What two characters will struggle against each other in "A Retrieved Reformation's" conflict?

Jimmy Valentine is a young career criminal who specializes in safecracking. Ben Price is his nemesis. Price apparently works for a private detective agency which specializes in protecting banks in the days before they were under the protection of the federal government. When the story opens, Jimmy is serving time in prison for a bank job. We learn after his release and return to his rented room that he was arrested by Ben Price after putting up a struggle. 

There on the floor was still Ben Price's collar-button that had been torn from that eminent detective's shirt-band when they had overpowered Jimmy to arrest him.

As soon as Jimmy recovers his suitcase full of specialized safecracking tools, he commits four bank jobs in the Indiana area in swift succession. This brings him to the attention of his nemesis Ben Price, who is so good at his job that he can recognize Jimmy's handiwork just from the evidence left behind.

Ben Price investigated the scenes of the robberies, and was heard to remark: “That's Dandy Jim Valentine's autograph. He's resumed business. Look at that combination knob—jerked out as easy as pulling up a radish in wet weather. He's got the only clamps that can do it. And look how clean those tumblers were punched out! Jimmy never has to drill but one hole. Yes, I guess I want Mr. Valentine. He'll do his bit next time without any short-time or clemency foolishness.”

Jimmy believes he is getting too well known, too "hot," in the area where he has been committing his bank burglaries, so he moves to Arkansas and adopts the name of Ralph Spencer. He sets up a shoe business in the town of Elmore, but only intends to use his store as a "front" while he continues cracking safes in this virgin territory. Everything changes when he falls in love with Annabel Adams at first sight. He is doing well with his shoe business and decides to reform in order to be worthy of a respectable girl like Annabel. 

But the formidable sleuth Ben Price traces Jimmy to Elmore, Arkansas and is ready to arrest him for the four bank jobs he pulled in Indiana. The conflict throughout the story is between Ben Price and Jimmy Valentine. It is resolved in one of O. Henry's surprise endings when Price decides to let Jimmy retain his new identity as Ralph Spencer and go ahead with his reformation. Jimmy is a changed man, but Ben Price changes too. He is a witness to Jimmy's noble act of exposing his true identity by opening his suitcase full of safecracking tools and saving the little girl who has gotten accidentally trapped in Annabel's father's bank vault. When Jimmy feels he has lost Annabel and everything connected with his reformation, he is ready to surrender to Price and be sent to prison for a long term. But Price surprises Jimmy, as well as the reader.

“Hello, Ben!” said Jimmy, still with his strange smile. “Got around at last, have you? Well, let's go. I don't know that it makes much difference, now.”

And then Ben Price acted rather strangely.

“Guess you're mistaken, Mr. Spencer,” he said. “Don't believe I recognize you. Your buggy's waiting for you, ain't it?”

What are three facts about Native American culture and/or life today that connect with the short story "The Red Convertible"?

Louise Erdrich illustrates a number of issues facing Native people today, particularly younger people in her short story, "The Red Convertible."

I would point out the effect of war on returning veterans, for one. This is of course an issue that extends beyond the Native community, but it is also true that throughout our modern history Native peoples have played an extremely important role in US war efforts. Lyman Lamartine and his brother, Henry, were close before the Vietnam War returned Henry a changed person. We would now call it PTSD. Lyman goes to great lengths to try and bring his brother back, even to the point of destroying the story's namesake, which they both loved, in order to try and get Henry to come back to himself by forcing him to restore the damaged car (much like how Lyman hoped Henry would restore himself to his pre-war state). It almost works, too. I see this as allegorical of the way many families affected by war, including in the Native community, try and bring their loved ones back, and the pain everyone experiences when a veteran returns damaged.

Another theme in contemporary Native cultures is the desire to preserve a connection to their traditions while at the same time navigating the modern world. This is evidenced in the history the brothers shared of touring the country in the convertible following the pow wow circuit. This was a highlight of the brothers' relationship and shows how they wanted to maintain a connection to their roots while at the same time be cool teenagers just like any other young person of any background wants to be cool--such as by traveling the country in a red convertible and meeting up with girls.

I would also point out the sad rate of suicide in the Native community. Unfortunately, despite his best efforts and even when he thought he had succeeded in pulling Henry back, Henry drowns himself right in front of Lyman. This also is not a tragedy unique to the Native community, but it does occur at a higher rate than mainstream Anglo society.

I hope I have given you some ideas to use.

What are the characters' names in "The Rich Boy"?

The first few paragraphs of the story "The Rich Boy" seem so vague and general that you might ask yourself, "Well, who IS the rich boy? Who is this story about?" But the narrator does explain who the characters are as the story really begins. Let's consider all the characters important enough to play a noteworthy role in the story:

1. Anson Hunter. He is the main character and the "rich boy" from the title. He has a "keen and somewhat sardonic mind." He's handsome and seems obsessed with seeking pleasure in life. You can tell he's outgoing because he likes to tell people amusing stories. And, he's an alcoholic.

2. The narrator. He suddenly pops into the story as a character at the start of the ninth paragraph, when he says: "[Anson] and I first met in the late summer of 1917." They meet at a dance in a hotel. Anson was in the Navy, and the narrator was an officer as well, so they had that in common. Then we don't see much of the narrator until he pops back in toward the end of the story to comfort Anson when they find out that Paula has died.

3. Paula Legendre. A beautiful girl from California, and Anson's love interest. She's emotionally simple and fabulously wealthy, and she hates Anson's alcoholism.

4. Paula's cousin, called Cousin Jo. She's described as bitter and jealous of Paula's engagement to the rich and handsome Anson, but she's also naive.

5. Paula's mom, Mrs. Legendre. She doesn't approve of Anson's drunken behavior.

6. Anson's uncle, Uncle Robert. He helps Anson sober up and not make a further fool of himself; he takes care of Anson's family estate, and he's basically Anson's best buddy.

7. Dolly Karger. She's a society girl, boy-crazy, and loves to dance. She has a fling with Anson, but the whole time, Paula's picture is on his wall (meaning Paula is still in his heart).

8. Anson's mom. She wants Anson to be happy and find a girl to settle down with. She dies before Anson does so, though; he's just under thirty years old when his mom dies.

9. Anson's aunt, Aunt Edna, who's married to his Uncle Robert. She's cheating on him.

10. Cary Sloane. An angry alcoholic, and the guy who's having the affair with Edna. Somehow he ends up drowning in a river. (It's unclear how it happened.)

11. Anson's sisters. These unnamed girls are simply described as snobby and not very self-reliant.

12. Nick, a bartender who is friendly with Anson. His conversation with Anson helps show how lonely and sad Anson is becoming.

13. Peter Hagerty, the eventual second husband of Paula. She seems to love him dearly.

14. "The girl in the red tam." We don't know her name, but Anson has a fling with her at the end of the story. We can tell that he's still really lonely and that his girl isn't helping, but having flings is the only thing Anson knows how to do.

How is there interdependence in The Giver by Lois Lowry?

The concept of interdependence means relying on someone else.  In Jonas’s community, it is related to the concept of Sameness.  Everyone is the same, everything is controlled, and people need to learn to rely on the community.  This means that as children they need to learn to rely on other children. 

