin. The crust is far thicker when it is part of land masses. We call the crust that makes up land masses the continental crust, and the composition here is primarily granite rock. The oceanic crust at the sea-floor has higher levels of basalt and gabbro rock. Both kinds of crust also contain the minerals aluminum, uranium, iron, and silicon. 

What is one negative result of the Columbian Exchange?

The biggest negative effect of the Columbian Exchange was the introduction of European diseases to the Americas. Diseases like typhus, measles, plague, and especially smallpox devastated Native Americans who had no immunity to them. The death toll, which some historians estimate at close to 90% of the indigenous population before contact, makes this aspect of the Columbian Exchange one of the worst demographic disasters in the history of the world. Native peoples who were lucky enough to be spared by these diseases, which hit in waves of so-called "virgin soil epidemics," saw their lives change dramatically. Villages and entire tribes of people were forced to seek shelter with other native groups, and many were adopted into tribes like the Catawba, which emerged in the seventeenth and eighteenth centuries in response to the disaster. Disease also facilitated the conquest of many Native peoples, perhaps most famously the Inca, who faced a terrible smallpox epidemic that paved the way for Pizarro and his conquistadores. So the spread of epidemic diseases was by far the worst impact of the Columbian Exchange.

What is the difference between a rift valley and a mid-oceanic ridge?

As tectonic plates move they sometimes move away from each other at divergent plate boundaries. The space left behind opens a large hole between the plates that is either filled with sediment, magma flowing from the mantle, or water. The major difference between different types is what type of plate the divergent boundary is between. 

If the boundary is found between two continental plates you are left with a rift valley. This leads to steep mountainsides spreading apart from a widening valley. In the center of the valley either large gaps can form or the area will fill with water from water sources or rain creating rift lakes, much like what can be found in the African Rift Valley. Many lakes have sprung up in the valleys left behind as the plates there move slowly away from each other. 

If two oceanic plates begin moving away from each other it creates a mid-oceanic ridge. Continental plates are less dense, and thus float much higher on the mantle. Magma is usually much farther away, so it's rare to find a splitting continental plate seeping magma. On the other hand, oceanic plates are thin and dense, meaning magma is much more likely to flow to the surface at one of these splits. At the Mid-Atlantic Ridge, the boundary between the North American plate and the Eurasian plate, the spreading boundary is constantly seeping hot magma out of the mantle below. This creates a constantly growing mountain chain. 

The main difference between these two seismic structures would be what types of plates are creating the diverging zone and what is being created at the divide: a valley that may fill with water or sediment, or a growing mountain chain as magma fills the opening gap.

Temperature and pressure are inversely related, so how, in the core of the Earth, are both temperature and pressure high?

Temperature and pressure are not inversely proportional. In fact, if the volume is held constant, temperature and pressure are directly proportional to each other. One way to think about it is to understand what happens when we increase the temperature of a substance. When the temperature increases, the molecules comprising the substance gain kinetic energy and start moving faster. When that happens, their collisions with each other and with the material they are held in (especially for fluids) increases and this causes an increase in temperature. The same is observed when we cook something in a pressure cooker or boil water for making tea or coffee.

Thus, it is entirely feasible for the temperature and pressure to increase simultaneously, provided the volume is held constant. In the earth's core, the temperature and pressure both are very high, and it is estimated that the core is divided into two parts. The external layer is liquid, while the inner core is solid (due to very high pressures, iron cannot melt, even at high enough temperatures).

Hope this helps. 

Discuss what major policies Congress passed during World War 2 that transformed the economic and financial systems of the United States.

The US economy during WW2 underwent a radical overhaul. Indeed, we essentially became Communists for a few years, but the most successful Communists ever.

That probably sounds very weird to you, so let me explain.

It started with the establishment of a draft---even before we officially entered the war. Then came enormous increases in military spending, used to invest in huge factories for making war materiel.

This huge investment in capital made labor much scarcer, allowing workers to bargain up their wages and benefits substantially. Indeed, labor was so scarce during the war that businesses which had previously only hired White men were forced to hire women and minorities just to have enough workers. Unemployment dropped to the staggeringly low figure of 1.2%.

But that's not the Communist part---no, that part came when the government started rationing things, essentially claiming for its own use a large portion of America's steel, gasoline, rubber, and even foods such as butter and meat (good for feeding soldiers), just as they did in the Soviet Union. People had to have ration cards to buy many of these products, and there weren't enough to go around.

A large number of new government agencies were established, like the Office of War Mobilization and the War Production Board, to oversee production in what was essentially a Communist command economy, where the central planners decides who gets what.

All this high spending triggered inflation. In response to the inflation, the government instituted price controls via the General Maximum Price Regulation; this did slow inflation, but also caused even more shortages of goods than the rationing already had. Because of rationing and shortages, personal consumption fell to its lowest level in decades even as total economic output surged to the highest of any country in the history of the world.

This meant that saving went through the roof, and most families ended up living through very hard times during the war but found that their net wealth had dramatically increased by the end of it. Most of this saving was in the form of government bonds, particularly US Treasury bonds and war bonds; the government borrowed an enormous amount of money, but then eventually paid it back and made everyone richer. It was during this period that owning US Treasury bonds became a staple of private saving, establishing what is now the backbone of the financial system not only in the US, but around the world.

Yet it wasn't just borrowing---taxes also rose enormously. By the end of the war, over 60% of all spending in the United States was government spending---and over 50% of all US spending was military spending in particular. For the first time, income taxes were raised to high rates on the general population. (Actually very high rates---the top marginal rate was 90%.)