The community teaches interdependence by making children rely on each other.  From the age of Four to Six, the children’s jackets have buttons in the back so that they will have to help each other dress.  When they are Sevens, they are considered old enough to button their own jackets. 

The little girl nodded and looked down at herself, at the jacket with its row of large buttons that designated her as a Seven. Fours, Fives, and Sixes all wore jackets that fastened down the back so that they would have to help each other dress and would learn interdependence. (Ch. 6) 

In addition to clothing, the people of the community rely on each other in different ways.  Mostly, everyone relies on the community.  Spouses, children, and jobs are all provided by the community.  Individual choice is not really a concept.  Everyone dresses alike, and due to genetic manipulation they even look alike.  With rare exceptions they all have the same skin, eye, and hair color. 

Everyone in the community also depends on the Receiver of Memory.  This is the person who holds the community’s collective memories and history, of which all other community members remain ignorant.  There are not even books in the community other than instruction manuals. 

The Giver shook his head. "Jonas," he said, "the community has depended, all these generations, back and back and back, on a resident Receiver to hold their memories for them. I've turned over many of them to you in the past year. And I can't take them back. There's no way for me to get them back if I have given them. (Ch. 20) 

Since everything in the community is collective, and the community takes care of everyone’s needs, it never occurs to anyone to question anything.  Things just are the way they are, and if you are a citizen of the community you follow the strict rules.  To not do so is socially unacceptable and can result in grave consequences, such as release.

Where does Macbeth go after he kills King Duncan?

Scene 1 of Act II ends with Macbeth following a floating dagger towards Duncan's chamber and holding his own dagger in his hand.

A bell rings.

I go, and it is done: the bell invites me.
Hear it not, Duncan, for it is a knell
That summons thee to heaven, or to hell.

Scene 2 of Act II opens in an unspecified place, probably representing the Macbeths' chambers. Lady Macbeth is waiting for her husband and speaks a long soliloquy beginning with these lines:

That which hath made them drunk hath
made me bold;
What hath quench'd them hath given me fire.

At the end of this soliloquy her husband enters. The murder of King Duncan is skipped over between Scene 1 and Scene 2. Presumably Macbeth has returned to his chambers directly after murdering Duncan. However, Macbeth has forgotten to leave the murder weapons, the grooms' two daggers behind. This suggests that he is in a sort of trance brought on by the horror of killing Duncan without really wanting to do it but driven by his wife. She reproaches him:

Why did you bring these daggers from the place?
They must lie there. Go carry them, and smear
The sleepy grooms with blood.

Macbeth must have returned to his own chambers in great haste because of his mixed feelings of guilt, fear, and horror. He replies:

I'll go no more:
I am afraid to think what I have done;
Look on't again I dare not.

So Macbeth goes to his chambers after killing King Duncan and stays there until he is forced to go downstairs to find out who is knocking at his gate and why the Porter is not opening it.

How do oxygen and carbon dioxide get exchanged in the air sacs of the lungs?

Deoxygenated blood that has just returned from the tissues of the body and the coronary circulation (the system that provides oxygenated blood to the tissue of the heart itself) enters the right atrium of the heart.  From there, it will be pumped through the tricuspid valve and into the right ventricle.  The ventricles contract and the blood travels from the right side through the pulmonary trunk and artery to the lungs.  From the pulmonary artery, the blood makes its way to the capillary beds surrounding the alveoli (air sacs) of the lungs.  This is where gas exchange takes place.

The gases being exchanged are oxygen and carbon dioxide.  When gas exchange occurs, it is important to remember that each gas must be considered separately (the diffusion of one gas will not be influenced by another gas--Dalton's law) and that gases will diffuse from high partial pressure to low partial pressure.  

The cells that make up our tissues utilize oxygen for metabolic processes and produce carbon dioxide as a byproduct so blood that is returning from the tissues and making its way to the lungs has a relatively high partial pressure of carbon dioxide (45 mmHg) and a relatively low partial pressure of oxygen (40 mmHg).  The air that has just been inhaled and is entering the alveoli of the lungs is the opposite, the partial pressure of oxygen is relatively high (105 mmHg) and the partial pressure of carbon dioxide is relatively low (40 mmHg) due to their concentrations in atmospheric air.  

Considering each gas separately (Dalton's law), all you have to do is compare the partial pressures of each gas across the membranes.  The membranes between the capillaries and alveoli are simple squamous epithelium so diffusion will occur readily.  Carbon dioxide's partial pressure is higher in the capillaries than in the alveoli so the carbon dioxide will diffuse from the capillaries and into the alveoli where it can be exhaled.  The partial pressure of oxygen gas is higher in the alveoli than in the capillaries so the oxygen will diffuse from the alveoli and into the capillaries.  The blood is now oxygenated and will return to the left side of the heart and then to the body (systemic circulation) where oxygen can be delivered again to the tissues.

What are some examples of satire in the novel Fahrenheit 451 by Ray Bradbury?

Throughout the novel Fahrenheit 451, Ray Bradbury satirizes society by exaggerating, ridiculing, and criticizing various aspects of American culture. Bradbury satirizes society's fascination with entertainment through Mildred's obsession with her 'parlor walls.' At the beginning of the novel, she argues with Montag about buying a fourth 'parlor wall.' She says,

If we had a fourth wall, why it'd be just like this room wasn't ours at all, but all kinds of exotic people's rooms. We could do without a few things (Bradbury 18).

Bradbury also satirizes America's education system and society's infatuation with sports. When Clarisse discusses a typical day at school with Montag, she describes it as

An hour of TV class, an hour of basketball or baseball or running, another hour of transcription history or painting pictures, and more sports, but do you know, we never ask questions, or at least most don't; they just run the answers at you, bing, bing, bing, and us sitting there for four more hours of film-teacher (Bradbury 27).

When Montag seeks Faber's advice about how to understand the texts he has been reading, Faber notices Montag has brought a Bible with him. Faber takes the Bible and begins to flip through its pages. He says,

It's as good as I remember. Lord, how they've changed it in our 'parlors' these days. Christ is one of the 'family' now. I often wonder if God recognizes His own son the way we've dressed him up, or is it dressed him down? He's a regular peppermint stick now, all sugar-crystal and saccharine when he isn't making veiled references to certain commercial products that every worshiper absolutely needs (Bradbury 78).

In this conversation between Faber and Montag, Bradbury satirizes the commercialization of religion. He satirizes how American society has used sacred religious figures to market products by appealing to consumers' emotions.

How can I compare the medieval heroes depicted in Yvain with the Renaissance courtiers depicted in The Book of the Courtier? In what ways did the...

In Chretien de Troyes' Yvain, the author introduces the reader to the concept of chivalric discourse. In these types of stories, we see the characters realize the principles and rules of courtship through both conversation and the completion of knightly deeds. This is an essential feature of twelfth-century romance, in which a certain "code of ethics" was alluded to. This code of ethics was followed by knights and ladies, and its purpose was essentially to help the nobles adhere to certain social norms which were an important step in reconciling their own desires for romance with their responsibilities as highborn nobility. 

Above all, these values are what help maintain the balance between the life of a husband and the life of a knight. If one neglects his knightly duties to spend time with his lover, as in the case of the character Sir Erec, then he is failing to adhere to his duties. Likewise, it is bad for a husband at court to spend so much time serving his knightly duties that he neglects to spend time with his lover, as is the case with Yvain. He is rejected by her when he fails to keep a promise, which is one of the most basic tests of maturity and good behavior.

Because of this, Yvain must rediscover himself and win back the favor of his wife. It is significant that he embarks on a quest to complete heroic deeds to win back her favor, as this was a popular trope in romances of this time period, and a requirement of courtly love in medieval times, which required a demonstration of the character of one's heart. Because Yvain proves his bravery and the goodness of his heart, both to himself and to everyone else, this is enough to win back the love and respect of his wife. 

In contrast to the lofty adventures of the medieval knights in Yvain, The Book of the Courtiers gives us an image of how the ideal courtier would look, act, and think. The fictional conversations which occur in the book demonstrate a Renaissance courtier that has a calm mind, a voice that is elegant and which speaks courageously, and who uses proper gestures and form when conducting himself. These conversations reveal what nobles considered valuable in a person during the Renaissance time period. For example, although he must be cool and collected, a courtier must also be a great athlete and have the spirit of a great warrior. Not only that, but he must be knowledgeable in the arts and humanities. He must be humorous, well-versed in the ways of women, and able to understand the subtleties of love.

In many ways, heavier expectations were placed upon the Renaissance courtier. In order to be respected in such a cultured world, one must have a deep understanding of both heroic pursuits and academic pursuits. These expectations were not just about cultivating an understanding of one's own upright behavior and physical ability, but an understanding of the potential of one's own mind and creativity. One must have, for example, "a certain nonchalance" and a "careful negligence." In this world, every single action, no matter how small, must be done with precision and purpose. According to the book, the ideal courtier is a person who “conceals art, and presents what is done and said as if it was done without effort and virtually without thought.” (31). In short, one must be a well-rounded individual capable of holding the attention of highly-esteemed nobles at all times.

By holding such high expectations on its members, a court could be ensured of its own greatness. The Renaissance was indeed a time in which the subtle beauties and pleasures of the world were to be engaged in and admired. During the Medieval times, however, it was not so much how something was said, but what was said that mattered. Many clues to the differences between the two time periods are housed in that period's attitude toward language as a tool to measure character. According to the count in The Book of the Courtiers, it is not the language used that matters, but rather the authority, style, and grace with which it is delivered. It was confidence, not content, that the courtiers of the Renaissance prized, but the same is not true for the courtiers of the Medieval times, who tended to prize actions and deeds over words and style. 

What is adrenoleukodystrophy?

Causes and Symptoms

X-linked adrenoleukodystrophy (ALD) is caused by mutations in the ABCD1 gene. The ABCD1 gene codes for the ALD protein. This protein is located in the membrane of an essential cellular organelle, the peroxisome, which has a role in cellular metabolism. Very long chain fatty acids (VLCFA) are metabolized in the peroxisome. The buildup of saturated VLCFA in tissues causes the symptoms of X-linked adrenoleukodystrophy. A diagnosis can be made in males by identifying an elevated VLCFA level in body fluids. In females, VLCFA levels are not reliable, and genetic testing is necessary.

The symptoms of X-linked ALD vary from one individual to the next, even within the same family. The gene mutation or level of VLCFA in body fluids is not a predictor of symptom type or age of onset. Because the ABCD1 gene is located on the X chromosome, the disease presentation is different in males and females. The clinical presentation of X-linked ALD in males can be categorized into three groups. About 35 to 50 percent of males with X-linked ALD have a childhood cerebral disorder. The age of onset varies from three to ten years but can occur as late as twenty-one years of age. Boys with the cerebral type of X-linked ALD have a progressive loss of the myelin that encloses the nerves in the brain (demyelination). As the condition progresses, characteristic abnormalities can be seen on brain
magnetic resonance imaging (MRI). The neurological symptoms may include cognitive disturbances, hyperactivity, seizures, and psychosis. Boys with X-linked ALD may also experience vision and hearing loss. They enter a vegetative state and die
within approximately two to four years of the onset of neurological symptoms. Insufficient hormone production from the adrenal gland, also known as Addison’s disease, is identified in 90 percent of boys with the childhood cerebral type of X-linked ALD. The symptoms of untreated Addison’s disease may include vomiting, fatigue, low blood pressure, weakness, increased skin
pigmentation, and coma. Adrenal insufficiency can be detected through identification of an elevated plasma adrenocorticotropin (ACTH).

The second type of X-linked ALD is an adult-onset disorder typically referred to as adrenomyeloneuropathy (AMN). The symptoms of AMN include progressive weakness of the legs, paresis, sphincter disturbance, and sexual dysfunction. Onset of symptoms ranges from the second to fourth decade but typically occurs in the late twenties. About 70 percent of men with AMN also have Addison’s disease.

For approximately 10 percent of males with X-linked ALD, Addison’s disease is the only symptom, which usually manifests initially at around age eight but can start in adulthood. Most men with Addison’s disease as the only symptom of X-linked ALD will eventually develop neurological involvement. Rarely, males with an ABCD1 gene mutation are asymptomatic.

Approximately 10 to 50 percent of females with an ABCD1 gene mutation will have neurological symptoms, which are milder and progress more slowly than in men but are otherwise similar to AMN. The onset of symptoms is typically in a person’s thirties.

Treatment and Therapy

The treatment for the adrenal insufficiency identified in most males with X-linked ALD is steroid hormone replacement.

For the childhood cerebral type, management is typically supportive, and stimulants can be helpful for treatment of hyperactivity. However, bone marrow
transplantation is a permanent cure. Because it is associated with a high mortality rate of about 20 percent, as of 2009, it is only recommended in the early stages of cerebral involvement, when abnormalities are first noted on brain MRI.

For males with AMN and symptomatic females, treatment is typically supportive, including physical therapy and psychological counseling.

Perspective and Prospects

The first description of symptoms consistent with childhood cerebral X-linked adrenoleukodystrophy in the medical literature was by Ernst Siemerling and Hans Gerhard Creutzfeldt in 1923. The first adult patient with AMN was described by Herbert Budka in 1976. The incidence of X-linked ALD is now estimated at 1 in 20,000 male births.

The first attempt to cure X-linked ALD was in the 1980s. The proposed treatment was dietary restriction of VLCFA; however, the levels of VLCFA were not lowered in body fluids. The next attempt was a combination of dietary restriction and administration of a dietary supplement called “Lorenzo’s oil,” a mixture of glyceryl trioleate and glyceryl trierucate. This combination lowers the level of VLCFA in the body fluids. Unfortunately, in symptomatic patients, it does not alter the course of their disease. In presymptomatic patients, some studies have suggested that administration of Lorenzo’s oil and dietary restriction of VLCFA reduces the chances of cerebral or neurological involvement. The efficacy of Lorenzo’s oil is an area of research. Gene therapy is also an area of research for the treatment of X-linked ALD. A few cases of successful gene therapy in patients with cerebral type X-linked ALD were reported in 2009.