After the war, people had become accustomed to high wages---and women and minorities had become accustomed to having jobs at all. The attempt to shift back to the old system where White men did most of the work failed; that model was no longer viable. The result was a very contentious period politically but a huge surge in economic prosperity, and ultimately a great deal of social progress as well (primarily in the 1960s).

So we ended up with economic prosperity and social progress; it's a shame we had to fight a war that killed millions of people in order to get there.

In Romeo and Juliet, is there a simile showing how they long for each other but they can't be together due to their families' feud?

It seems that the best place to look for such an example would be the first balcony scene, in Act 2, Scene 2, before Romeo and Juliet have decided to pursue their love for one another. A close example would be the famous "rose by any other name" line that Juliet speaks out to what she thinks is the empty night:

"That which we call a rose
By any other word would smell as sweet.

So Romeo would, were he not Romeo called,
Retain that dear perfection" (2.2.43-46)

This example is really more of a metaphor than a simile, since it doesn't use the words "like" or "as" (though the word "so" in this case is basically the same thing). Still, it compares how a rose would still smell the same if we called it something else, just as Romeo would be the same person even if he had a different name. She is saying this, of course, because with a different name, he would belong to a different family and they could be together.

Another example comes in the next scene, when Romeo comes to Friar Lawrence to ask for his help. He explains the situation to him (confusingly), saying:

"I have been feasting with mine enemy

Where on a sudden one hath wounded me,

That’s by me wounded. Both our remedies

Within thy help and holy physic lies." (2.3.49-52)

Here he is comparing the love he and Juliet feel for one another to being wounded by each other. This is a common metaphor (sorry, this one isn't a simile either) for love, but it is all the more poignant because he prefaces it with the statement that he was dining with his enemy (the Capulets). This metaphor hints at the problems the family feud will have for Romeo and Juliet without stating them outright. 

Sorry I couldn't find any similes, but hopefully these metaphors work well enough!

How does Kipling present hopes and fears in "If?"

In "If," Kipling presents hope as a way to avert fear.

Kipling frames hope and fear in a conditional relationship. Throughout the poem, this relationship is displayed.  For example, in the line, "If you can dream—and not make dreams your master;" the fear is that dreams will exert excessive control over the individual.  A person's best hope is for autonomy over dreams.  In "If you can talk with crowds and keep your virtue," the fear is a loss of conviction in the presence of others.  The hope that will defeat it is that authenticity and sincerity be displayed at all times. The line, "If you can trust yourself when all men doubt you," shows how the fear of losing trust with oneself can be countered through the hope of sustaining faith even when all others doubt.  In each of these examples, the speaker has fears which are countered through the hope expressed.  The use of "if" is conditional.  It communicates how if there is no hope, then fears will be realized.

In "If," Kipling establishes a precarious balance between hope and fear.  The reality of fears can only be offset through hope.  Maturation means we recognize our hopes as the best antidote to our fears.

How do Portia, Nerissa, and Jessica defy the conventional stereotype in Shakespeare's society of being submissive and powerless? What are three...

In Act 1, Scene 2, Portia questions the extreme conditions of her father's will. This would be a rare occurrence at the time, for a daughter was not supposed to question whatever a father decided for her; she should be subservient. Questioning or doubting his decisions was regarded as disrespectful and was frowned upon. Portia tells Nerissa, her maid in waiting,

But this reasoning is not in the fashion to
choose me a husband. O me, the word 'choose!' I may
neither choose whom I would nor refuse whom I
dislike; so is the will of a living daughter curbed
by the will of a dead father. Is it not hard,
Nerissa, that I cannot choose one nor refuse none?

Another aspect of her speech also indicates her desire for the freedom to choose a life-partner, instead of having to submit to her father's instruction. In the paternalistic society of the time, a father's word was law and should be obeyed — a daughter (especially in esteemed society) did not marry for love. Marriages were arranged affairs in which the father was the chief negotiator. Portia's disapproval is, in this instance, a break from her assigned role of servile and unquestioning acquiescence.   

Clearly, Portia feels she is an unwilling victim of her father's wishes. She does not have a choice, though, for she will be disowned if she does not obey the instructions in her father's will. Her obedience is, therefore, born out of practical necessity — she would rather follow his instruction than be left destitute.  

Another quote in which Portia breaks from convention is found in Act 4, Scene 2, when she decides to visit Venice in disguise to help Antonio:

When we are both accoutred like young men,
I'll prove the prettier fellow of the two,

Portia decides she and Nerissa will go to Venice disguised as men. This act would have been condemned at the time since it was expected that ladies of stature were supposed to be just that — ladies, who were demure and feminine. Any sign of manliness would be seriously criticized. It was practically taboo for a woman to misrepresent herself in such a way.

In Act 5, Scene 1, Portia tells Bassanio,

I will become as liberal as you;
I'll not deny him any thing I have,
No, not my body nor my husband's bed:
Know him I shall, I am well sure of it:
Lie not a night from home; watch me like Argus:
If you do not, if I be left alone,
Now, by mine honour, which is yet mine own,
I'll have that doctor for my bedfellow.

This statement by Portia would evoke exclamations of shock and horror at any time and even more so during such a conservative period, where the stereotypical woman, especially if she was of the upper class, was expected to be humble, quiet, and respectful. Portia's unexpectedly provocative declaration that she would give her all, even her body, and sleep with another man whilst married, would surely have produced a surprised response. 

In Nerissa's case, her open and confidential relationship with Portia is certainly a break from the norm. Serving women were supposed to be respectful to their mistresses at all times. They were supposed to show a servile obedience. Nerissa, however, speaks to Portia as an equal.

You need not fear, lady, the having any of these
lords: they have acquainted me with their
determinations; which is, indeed, to return to their
home and to trouble you with no more suit.