Bibliography:

Alan, Rick. "X-linked Adrenoleukodystrophy." Health Library, Sept. 30, 2012.

Fernandes, John, et al., eds. Inborn Metabolic Diseases. 4th ed. New York: Springer, 2006.

MedlinePlus. "Adrenoleukodystrophy." MedlinePlus, Dec. 1, 2011 (updated Mar. 22, 2013).

Rimoin, David, et al., eds. Emory and Rimoin’s Principles and Practice of Medical Genetics. 5th ed. Philadelphia: Churchill Livingstone, 2007.

Scriver, Charles, et al., eds. The Metabolic and Molecular Bases of Inherited Disease. 8th ed. New York: McGraw-Hill, 2001.

The speech “Communists in the State Department,” by Sen. Joseph McCarthy, was delivered _____. after the fall of the Soviet Union at a...

Let me finish the question:  The speech "Communists in the State Department" by Senator Joe McCarthy was delivered at a time when the Soviet Union was America's main rival in the world; you want the second choice out of your answers.  Joe McCarthy was a grandstanding politician who claimed that the State Department was rife with Communist infiltrators and he led a Red Scare in America during the early 1950s.  Remember, America had already had one Red Scare in the early 1920s, and it resulted in trials and deportations of people suspected to be Communists.  After the Soviet Union developed the atomic bomb in 1949, America suspected that the Soviet Union had some spies here.  Communism was also gaining ground in China, North Korea, North Vietnam, and Central America.  There were even rumored Communist takeovers in Greece and France.  McCarthy claimed to have a dossier on several hundred Communists throughout the government and in the media.  He led the investigation on "un-American" activities in Congress, but he was later discredited by president Dwight D. Eisenhower who saw through McCarthy's incendiary tactics.  Eisenhower would never be accused of being a Communist, as he was the general associated with the victory in Europe against the Nazis and had many conservative policies as president.  

Why does the Earth spin?

There are various phenomena that are caused by movement of heavenly bodies. We observe different seasons throughout the year because the earth is at different positions relative to the sun as it revolves around it. Tides are caused by the relative position of the earth and the moon. Similarly, day and night are caused by the earth's rotation. But why is the earth spinning?

Earth, and other planets, rotate about their axis - or spin - due to inertia. Inertia is the tendency of objects at rest to stay at rest, or to move at a constant rate when they're moving unless external force is applied. Hence, the earth is spinning because it was spinning when it was formed, and has just continued to do so due to inertia.

To understand why it started spinning in the first place, one has to go back to the birth of the entire solar system. Dust and gas are what started everything. The cloud began to collapse and the gravity in the center started pulling things in as it collapsed, compacting dust and gas forming stars-- and planets. As this happened, the formed bodies started spinning faster. There was angular momentum, or the tendency of objects to spin. Hence, when earth was formed, it was spinning, and it hasn't stopped since.

Interestingly, it is believed that the earth hasn't always spun at the same rate. It was slower. However, it was hit by a large object - which ultimately caused the formation of the moon - and increasing the earth's speed in the process.

Compare and contrast Sidi's feelings about each of her suitors.

At the beginning of the play, Sidi is open to the possibility of marrying Lakunle. She says that she is willing to marry him if he will simply pay the bride-price. Lakunle refuses to pay the bride-price by claiming that it is a savage custom. Sidi is attracted to aspects of Lakunle's personality but essentially tolerates his behavior. She criticizes Lakunle about his affinity for Western culture and questions why they let him run the school. After Sidi learns that her image is everywhere in a popular magazine, she becomes conceited and tells Lakunle, "In fact, I am not so sure I'll want to wed you now" (Soyinka 12). She begins to view herself as "above" Lakunle and dismisses the possibility of marrying a lowly teacher. Initially, when Sadiku tells Sidi that Baroka requests her hand in marriage, Sidi makes fun of Baroka's old age and rejects his offer. She ridicules the Bale and mentions that she is more famous than him. After finding out that Baroka is impotent, Sidi visits his palace because she wishes to mock him to his face. After he successfully woos her and takes her virginity, Sidi decides to marry the Bale over Lakunle. She mentions that she has felt that strength of "the panther of the trees," and is attracted to Baroka's masculinity. Sidi views Lakunle with contempt and refers to him as a "book-nourished shrimp." By the end of the play, Sidi marries the Bale and ridicules Lakunle.

What are nightmares?

Causes and Symptoms

Nightmares have intrigued people for centuries, inspiring a range of explanations about what causes them. It is now known that they occur in all children shortly after the developmental stage of the “terrible twos,” which overlaps but is not the same as the chronological age of two.

Two concurrent developments mark this period of growth. The first is intellectual and cognitive. Children develop the ability to conceptualize, process, and recall information in ways that they could not before and begin reporting that they had dreams the previous night. These dreams usually involve things they wish for, playful fantasies, and daytime activities. The second development is emotional. At this stage, children are growing beyond the autonomy and individuation issues that characterize the infamous “terrible twos.” They start involuntarily to experience strong aggressive feelings and desires to control, and they direct these emotions toward those with whom they have the most trouble in establishing their autonomy: parents and siblings. At the same time, children also experience anxiety from speculating about what would happen if their feelings were ever directly expressed. This intellectual and emotional combination gives rise to vividly intense nightmares, what children commonly refer to as “bad dreams.”

In addition to aggressive impulses, nightmares may involve big dogs, snakes, insects, or other dangerous animals; monsters; giants; a “bad man”; or harm coming to them or someone in their family. During nightmares, children sense their own helplessness and vulnerability, which adds to the awful feelings experienced afterward. Children who dream that they are victorious over the threat—for example, they beat up the monster—usually report that they have had “good dreams” and are not frightened.

Nightmares affect boys and girls equally, although individually children experience, or recall the experience, with wide-ranging frequency. Some will have few nightmares throughout this preschool period; others will have many. Regardless of the baseline, all children will experience an increase in frequency during times of worsening stress. Oftentimes those struggling with post-traumatic stress disorder will experience greater numbers of vivid nightmares. Both a marked increase in the frequency of nightmares and the experience of having a single frequently recurring nightmare have psychological significance and causes. Rapid awakening after any dream is associated with good recall, which is also true with nightmares.

Night terrors also begin around this time; however, unlike nightmares, not all children experience them. They occur with regularity only between the ages of two and six. Night terrors are characterized by screaming and rapid awakening from deep sleep during the first third of the night, with vague or no recollection of the scary dream or image that presumably caused them. The child is terrified, hard to comfort, and difficult to awaken fully. Episodes last from ten to twenty minutes. It is often more upsetting for parents to witness a child thrashing and screaming than it is for the children who experience night terrors, as there is usually no recollection of the episodes the next morning.

Electroencephalogram (EEG) testing during night terrors shows the electrical activity in the brain as similar to that which occurs during small seizures, although night terrors are neither seizures nor caused by seizures and should not be treated as such. Usually, when night terrors occur, either the preceding day or the period right before bedtime has been particularly challenging or difficult. Night terrors may be a way in which children work off the psychological steam that they have built up as a result.

Even with advanced technology, a science does not exist to explain in clear terms the cause and meanings of nightmares. Research has been ongoing, with experts examining the impact and occurrence of nightmares in both children and adults. Some studies have even investigated the difference in subject matter regarding nightmares experienced by women versus men. Others have sought to establish whether nightmares could in fact be a kind of learned behavior.

Treatment and Therapy

Nightmares are often problematic because parents are uncertain about what to do. Do they look under the bed or in the closet for the “bogeyman”? Do they keep the lights on all night? Do they let the child sleep with them after having a nightmare? Parents can help a child who has had a bad dream and who is afraid of monsters by looking under the bed or opening the closet together, while reassuring the child that they both know nothing is there.

All children experience imagined fears like monsters or spiders. These fears need to be taken seriously because they are real to the children having them. It is important that parents not scold or embarrass already frightened children or tell them that they should not feel the way they do. Parents should not discount or dismiss fears of imaginary and fantasized threats. Children need to feel that when their fantasies and worries get out of control, as in nightmares, someone can take charge and provide safety, security, and reassurance. Children must know that their worries and fears are important to their parents and caregivers.

When nightmare frequency begins to signal an underlying adjustment problem, nightmares should be thought of as an expression of intense anxiety caused by something or someone. In such cases, professional help in the form of a child therapist should be sought.

Night terrors, as disturbing as they can be, usually do not require professional intervention. In most cases, a calm, reassuring parent is all that a child needs to be comforted, to settle down, and to resume the sleep cycle. When the frequency of night terrors becomes problematic, parents should consult a sleep disorder specialist, whose professional discipline is usually medicine or psychology. In both disciplines, sleep disorders constitute a specialized area of clinical practice, and most physicians and psychologists are not trained to treat them.

Bibliography

Adler, Shelley R. Sleep Paralysis: Nightmares, nocebos, and the Mind-Body Connection. Piscataway: Rutgers U, 2010. Print.

Brazelton, T. Berry, and Joshua D. Sparrow. Sleep: The Brazelton Way. Cambridge: Perseus, 2003. Print.

Brazelton, T. Berry, and Joshua D. Sparrow. Touchpoints: Your Child’s Emotional and Behavioral Development. New York: Addison, 1994. Print.

Caldwell, J. Paul. Sleep: The Complete Guide to Sleep Disorders and a Better Night’s Sleep. Rev. ed. Toronto: Firefly, 2003. Print.

Cohen, George J., ed. American Academy of Pediatrics Guide to Your Child’s Sleep: Birth Through Adolescence. New York: Villard, 1999. Print.

Ferber, Richard. Solve Your Child’s Sleep Problems. Rev. ed. New York: Simon, 2006. Print.

Fireman, Gary D., Ross Levin, and Alice W. Pope. "Narrative Qualities of Bad Dreams and Nightmares." Dreaming 24.2 (2014): 112–24. Print.

McNamara, Patrick. Nightmares: The Science and Solution of Those Frightening Visions during Sleep (Brain, Behavior, and Evolution). Westport: Praeger, 2008. Print.

Nadorff, M. R., S. Nazem., and A. Friske. Insomnia Symptoms, Nightmares, and Suicide Risk: Duration of Sleep Disturbances Matters 43.2 (2013): 139–49. Print.

Nathanson, Laura Walther. The Portable Pediatrician: A Practicing Pediatrician’s Guide to Your Child’s Growth, Development, Health, and Behavior from Birth to Age Five. 2nd ed. New York: HarperCollins, 2002. Print.

Spurr, Pam. Understanding Your Child’s Dreams. New York: Sterling, 1999. Print.

What is benign prostatic hyperplasia (BPH)?

Related conditions:

Prostate cancer, urinary retention

Definition:

Benign prostatic hyperplasia (BPH) refers to an enlarged prostate gland. The prostate is a reproductive gland in men that produces semen, the fluid that nourishes and transports sperm. It is about the size and shape of a walnut and is located below the bladder. The gland surrounds the urethra, the tube that carries urine outside the body. The prostate grows in size in most men as they age.

Risk factors: Increasing age and a family history of BPH contribute to the risk of developing this condition.

Etiology and the disease process: The exact cause of BPH is unknown. It is not cancerous, nor does it increase the risk of developing prostate cancer.

Incidence: Approximately 50 percent of men between the ages of fifty-one and sixty and 90 percent over age eighty develop BPH. About half of all men diagnosed with BPH have moderate to severe symptoms.

Symptoms: The enlarged prostate presses down on the urethra and irritates or obstructs the bladder. Common symptoms include frequent urination two or more times per night, a sudden urge to urinate, a weak urine stream, dribbling after urinating, straining to urinate, the inability to prevent urine leakage, or the sensation that the bladder is not empty even after urinating. In extreme cases, urinary retention, the complete inability to urinate, is a problem.

Screening and diagnosis: The evaluation typically consists of a complete medical history, a digital rectal exam to feel the size of the prostate, a urinalysis to check for blood or infection in the urine, a prostate-specific antigen (PSA) blood test to screen for prostate cancer, and questions to assess the severity of symptoms. Additionally, urine flow rate, a post-void residual urine test, a pressure-flow study, an x-ray of the urinary tract, or cystoscopy (a test using a scope inserted into the urethra and bladder) may be recommended.

Treatment and therapy: Depending on the severity of symptoms, treatment can include lifestyle modifications, such as decreasing the intake of fluid before bedtime and limiting the consumption of alcohol and caffeine, or medication to increase urine flow. In extreme cases, surgery to remove part of the prostate may be recommended.

Prognosis, prevention, and outcomes: Many men with BPH have only minor symptoms and are able to manage their discomfort with lifestyle modifications. A yearly exam is recommended to monitor symptoms and the impact of BPH on daily life.

Alan, R., and A. Carmack. “Benign Prostatic Hyperplasia.” Health Library. EBSCO Publishing, 1 Aug. 2014. Web. 12 Sept. 2014.

Bachmann, Alexander, and Jean J. M. C. H. de la Rosette. Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms in Men. New York: Oxford UP, 2012. Print.

Chapple, Christopher R., John D. McConnell, and Andrea Tubaro. Benign Prostatic Hyperplasia: Current Therapy. Malden: Blackwell, 2000. Print.

Kirby, R. S., and Peter J. Gilling. Fast Facts: Benign Prostatic Hyperplasia. Abingdon: Health, 2011. Digital file.

Rosario, Derek J. P., Scott A. MacDiarmid, and John E. T. Pillinger. Benign Prostatic Hyperplasia. Philadelphia: Elsevier, 2005. Print.

What is traditional healing?

Overview

Traditional healing methods are holistic because they focus on disease prevention and on healing the body, mind, and spirit. In contrast, modern Western medicine treats specific symptoms. Traditional healing methods are used worldwide and have several commonalities: They focus on using what is provided by nature to prevent and heal illness, they believe in the interconnectedness of all living (and sometimes nonliving) things, and they believe that the balance of a person’s energy flow with that of the rest of the universe is crucial to maintaining health.

The use of herbal medicines, music, special diet, meditative states, and healing touch are common to many of the traditional healing practices around the world. While some of these practices have been maintained only in small native communities within their countries of origin, other practices remain in use as complementary and alternative healing practices in Western countries.