Although Nerissa's tone is quite respectable, she comes across more as an advisor and confidante. Her direct address would have been deemed inappropriate in Shakespearean society. She would be observed as 'putting on airs' — acting out of her station and taking privileges she was not supposed to have.

When she later decides to marry without having undergone the normal traditional practice of having a husband chosen for her, Nerissa again breaks from the norm. Gratiano tells Bassanio in Act 3, Scene 2,

I got a promise of this fair one here
To have her love, provided that your fortune
Achieved her mistress.

She has promised marriage to Gratiano and set the conditions as well. She would marry him if Bassanio successfully chose the right casket. Normally the bride was not entitled to set any conditions. 

Her decision to later follow Portia and dress as a man and make a similar threat as Portia's to Bassanio sets her apart as a woman who knows and speaks her own mind. She is clearly also the one who takes the lead in their relationship, which was quite unconventional. She tells Gratiano in Act 5, Scene 2,

And I his clerk; therefore be well advised
How you do leave me to mine own protection.

This ties in with Portia's statement that she would sleep with the 'lawyer' who defended Antonio. She promises to do the same with the lawyer's clerk.

Jessica's decision to disobey her father, Shylock, is a clear break from tradition. As mentioned earlier, a daughter was supposed to obey her father's every instruction, whether she liked it or not. She takes the drastic step of eloping with a Christian, someone she knows her father will despise. She takes the risk of being disowned. Her decision is made clear in the following lines from Act 1, scene 2:

O Lorenzo,
If thou keep promise, I shall end this strife,
Become a Christian and thy loving wife.

It is also surprising that Jessica refers to living with her father as a 'strife.' Daughters were expected to be loving and loyal to their fathers and appreciate them, no matter what. She would have been deemed ungrateful, ungracious, and disgraceful. 

Jeesica's decision to be disguised as a boy, Lorenzo's torchbearer, is, similar to Portia and Nerissa's actions, an oddity. It was unacceptable for a woman to want to look like a man. In such a society, women were meant to be pleasing to the eye, graceful, and true to their gender. Although Jessica expresses some embarrassment about her attire, she is driven by her desire for Lorenzo and does what is needed.

I am glad 'tis night, you do not look on me,
For I am much ashamed of my exchange:
But love is blind and lovers cannot see
The pretty follies that themselves commit.

Probably the most drastic of all Jessica's actions in her bid for freedom from her father's control is her rejection of his religion. The fact that she adopts Lorenzo's faith and denies her own is surely a sign that she wishes to make a clean break from Shylock. For a woman of the time to take such a step was extremely rare indeed. She informs Launcelot of this in Act 3, Scene 5:

I shall be saved by my husband; he hath made me a
Christian.

Her contention is that she will not only be saved from her father's control but she would also be rescued in a spiritual sense.

From Lois Lowry's The Giver, please explain the community.

The community in which Jonas, the protagonist, lives is made up of family units. Mothers and fathers do not choose each other based on love; rather, they are placed together based upon compatibility for living together. Parents are required to apply for children, no more than one boy and one girl, and to bring them up according to the rules of the community. Children are born to birth mothers who, after three years, do not get to raise their children, but go to labor in the fields for the rest of their lives. There is no mating allowed, so those who hit puberty and beyond must take pills to suppress sensual desires. Parents receive one baby at a time, and only during the naming ceremony, which happens along with all of the other yearly ceremonies for all childhood age groups.

Each December at the annual ceremonies, children receive more freedom and responsibility as they age. For example, at age nine, girls are permitted to remove their hair ribbons and everyone gets a bicycle. However, with the bicycles, there are more rules to follow, such as maintaining it and parking it where it should go. The most important ceremony, however, is for those who turn twelve. This is the year they receive their assignments for the careers they will train and fulfill for the rest of their lives. 

The community lives under a condition which they call Sameness. This permits everyone to live as equals, happy and under no anxiety for their survival. As long as a person is fulfilling his or her role in the community, life can be pleasant. They are able to live this way, without stress, fear or pain, because of a Receiver who holds within himself all of the memories of the history of the world. Since all of the pain, misery, and even love resides in the Receiver, the people of the community can live emotion-free lives. 

One governing committee, called the Elders, run everything, keep an eye on citizens, and enforce the rules so that living under Sameness can be maintained. It is this group that decides what occupations children will train and study for. They are also the ones who make any changes to the community or rules, and also grant releases. People do not exactly know what the word release means, though. As a result, they do not know about or understand death.

How does Macbeth interpret the statements of the apparitions in Act 4, Scene 1 of the play?

Macbeth interprets the statements of the apparitions in Act 4, Scene 1 in a very specific way. To Macbeth, the statements are assurances of his safety.  However, closer analysis reveals them to be very specific statements regarding and how he will die.

The first apparition, an armored head, tells him simply to

"Beware Macduff!/ Beware the Thane of Fife!  Dismiss me.  Enough" (81-82). 

In other words, Macbeth should be wary of Macduff.  At first, Macbeth thinks very little about the warning, but after the statements from the next apparition he decides to wipe out Macduff's entire family, which provides even more incentive for Macduff to try to kill Macbeth.  Further, the first apparition's manifestation as an head wearing a helmet foreshadows the military action, led by Malcolm and Macduff, that will march against Macbeth.  Given that the apparition is a disembodied head, it also foreshadows Macbeth's own demise and decapitation during the final battle.  Quite simply, the apparition warning Macbeth could very well be Macbeth's own decapitated head.

The second apparition tells Macbeth,

Be bloody, bold, and resolute.  Laugh to scorn The power of man, for none of woman born Shall harm Macbeth.

Macbeth takes this to mean he can be as vicious and ambitious as he wants, that he shouldn't fear men because no man of woman born can hurt him.  Here he briefly discounts the warning of the first apparition, feeling he has nothing to fear from Macduff, as every man is born from a woman.  However, Macbeth is too quickly assured.  The second apparition, the bloody child, represents the very man that could (and will) harm Macbeth.  At the end of the play, it is revealed that "Macduff was from his mother's womb/ untimely ripped," meaning that he was not born in the traditional fashion (5.8, 19-20).  He is the product of a Cesarean section, which would result in much more blood than a traditional birth.  Therefore the apparition itself may be manifesting as the infant Macduff himself.

Finally, the third apparition, a child wearing a crown, holding a tree, further assures Macbeth, saying

Be lion-mettled, proud, and take no care
Who chafes, who frets, or where conspirers are. Macbeth shall never vanquished be untilGreat Birnam Wood to high Dunsinane HillShall come against him. (103-107)

Macbeth believes this means he will never die until Birnam Wood, the forest near his castle, Dunsinane, grows the entire way to the castle itself.  This would take a great deal of time, perhaps hundreds of years if the forest was not tended to and kept away.  Once again, Macbeth feels assured by this statement.  However, as Malcolm's army approaches Dunsinane in Act 5, Scene 4, Malcolm orders the men to hew down the boughs of the trees to help disguise their numbers as they approach (6-9).  The image of Malcolm, the rightful heir to the throne of Scotland, hewing down and holding a branch bears a striking resemblance to the third apparition itself.  He is basically the child crowned, holding the tree in his hand.

After the apparitions disappear, Macbeth pushes for more information and is shown a parade of kings, representing Banquo's descendants.  He is confused by this vision, but is interrupted as Lennox enters.  While he begins to feel more safe in his rule, he nevertheless takes measures to protect himself further.  As stated above, he orders the death of Macduff and his family.  When the murderers arrive at Fife, Macduff has already left for England to convince Malcolm to return and overthrow Macbeth.  Upon hearing of his tragic loss, Macduff resolves to be the one to kill the tyrant.  Because Macbeth acts on the warning of the first apparition, emboldened by the words of the second and third, the characters represented by the second and third apparitions become even more resolute, thus fulfilling the predictions of all three manifestations.

What is the mood of the poem "Mother to Son" by Langston Hughes?

The mood of "Mother to Son" is one of optimism in the face of hardship and sadness. 

The poem starts off, it seems, on a note of resignation:

Well, son, I'll tell you:

Life for me ain't been no crystal stair.

A "crystal stair" indicates luxury and delicacy. Hughes contrasts this symbol of privilege with images of roughness:

It's had tacks in it,

And splinters,

And boards torn up,

And places with no carpet on the floor --

"Tacks" and "splinters" indicate pain and hazardous territory. Torn boards symbolize destruction, possibly even the loss of a foundation. Finally, "no carpet on the floor" is a loss of comfort and warmth. The anaphora, or the repetition of "and" at the beginning of several lines, emphasizes the continuity of these deplorable conditions. The lack of change is broken only by a single word, "bare," which creates a stark and lonely image.

The pessimistic tone is discontinued, which is indicated by the use of "but" as a transition:

But all the time

I'se been a-climbin' on,

And reachin' landin's,

And turnin' corners,

And sometimes goin' in the dark

Where there ain't been no light.

Anaphora is used again, but this time to show the narrator's continual motion. Notice, too, that she uses the present tense: "a-climbin'," "reachin'," "turnin'," "goin'." This pattern, too, is broken by a line that evokes an image of a space: "Where there ain't been no light."

Her focus shifts from her narration of experience back to her son:

So boy, don't you turn back.

Don't you set down on the steps

'Cause you finds it's kinder hard.

Don't you fall now --

Anaphora is used once again, though less consistently, with the imperative "don't." Finally, the poem ends with motion:

For I'se still goin', honey,

I'se still climbin',

And life for me ain't been no crystal stair.

"Goin'" and "climbin'" are contrasted with her warnings to her son not to "set down" (a resignation of action) and "[falling]" (a failure to remain steady).

How do you write conditional sentences, specifically about both supporting and opposing the concept of homework?

Conditional sentences are about conditions. That is, they say that one thing (the result) will happen if a second thing (the condition) happens.

"If I sleep through my alarm clock, I'll be late to school." That's a conditional sentence. It has a condition ("If I sleep through my alarm clock") as well as a result ("I'll be late to school"). Be sure to use a comma after the condition, before the result: "If (condition), result." 

You can flip around the condition and the result, if you prefer: "I'll be late to school if I sleep through my alarm clock." In this case, you don't use a comma between the result and the condition.

Now let's think about how to write sentences like this about your topic: whether we should be for or against the practice of assigning homework to students.

Think about what you might say about homework as you use these sentence patterns:

1. "If _____, _____."

2. "_____ if _____."

Whenever you're considering whether to support or oppose an idea, think of how supporting the idea could lead to good results and bad results; then think of how opposing the idea could lead to its own set of good results and bad results.

So, ask yourself these 4 questions:

1. What would a good result be if we do have homework?

Examples: "If students practice what they've learned in school, they'll become more skilled and competent." "Students will gain confidence in problem-solving skills if they practice by themselves what they've learned."

2. What would a bad result be if we do have homework?

Examples: "If teachers assign homework regularly, they will quickly become overwhelmed with grading piles and piles of assignments." "Students will miss out on recreational and social activities if they are stuck in their rooms all afternoon doing homework."

3. What would a good result be if we don't have homework?

Examples: "If our weekends are free from homework, we can develop our talents for non-academic skills like baking and archery." "We can spend more time with our friends and develop better social skills if we aren't worried about completing daily homework assignments after school."