Shamanism

Shamanism is considered by Westerners to be an alternative and nontraditional means of practicing medicine; however, it is actually the most traditional form of health care in existence today. Shamanism is a spiritual practice that has existed for tens of thousands of years. Many cultures have abandoned their ancient shamanic practices as the biomedical model has become the gold standard in several areas of the world. Recently, though, there has been a resurgence of interest in the traditional shamanic rituals, treatments, and herbal remedies.

Shamans practice an ancient way of healing that includes using objects from nature and songs, chants, dance, drums and other musical instruments, special items of clothing, spirit guides, and sacred rituals. In comparison with biomedical physicians who attempt to cure a disease, shamans strive to heal the condition. Also, this healing practice is typically more community-centered than personal. Shamans are traditionally highly regarded members of the tribe because of their ability to heal. The effectiveness of shamanic practices is difficult to study without impacting the cultures one is researching. The communities believe that their techniques are effective, and some researchers who have tried shamanic treatments personally have found them to be beneficial. Researchers have expressed concern over the potential loss of shamanic and herbalist knowledge from these cultures.

Traditional Chinese Medicine

Aspects of traditional Chinese medicine (TCM) date back five thousand years. Variations are practiced in South Korea, Japan, and Vietnam. The first known medical text in the world was reportedly written in China by Emperor Huang-Ti in 2697 b.c.e. and focused on the interaction of the “tiny” human being with the immense universe.

TCM does not differentiate between the mind and the body, as does Western medicine, and it includes spiritual and religious elements. Huang-Ti wrote about the principles of yin and yang, which have separate meanings but also are ever-present together. The yin represents blood, spirit, and specific organs such as the heart, liver, and lungs, while the yang represents qi (pronounced “chee”) and organs such as the stomach, intestines, and bladder. A major belief of TCM is that illness results from disruption or blockage of qi, or vital energy, which flows with blood through a network of twelve primary channels called meridians. Blockages are treated with acupuncture, acupressure, manipulative massage, or herbal medicines. Acupuncture has been demonstrated to decrease inflammation. Research to determine the mechanism of this effect is ongoing.

Huang-Ti also wrote about preventive medicine, stating that disease could be avoided by proper diet, regular habits, a proper amount of work and rest, and keeping the mind at peace. Qigong (breath exercise training) and Tai Chi (a focus on breath and specific postures) are practiced for health and for the prevention of disease and are used in hospitals to increase the stamina of patients. For example, people being treated with chemotherapy were found to have fared better when also participating in qigong therapy. They are able to eat more and to better tolerate the side effects of chemotherapy, and they have an increased rate of remission. Daoism, which believes that each person should follow the path intended for him or her by the universe, was promoted by Lao Tzu in the sixth century b.c.e. According to Daoism, one’s youthfulness and longevity depend on one’s behavior toward Dao (“the way”).

Ayurvedic Medicine

Ayurveda (“the science of life”) is a traditional system of medicine practiced in India, Bangladesh, Sri Lanka, Nepal, and Pakistan. As with other traditional healing practices, Ayurveda focuses on the interconnectedness between humans and everything else in the universe. A major belief of Ayurveda is that one will find health if balance with the universe is maintained, while illness results from imbalance. The human constitution (prakriti), or one’s stable state of physical and psychological characteristics, is another important concept in Ayurvedic medicine. Prakriti influences a person’s likelihood of becoming ill as a result of imbalance. Another major Ayurvedic concept is the life forces (doshas): vata, pitta, and kapha. A person may have a dominant type of life force, and imbalances in the life forces are thought to cause illness. Prevention and treatment are tailored to the person’s constitution and dosha. Treatment methods include meditation, stretching and breathing exercises, massage, purging toxins through enema, and tonics of herbs, vitamins, and protein.

Herbal Medicine

Plants or portions of plants (roots, stems, leaves, flowers, seeds) that have been used traditionally for long periods of time for healing and are generally regarded as safe are known as traditional herbal medicines. Shamans often use herbs in their ceremonies or prescribe them after a healing session. For example, a researcher in 2003 found that plants used by curanderos (shamans) in the highlands of Mexico for the treatment of “sweet blood,” or diabetes, could be shown to successfully treat rats and humans with type 2 diabetes. The researcher used a water decoction, the same way the curandero would use it, except that the dose was adjusted for a person’s weight.

Traditional herbal medicine generally involves maintaining the combination of ingredients within a plant or mixture of herbs. Drug manufacturers, however, attempt to harvest the plants to isolate the one or few compounds they believe are “active” in affecting illness. TCM, conversely, usually involves a specific combination of herbs to heal an illness, as Chinese medicine has shown that a blend of herbs offers an enhanced therapeutic effect and a wider range of actions on the patient. Ayurvedic medicine uses more than 600 herbal formulas and about 250 single-plant medicines. The naturally occurring variability in active ingredients in these mixtures makes standardization more difficult when one is attempting to study them scientifically.

Some traditional herbal treatments have been shown effective and safe through controlled clinical trials. For example, ginger root helps in the treatment of nausea. Cases of illness and poisoning have been reported, however, because the wrong plant was used, because of contamination with heavy metals, or because of interactions with other medications or herbs. Precautions to be taken when selecting herbal supplements include being certain that the bottle has a seal on it that states the herb has been tested for heavy metals and other toxic contaminants; using caution when taking herbs with prescription and over-the-counter medications, as some can have dangerous interactions; and notifying one’s medical practitioner about the use of herbs in conjunction with prescription or over-the-counter medications.

Reiki

Reiki is an ancient form of energy healing from Japan, believed to have been “lost” for thousands of years and rediscovered in the nineteenth century by Mikao Usui. Practitioners train and receive “attunements” to reach certain levels of ability, including levels one through three, advanced, and master. There are many schools of Reiki that vary in the methods used. Typically, however, the hands of the practitioner are placed on twelve specific areas of the body (the seven chakras), or from head to toe, and energy is delivered from the source through the practitioner to the client. This method of healing is becoming mainstream, as it is increasingly being offered in many Western hospitals. It is believed to be relatively harmless, and some studies have demonstrated the potential benefits, including decreases in heart rate, blood pressure, levels of depression, and pain. Hematocrit, hemoglobin, and glucose levels in the blood have also been shown to be affected by Reiki treatment. Distance Reiki is also practiced by those with higher levels of training; however, there has been little clinical research regarding this type of treatment.

Conclusions

Scientific evidence for these traditional healing practices is considered lacking in most areas because of poorly designed studies with small sample sizes and because of the issues associated with creating a control condition (particularly a placebo control) that meets Western scientific standards. For example, a placebo for acupuncture is impossible; however, one can study the impact of treatment versus nontreatment. Certain types of traditional healing have been shown to be beneficial and to cause no harm, while others, such as herbal medicines, should be used with caution because of interactions with drugs and because of the possibility that the herbal is contaminated with high levels of heavy metals.

Bibliography

Anhauser, Marcus. “Pharmacists Seek the Solution of a Shaman.” Drug Discovery Today 8 (2003): 868-869. This article describes the scientific study of plant medicines to treat diabetes.

Hammerschlag, Carl Allen. “The Huichol Offering: A Shamanic Healing Journey.” Journal of Religion and Health 48 (2009): 246-258. The author, a psychiatrist who practices shamanism, describes the intersection of science and medicine in the Huichol culture in Central Mexico.

Hou, Joseph P., and Jin Youyu. The Healing Power of Chinese Herbs and Medicinal Recipes. Binghamton, N.Y.: Haworth Press, 2005. An overview of the history of Chinese medicine in general and herbal medicine in particular. Includes chapters on specific herbal treatments and the treatment of specific issues, featuring herbal remedies for specific issues such as pain and fever.

Hyman, Mark. A. “Notes from Nepal: Reflections of a Medical Student on Shamans, Lamas, Serpents, and Fortunes.” Alternative Therapies 12 (2006): 10-18. Journal entries written by the author during a public health project in the 1980s make up this article, which focuses mainly on the Tibetan shamans he encountered.

Ingerman, S. Interview by B. Horrigan. “Medicine for the Earth, Medicine for People.” Alternative Therapies 9 (2003): 77-84. An interview with Ingerman about her expertise on the topic of shamanism.

Kavoussi, Ben, and Ross, B. Evan. “The Neuroimmune Basis of Anti-inflammatory Acupuncture.” Integrative Cancer Therapies 6 (2007): 251-257. This review article describes the literature on basic research into the effects of acupuncture on inflammation.

Lenaerts, Mark. “Substances, Relationships, and the Omnipresence of the Body: An Overview of Asheninka Ethnomedicine (Western Amazonia).” Journal of Ethnobiology and Ethnomedicine 2 (2006): 49-68. This ethnographic report focuses on plant medicine used along the border of Peru and Brazil, using data collected between 1997 and 2000.

Rittner, Sabine. “Sound-Trance-Healing: The Sound Pattern Medicine of the Shipibo in the Amazon Lowlands of Peru.” Music Therapy Today 8 (2007): 196-235. This article discusses field research with the Shipibo tribe about its use of Ayahuasca, songs, and visual structures in healing practices.

Villoldo, Alberto. “Jaguar Medicine.” Alternative Therapies 13 (2007): 14-16. The author details his experiences studying with shamans in South America, using direct observation and quotations from the indigenous peoples.

Vitale, Ann. “An Integrative Review of Reiki Touch Therapy Research.” Holistic Nursing Practice 21 (2007): 167-179. This review article focuses on research studies of the effectiveness and potential for improvement of research on Reiki.

Vuckovic, Nancy H., et al. “Feasibility and Short-Term Outcomes of a Shamanic Treatment for Temporomandibular Joint Disorders.” Alternative Therapies 13 (2007): 18-29. This article describes a clinical trial of shamanic healing for temporomandibular joint disorders, or TMJ.

Why do you think the ancient process of casting bronze is called "lost wax casting"?

"Lost wax" or "cire perdue" casting is one of the oldest ways of creating bronze sculptures, with examples dating to approximately 3700 B.C. having been found in Nahal Mishmar (the Cave of Treasure) in Palestine. This technique was also practiced in the Indus Valley culture, with examples from ca. 3500 BC having been found in Mohenjodaro and Harappa. The technique was also commonly used in ancient Egypt and in Graeco-Roman antiquity. 

Metal is difficult to shape with the traditional instruments used for sculpture in other materials such as wood or stone, especially using Bronze Age tools. The point of using the lost wax technique was that it enabled sculptors to create a model statue in a different material and then use that original to make a mold with which to cast a bronze sculpture. The technique allows the casting of a bronze sculpture with a bronze layer of the desired thickness rather than made of solid bronze.

First, the artist creates a rigid outer mold and then a layer of wax of the desired thickness of the bronze on the inner side of the mold, which in turn fits precisely around the model. Thin tubes run from the wax layer to the outside of the outer shell. Molten bronze is poured in, liquifying the wax which runs out or is "lost" in the process, and is replaced by bronze.

What does "binary oppositions" mean in the context of Romeo and Juliet? What are examples of binary oppositions in the play?

A key theme of Romeo and Juliet (and of Shakespeare's work in general, I might argue) is that "binary oppositions"--the ideological construction of two narrowly defined objects as absolute and antithetical alternatives to one another--is too simplistic and confining a framework to encompass the complexity, messiness, and variety of human emotions - of which love is of course among the most varied, messy, and complex. The most obvious "binary" in the play is of course the ancestral feud between the Capulet and Montague families. Shakespeare makes it clear from the beginning that this conflict is pure folly, something false and artificial that starves and hedges in the freedom and mutability of the human spirit. The affection that flowers so briefly between Romeo and Juliet is something that exists outside and beyond such restrictive structures of diametric oppositions. One of Shakespeare's profundities in this play is to understand that the boundaries and polarities erected and observed by elders are often invisible to the naive wisdom of children. Hence Juliet, the play's youngest character, is also (with the explosive Mercutio, whose very name evokes the Roman god of travel, communication, and transition) the one with the most uncontainable verbal imagination. Her words often express a blurring of opposed categories; when Romeo kills Tybalt, she says of him "My only love sprung from my only hate!" In one of my favorite scenes, she playfully muddies the distinction between night and day, in order to bid Romeo (who has heard the cry of the lark, signaling the dawn) to remain by her side: "Wilt thou be gone? It is not yet near day. / It was the nightingale, and not the lark, / That pierced the fearful hollow of thine ear." In the balcony scene she utters perhaps her most amazing and gorgeous paradox: "And yet I wish but for the thing I have. / My bounty is as boundless as the sea, / My love as deep. The more I give to thee, / The more I have, for both are infinite." The overflowing mystery and sensuousness of human passion transcends the tyrannical certitude of binary distinctions.

Shakespeare also explores this concept on the level of genre. Romeo and Juliet is a tragedy, but until the death of Mercutio it very closely resembles a Shakespearean comedy; this creates in us an awareness of the fallibility of generic distinctions, the fact that tragedy lurks, as a perpetual possibility, within all comedy. Shakespeare's imagination, like Juliet's, is too mobile, too eloquent, too sensitive to human possibility, to be bounded within such artificial categories as comedy and tragedy, or Montague and Capulet. Shakespeare is always creating and thinking in the open, uncertain spaces between ostensible opposites. Hamlet says "To be or not to be." Iago and Viola both say "I am not what I am."* Macbeth says "Nothing is but what is not." Juliet, in the tragic culmination of this play, comes to embody these epigrammatic formulations, by defying the most inviolate and fundamental of all binary oppositions: when she takes Friar Laurence's sleeping draught to be buried in the Capulet crypt, she blurs the boundary of life and death itself.

But this play is a tragedy, in the end, and such visionary, mystic mobility cannot be allowed to endure in the cruelly binary world of adults--so that Juliet's indeterminate state is ultimately collapsed and reduced; her mimicry of death becomes the real thing, confining her, with the destruction of her love, into the most immutable and definite of all human states. The tragedy of Romeo and Juliet isn't just the brief and ill-fated love affair of two very young people, but a vision of how absolutism and binary thinking murder possibility and passion in the world.