4. What would a bad result be if we don't have homework?

Examples: "If students are never held responsible for work outside the classroom, they won't develop a work ethic or a sense of independence." "Students will forget everything they learned in school if they don't practice it on their own outside the classroom."

Which landmark court decision changed the laws of separate but equal and began the desegregation of public education facilities: Barnett vs....

The correct answer to this question is Brown v. Board of Education.  The Supreme Court of the United States decided this case in 1954.  In that case, the Court ruled that the system of “separate but equal” schools for white and non-white children was unconstitutional.  This was the first major case to bring about desegregation in K-12 public education.

The other cases mentioned here are clearly not correct.  Only one of them even has anything to do with segregation.  The case that does have to do with segregation is Plessy.  That case was decided in 1896 and it set up the system of separate but equal.  In that case, the Court said that separate but equal accommodations for the different races were constitutional.  This led to the system that Brown started to dismantle.

The other two cases have nothing to do with desegregation.  The only Barnett v. Rice that I know of is about water rights.  Roe v. Wade is the famous 1973 case in which the Court said that the Constitution protects women’s rights to get abortions. 

From all this, we can see that the correct answer is clearly Brown v. Board of Education.

What is the moral of the poem "Ozymandias," by Percy Bysshe Shelly?

Ozymandias is the Greek name for the Egyptian pharaoh Ramses II, who reigned from 1279-1213 BCE. Shelley quotes Ozymandias as saying, “My name is Ozymandias, king of kings. / Look on my works, ye Mighty, and despair!” This is said in pride, warning anyone from thinking they could destroy him. Yet there are only ruins about the broken statue. His “works” have been obliterated, either by time or by an enemy. He is not invincible as he believed. The real warning is that all the “Mighty” should look on his works and take warning that, no matter how powerful they are, eventually they will lie in the dust, just as Ozymandias is. Their works will be destroyed. The warning is against hubris, the belief that one is not held accountable or subject to the laws of man, the laws of nature, or the laws of the gods.

In The Great Gatsby by F. Scott Fitzgerald, at what points does Gatsby stand alone?

At the end of Chapter 1, Nick returns home and sees Gatsby standing alone, staring at the green light at the end of Daisy's dock. He has the impulse to call out to him, but then he decides that Gatsby looks as if he wants to be alone. The green light is symbolic to Gatsby. It represents Daisy and money. Fitzgerald gives us the impression that staring at the green light is like a recurring ritual for Gatsby: 

But I didn’t call to him for he gave a sudden intimation that he was content to be alone—he stretched out his arms toward the dark water in a curious way, and far as I was from him I could have sworn he was trembling. 

In Chapter 7, after Daisy accidentally kills Myrtle with the "death car," Tom and Daisy return to their home. Nick finds Gatsby standing by himself, just outside their house. Gatsby says that he doesn't trust Tom. At this point, Gatsby feels guilty about the accident and he wants to feel as though he is Daisy's protector. Nick leaves him there, standing alone. 

He put his hands in his coat pockets and turned back eagerly to his scrutiny of the house, as though my presence marred the sacredness of the vigil. So I walked away and left him standing there in the moonlight—watching over nothing. 

At the end of Chapter 8, Gatsby is alone just before Wilson shows up. Nick imagines Gatsby, alone, contemplating how his dream of reuniting with Daisy has come to such a tragic end: 

He must have looked up at an unfamiliar sky through frightening leaves and shivered as he found what a grotesque thing a rose is and how raw the sunlight was upon the scarcely created grass. 

What is the poem "My Last Duchess" by Robert Browning about?

"My Last Duchess" is a dramatic monologue written by Robert Browning. That means that one person is speaking for the entire poem. In this case, the speaker is Duke Ferrara. Although there was a historical duke that Browning had in mind, Aphonso II, who lived in the second half of the 16th century in Italy, Browning was attempting to portray a way of life rather than a specific person.

The Duke is speaking to the emissary of a Count who is there to negotiate the dowry for the woman the Duke plans to marry and make his next duchess. The Count will pay a sum of money, which the Duke will have to agree on, so that the Duke will marry his daughter. As the poem begins, Ferrara is showing the portrait of his "last Duchess" to the emissary. He explains that he commissioned the painting and that only he pulls back the curtain that normally covers it. He then begins to speak of the Duchess. Her portrait shows a "spot of joy" in her cheeks, but rather than pleasing the Duke, it causes him to think about the things that bothered him about his former wife. The reader understands that the things that bothered the Duke were minor; the Duke reveals his desire for control and his jealousy as he speaks.

She was a woman who enjoyed everything and showed her pleasure toward things and people, but this aggravated the Duke because he thought she should gain greater pleasure from being his wife than from anything else. He admits that he could have instructed his wife on how to stop aggravating him, but he says that would be "stooping," that is, it would be beneath him to have to explain to his wife what he wanted. She was supposed to know. He then states that he "gave commands. Then all smiles stopped together." Readers, and the emissary as well, assume this means the Duke had his wife executed. Upon hearing this, the emissary tries to rush down the stairs to get away from the Duke, but Ferrara says, "Nay, we'll go together down, Sir." Finally, he points out a statue of "Neptune ... taming a seahorse," which he had commissioned. The statue is symbolic: It points to the fact that Ferrara believes he is a god and can control others, especially his wife.

To understand a dramatic monologue, especially one by Robert Browning, it is necessary to pay attention to what is not said as well as to what is said. By reading between the lines, you will be able to apprehend the poet's meaning.

Who was the Warden from Holes related to?

The Warden, from the book Holes, is related to Charles and Linda Walker.  We are told that the Warden is a direct descendant of those two. 

The story of Charles/Trout Walker is a bit convoluted, but I'll try to break it down simply. Charles Walker was in love with a woman named Katherine. Unfortunately for him, Katherine, a white woman, was in love with Sam, a black man. Bigoted Charles and the town wouldn't stand for such a thing, so they drove the couple away. Sam is killed making the escape. Katherine becomes the infamous Kissin' Kate Barlow, a notorious outlaw robber. She never reveals where she buried/hid all of her stolen money even though Charles Walker tried to torture the information out of her. That is why the Warden is obsessed with digging holes. She is attempting to find the money. 

How can I get started writing an essay on justice in the book Holes by Louis Sachar?

Justice is one of the major themes in Louis Sachar's book Holes. To get started writing your essay, you might want to try doing some brainstorming by writing down what you already think or know about justice in this book, and what you want to explore more. Do you think justice was served in this book? Why or why not? To whom?

The characters in Holes are working at a camp for boys who have committed crimes or are otherwise troubled. Do you think justice is served by sending these boys to a labor camp? Maybe it is justice for some, but not for others. Do you think justice only impacted the boys, who are supposed criminals, or also the overseers like Mr. Sir? What about characters from the past, like Sam and Miss Barlow?

If you don't think justice was served in some case, how might things have gone differently? Has this book prompted you to think about justice in your own life?

When doing brainstorming work and answering these questions, don't be too concerned with making it sound nice-- just get your ideas out there! You can go back and clean up your writing during your editing process. Don't be afraid to write down whatever comes into your head!

What is a physical examination in medicine?

Indications and Procedures

Physical diagnosis—the principles, practices, and traditions that form the foundation of the modern physical examination—has rightly been called an art. Usually taught during the first two years of medical training, the basic skills of observation, auscultation, palpation, and percussion are later augmented by hands-on experience with actual patients. For many students, this acquisition of physical diagnostic skills marks the point when they begin to feel like “real” doctors. Observation techniques may be overt or subtle, as a patient may have difficulty maintaining usual behavior if consciously aware of scrutiny. An examiner may even find it necessary to distract the patient in order to allow accurate assessment.

Auscultation, from the Latin auscultare (to listen), is generally performed with the aid of a stethoscope. Normal bodily functions generate sounds, the presence or absence of which may provide clues to health or illness. Palpation, from the Latin palpare (to touch softly), involves the application of the examiner’s hands to the patient’s body. This touching conveys information about the size, texture, consistency, temperature, and tenderness of physical structures. This person-to-person contact can also exert an important calming or reassuring effect on the patient. Percussion, from the Latin percussio (striking), entails a gentle tapping of the examiner’s finger, which has been placed on the patient. A resonant return is noted over hollow, air-filled structures. In contrast, solid or fluid-filled structures produce a dull fullness. A simple demonstration of this technique can be performed by partially filling a bucket with water. By tapping on the outside and noting the variations in sound, it is possible to estimate the fluid level without looking inside the bucket.

To some extent, the widespread use of sophisticated diagnostic imaging technologies has decreased the emphasis on physical examination skills in actual practice. This trend is unfortunate, because it lessens face-to-face contact between the patient and physician and may thus prove unsatisfying for both. It would be misleading, though, to view technological discoveries as competing only with the physical examination. Over the years, the usefulness of physical diagnosis has been enhanced by the availability of simple tools and elegant instruments that augment the examiner’s biological senses. Common examples include the stethoscope, the oto-ophthalmoscope (a handheld halogen light source with interchangeable optics, used to view the inside of the eyes and ears), the reflex hammer, and the tuning fork. Indeed, the line separating physical diagnosis from other diagnostic procedures has been blurred as more portable devices find their way into the hands of the practicing physician.

During the physical examination, diagnostic techniques are applied in an interaction between the examiner and the patient at a unique moment in time. As such, the outcome depends on the skills of the individual examiner and on the patient’s manifest physical characteristics. Changes in physical state over time are common; variation in physical examination findings over time is not unexpected. For example,
heart murmurs, which are sounds generated by the heart, are graded on a scale from I/VI (one over six), designating a very faint murmur, to VI/VI (six over six), designating a murmur loud enough to be heard even without a stethoscope at a distance away from the patient. It is not uncommon for physicians, even cardiologists, who specialize in the heart, to disagree on the description of a murmur. In addition, a murmur itself can get louder or softer, or even disappear entirely with advancing age, exercise, pregnancy, or other factors. Physical diagnosis is an imprecise science. Medical educators have attempted to address this imprecision by modifying traditional instructional methods.

The physical examination should be considered within the larger context of medical information gathering. Customarily, it follows the collection of historical information about the patient’s immediate and past health statuses. Like a road map, the history guides the scope and focus of the subsequent examination. This marriage of history taking and physical examination is colloquially referred to as the “H and P.” Though not as often recommended as in the past, the annual complete (or head-to-foot) physical examination may come to mind when this topic is discussed. More commonly, a physical examination is directed and focused on particular regions or organ systems.

In the general

screening examination of an apparently healthy subject, a systematic survey is undertaken, following an assessment of structural and/or functional relationships. A structural division would involve examination of all the organ systems contained in or adjacent to a particular body part (for example, the foot), such as the bones, muscles, nerve supply, blood vessels, and skin. A functional examination of the cardiovascular organ system would include the heart, neck, lungs, abdomen, skin, and extremities, because manifestations of cardiovascular disease may be present in locations physically remote from the heart itself. A patient complaining of a specific problem undergoes a detailed examination of the organ systems or body structures most likely to be affected.

The sequential performance of a physical examination incorporates both structural and functional strategies. Though most examiners follow a similar framework, individual differences in physicians and patients result in a wide variety of acceptable patterns. Ideally, the process begins when the patient first arrives. Clues to a patient’s overall level of independent function, such as mobility, dexterity, and speech patterns, may be noted. As the medical history is taken, the patient’s level of alertness, as well as orientation to time, place, and self, often becomes apparent. The complete examination generally begins with the head, including the face and scalp. A survey of the skin surfaces may be accomplished with the patient completely naked, or it may be divided into discrete segments to be checked as the examination proceeds. Inspection of the eyes, ears, nose, and throat follow. Next, the neck, chest, and back are surveyed. A breast examination may be done at this time. After evaluation of the heart and lungs, the patient is asked to lie down for the abdominal examination. Genital organs may be checked at this time or may be deferred until a later part of the session. The neurologic inspection usually follows and entails the integration of findings
from earlier parts of the examination with maneuvers specific to the neurological examination. In the mental status portion of the neurologic examination, formal evaluation of memory, orientation, speech patterns, and thought processes takes place. The musculoskeletal examination likewise integrates earlier findings with a detailed focus on bone and joint development and function. Finally, the extremities are checked. Upon completion of the history and physical, the diagnosis may be readily apparent or further evaluation may be needed.

Pertinent findings, whether normal or abnormal, are documented in the medical record and may be supplemented by diagrams or photographs if necessary. Depending on the purpose of the examination, these may be entered on a separate preprinted form with check-off spaces or simply noted in the chart. Computer technology allows the storage and retrieval of this information in a patient database file.

Uses and Complications

The application of physical examination techniques may be illustrated by considering three distinct cases: a child’s school physical, a routine gynecologic examination with a Papanicolaou (Pap) test, and the evaluation of a sprained ankle. Each has a unique purpose dictating the breadth and detail of the techniques employed. In the school physical, the purpose of the examination is to screen a symptom-free individual for signs of previously unrecognized medical conditions; thus, the survey is broad. The annual gynecologic examination with a Pap testing is more focused—screening for cervical cancer and other gynecologic illness, including sexually transmitted diseases—and will focus on the reproductive system. The evaluation of the sprained ankle is done to assess damage to an identified body part following a specific injury, and it will entail a detailed inspection of the affected area. How these underlying considerations influence the methods employed are apparent as each case is considered.

A child’s school physical examination is preceded by a broad historical investigation of the individual’s birth details, immunization status, social interactions, growth and development, and daily activity. Height and weight are measured and plotted on a growth chart to facilitate comparison with expected normal values for children of the same age and sex. In many cases, the actual numbers are of less importance than the trend relating repeated measurements. Vision and hearing
screening are employed to identify defects that could interfere with school performance.

Vital signs—temperature, pulse, blood pressure, and breathing—are determined. Temperature is usually determined orally, though rectal or axillary (armpit) locations may be used. Although 37 degrees Celsius (98.6 degrees Fahrenheit) is often quoted as normal, a range of body temperatures can be found in healthy patients.
Pulse rate is measured by palpation of the radial artery in the wrist. Circumstances may dictate performing this measurement in other locations, such as the carotid artery in the neck or the femoral artery in the groin. Most patients will have a pulse between sixty and one hundred beats per minute. Higher or lower numbers are common and may be related to athletic conditioning, medications, or illness.

Blood pressure is determined with the aid of a stethoscope and a sphygmomanometer (blood pressure cuff) and is expressed in millimeters of mercury. After pumping the cuff to a high pressure, the examiner slowly deflates the cuff while listening for the sounds of blood flow, usually in the brachial artery above the elbow. The onset and end of these sounds indicate the systolic and diastolic blood pressure measurements. A measurement of 120/80 (systolic over diastolic) is often considered normal, but acceptable blood pressures will vary among individuals. In this case, the normal blood pressure for a child is lower than for an adult. Breathing rate is checked by observation and varies, depending on age and medical conditions, from approximately twelve to forty breaths per minute. Infants and children have higher rates than adults.

Following the determination of vital signs, a general physical survey is performed. The head is inspected to confirm normal shape and absence of injury. Eye movements and response to light are noted, along with any inflammation. The ears, nose, and throat are checked for signs of inflammation or scarring. A puff of air may be used to test the mobility of the eardrum. Palpation of the neck may reveal enlargement of the thyroid gland or lymph nodes. The chest is observed for abnormalities, and auscultation of the lungs is performed to monitor air flow during breathing. The cardiac examination will focus on possible murmurs, sounds generated by turbulent blood flow. Since many murmurs are harmless, and many children will have a murmur noted at some point, careful auscultation is needed to define the nature of heart sounds. If a murmur is heard, the patient may be asked to perform certain maneuvers, such as standing up quickly or taking a deep breath and straining. These actions may cause the murmur
to change in a way that allows recognition of its underlying cause.

Next, the abdomen is observed for symmetry and distension. By palpation, the examiner may discover enlargement of the liver or spleen. Percussion over the liver area may confirm enlargement of that organ. Auscultation of the sounds produced by the bowels may provide clues to increased or decreased intestinal function. An external genital examination is appropriate for boys and girls. Proper descent of the testicles into the scrotum should be ascertained for boys, while menstrual complaints may dictate an internal examination for girls. Scoliosis (curvature of the spine) or other abnormalities in neurological or musculoskeletal development may be found. Examination of the skin surface is especially important in children; in addition to birthmarks, signs of child abuse may be visible and require evaluation. The length of time needed for the entire screening process will vary. If the child is already known to the examiner and has been seen recently for other reasons, the examination itself may be brief. The presence of abnormal findings may require a lengthy, detailed evaluation.

An annual gynecologic
examination and Pap testing is preceded by a directed gathering of the patient’s medical and family history, focusing on the reproductive system. This completed, the patient is asked to lie on her back, with her feet apart in foot rests that extend from the table. Examination of the female genital tract begins with a survey of the external structures, the clitoris, labia, and vaginal opening. A discharge or surface lesions such as sores or warts may arouse suspicion of sexually transmitted disease. Since many women have some discharge normally, however, laboratory tests are often needed to establish the diagnosis of infection. To examine the internal structures of the vagina, the examiner uses a speculum, a metal or plastic instrument about five inches long and shaped like a duck’s bill. A hinge in the back allows it to be opened after insertion into the vagina, permitting inspection of the cervix and the vaginal walls with the help of a bright light. At this time, the sample is taken from the cervix, usually with a small brush and wooden spatula. After removal of the speculum, the bimanual (literally, “two hands”) examination is done. Gloved, lubricated fingers are inserted into the vagina, while the other hand presses down from the outside of the abdomen. For many women, this is the most uncomfortable part of the examination, though sensitivity by the examiner can lessen the discomfort. The cervix, uterus, Fallopian tubes, ovaries, and bladder may be palpated. A rectovaginal examination is performed by placing one finger in the vagina and another finger of the same hand in the rectum. This allows palpation of the space between the vagina and the rectum, as well as of the rectum itself. A breast examination may be performed during the office visit. Although most women focus on lumps, other
potential signs of breast cancer, such as bleeding from the nipple, a persistent rash around the nipple, skin dimpling, or retraction (turning in) of the nipple, are noted. Because breast cancer is most common in upper and outer quadrants of the breasts and may spread to lymph nodes in the armpit, palpation of these areas is prudent.

In the
examination of an apparent ankle sprain, the presence of an abnormality is a given, and the evaluation is geared to the documentation of the extent of the injury to the ankle itself and to adjacent structures. Initial observation may reveal that the patient has obvious pain while walking into the examining area. Swelling and redness may be prominent. Palpation of the leg and ankle will likely elicit tenderness over the damaged ligaments, especially with movement. Intact circulation can be confirmed by placing the fingers over the arteries of the foot and noting strong pulses. Instability of the joint itself may be discovered by applying pressure in various directions. The possibility of nerve damage is assessed by testing sensation and the strength in the foot. Though this examination is directed toward a relatively limited area of the body, it may require considerable time because of the depth of detail involved.

Perspective and Prospects

The modern physical examination is the product of a gradual evolution rather than of a single discovery or invention. Though certain individuals are credited with the adoption of particular physical diagnostic techniques, the interpretation of bodily characteristics as indicators of health status has ancient roots that predate Hippocrates, who was born in 460 BCE on the island of Cos in Greece. From the Middle Ages until the eighteenth century, physical examination focused on the pulse, which was accorded much diagnostic significance, and the feces. The scientific foundations of current practices were uncovered in Europe during the late eighteenth century and early nineteenth century. René Laënnec (1781–1826), a French physician, is generally acknowledged as the originator of the stethoscope, which greatly enhanced the power of auscultation. Compared to modern instruments, it was crude, consisting of a straight rigid tube which was placed between the patient’s body and the physician’s ear. The use of percussion as a diagnostic technique is credited to Leopold Auenbrugger and Jean-Nicolas Corvisart des Marets, contemporaries of Laënnec. Since that time, many physicians have contributed to the body of knowledge that supports physical diagnosis, and texts on the subject are filled with descriptions of maneuvers and findings that bear their names: Sir William Osler, Moritz H. Romberg, Joseph F. Babinski, William Heberden, Antonio M. Valsalva, Franz Chvostek, and so on.

Though the patient’s history and physical examination have excellent diagnostic power, the adoption of advanced imaging techniques may lead to less reliance on physical diagnostic techniques. Thus, traditional hands-on examination risks falling by the wayside. Reasons for adopting new medical technologies in its place are many and controversial. Like other skills, physical diagnosis requires ongoing use if the practitioner is to remain sharp. Physical examinations can be imprecise, with disagreement among competent examiners regarding the presence or absence of findings. In contrast, electromechanical systems may provide more consistent information, though the interpretation of this information is still subjective. It is easy to forget that laboratory or radiological findings by themselves have very limited usefulness. It is not unusual for test reports to note, “Clinical correlation is advised.” In other words, test results must be interpreted in the light of the information that has been gathered about the patient through the history and the physical examination. The performance of a detailed evaluation can be time-consuming for the physician and the patient, especially when
compared to requesting a test. Pressured by patient expectations or liability concerns, physicians may be reluctant to rely on the physical examination alone in lieu of a battery of confirmatory or exploratory scans or blood tests.

The consequences of this shift are likely to change the way in which the patient views the physician and the way in which the physician approaches the patient. Traditionally, the healing role has been intimately associated with the face-to-face meeting of doctor and patient, exemplified by the laying on of hands. From the patient’s perspective, the concept of the personal physician, the familiar voice and touch of the healer who displays ongoing concern and compassion, should not be discounted. This therapeutic relationship will be compromised if physicians become mere brokers for imaging and testing services. With such an arrangement, there would be no reason for the doctor and patient even to see each other. Additionally, important diagnostic information may present itself in a manner that cannot be detected by a scan, such as a subtle clue in the patient’s mannerisms or body language. Even a human examiner may have difficulty analyzing such vague information, but impressions can nevertheless contribute to the clinical evaluation. This suggests that the physical examination will continue to hold an important place in the physician’s array of diagnostic tools.

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Vorvick, Linda J. "Physical Examination." MedlinePlus, January 1, 2013.