*Viola is specifically referring to the fact that she is a woman dressed in a man's clothing; gender-bending is a recurrent theme in Shakespeare, and the word "non-binary" is rapidly gaining currency in contemporary language to refer to gender identities which are not exclusively male or female.

What is the foreshadowing in "The Masque of the Red Death"?

The long list of precautions taken by the prince and his thousand healthy and carefree friends, immediately following the description of how deadly and awful the Red Death is, seems to foreshadow the uselessness of such precautions.  The abbey to which they retire is geographically isolated, far away from where the disease rages; it is surrounded by a strong and tall wall; it has gates made of iron; Prince Prospero's guests plan to weld the bolts shut so that the gates cannot even be opened; the abbey has been stocked with anything and everything they could possibly want while there; and, most damning of all is their resolution "to leave means neither of ingress nor egress to the sudden impulses of despair or of frenzy from within."  They have determined to leave no way in and no way out of the castle.  On the one hand, this might seem positive since no one with the disease could push their way in; on the other hand, however, no one will be able to escape the castle should danger arise.

Furthermore, the dread that the courtiers seem to feel every time the ebony clock strikes, but especially when it chimes for midnight, foreshadows their ultimate demise.  When they hear those chimes, "for a moment, all is still, and all is silent save the voice of the clock.  The [masqueraders] are stiff-frozen as they stand.  But the echoes of the chime die away -- they have endured but an instant -- and a light, half-subdued laughter floats after them as they depart."  Clocks are often associated with mortality (as it keeps track of time), as is midnight (since it is the death of day) and the color black (often symbolic of mystery and/or death.  When this terrible black clock announces the death of day, it seems as though the courtiers cannot help but be reminded of their own mortality, foreshadowing their coming end.

Explain the meaning and irony behind Puck's statement: "Lord, what fools these mortals be!"

Puck calling mortals fools is ironic because he is the one causing them to act foolish and because the fairies Titania and Oberon also act very foolish.

There are a couple of reasons that Pucks’s condemnation of mortals is ironic.  First of all, he is the one causing a lot of the foolishness.  The people he is anointing cannot control their behavior.  It is a result of a magic spell. So Puck is laughing at people for acting just the way he is forcing them to act.

PUCK

Then will two at once woo one;
That must needs be sport alone;
And those things do best please me
That befal preposterously. (Act 3, Scene 2)

However, the other aspect of the people being fools has nothing to do with magic.  Love makes people do foolish things, as the play demonstrates.  The irony is that the mortals are not the only ones acting foolish.  Titania and Oberon certainly engage in their share of foolish behavior.  They fight and make up, and they drag the whole forest into their mayhem.

Titania and Oberon fight over their jealousies.  Oberon is jealous about the changeling Titania has. He is also jealous because he thinks she has something for Theseus and Titania is jealous because she thinks he has something for Hippolyta .

TITANIA

These are the forgeries of jealousy:
And never, since the middle summer's spring,
Met we on hill, in dale, forest or mead,
By paved fountain or by rushy brook,
Or in the beached margent of the sea,
To dance our ringlets to the whistling wind,
But with thy brawls thou hast disturb'd our sport. (Act 2, Scene 1)

Titania’s mood is not good for the forest.  I would consider her behavior foolish, and Oberon’s too.  They both kept pushing each other’s buttons, even though as fairy king and queen their behavior affected the entire forest.

In the end, foolishness abounds in this play for both mortals and fairies.  Magic or not, people in love sometimes act in ways that make no sense.  Jealousy can hit anyone, mortal or not.

Why do Oliver and the Duchess need each other in "The Duchess and the Jeweller"?

The Duchess of Lambourne needs Oliver to provide her with the money to pay her gambling debt, and Oliver needs her to provide him the opportunity to court her daughter Diana because he is not royalty.

As the story opens, Oliver Bacon seems to have all that he desires as he opens invitations from prestigious people: "duchesses, countesses, viscountesses, and Honorable Ladies." He is the richest jeweler in all of England. He stands before a portrait of his mother, telling her "I have won my bet." However, he is yet

...a dissatisfied man, a man who seeks something that is hidden, though he had won his bet.

When the Duchess of Lambourne appears at his shop, Bacon purposely makes her wait ten minutes. Nevertheless, the Duchess understands that she has power over the commodity that he desires. She pulls from her bag a leather pouch that contains pearls, pearls she says are from the Appleby cincture, an ornamental belt. Oliver is tempted to have them tested; then he stops. "Arminta, Daphne, Diana," she moaned. "It's for them."

"Diana"--the name of the beauty he desires, the "commodity." Oliver imagines himself in a white waistcoat with the Prime Minister, at a dinner of trout and other delicacies. Then, he pictures a ride in the woods alone with Diana. So, he decides not to verify the pearl's quality; instead, he writes a check in the amount of twenty thousand pounds for the pearls.

They were friends, yet enemies; he was master, she was mistress; each cheated the other, each needed the other, each feared the other...

Oliver feels no real sense of achievement because he and the Duchess have measured everything as a commodity. 

`int tan^2(x) sec(x) dx` Evaluate the integral

`inttan^2(x)sec(x)dx`

use the identity:`tan^2(x)=sec^2(x)-1`

`inttan^2(x)sec(x)dx=int(sec^2(x)-1)sec(x)dx`

`=int(sec^3(x)-sec(x))dx` 

Now apply the Integral Reduction:`intsec^n(x)dx=(sec^(n-1)(x)sin(x))/(n-1)+(n-2)/(n-1)intsec^(n-2)(x)dx`

`intsec^3(x)dx=(sec^2(x)sin(x))/2+1/2intsec(x)dx` 

Use the common integral:`intsec(x)dx=ln(tan(x)+sec(x))`

`:.inttan^2(x)sec(x)dx=(sec^2(x)sin(x))/2+1/2intsec(x)dx-intsec(x)dx`

`=(sec^2(x)sin(x))/2-1/2intsec(x)dx`

`=(sec^2(x)sin(x))/2-1/2ln(tan(x)+sec(x))`

add a constant C to the solution,

`=(sec^2(x)sin(x))/2-1/2ln(tan(x)+sec(x))+C`

What did Genesis mean to its most ancient audience? What did Genesis tell its ancient readers?

This is a huge question, but I will rely on the work of theologian Walter Brueggemann in his book Genesis: Interpretation: A Bible Commentary for Teaching and Preaching, which focuses on preaching Genesis within a modern context but also provides an account of how ancient Israelite theologians structured Genesis to reflect their own worldview.

Genesis, which was actually one of the later books of the Old Testament to be composed, contains a creation myth that explains the ancient Israelite view of the universe. Unlike other Near East creation narratives, Genesis focused on the idea that creation is good in and of itself. This concept is central to ancient Jewish thought: the material world is not some evil or some illusion that we need to rid ourselves of to attain connection with the godhead, but is a reflection of God and his goodness. Likewise, humans, as part of God's creation, are good. As Brueggemann puts it: "The world has been positively valued by God for itself" (13). Humans, therefore, are to value creation. This differs from, for example, a Platonist notion that sees the world as a shadow of an eternal perfection existing outside of the world.  

Genesis, reflecting ancient Israelite theology, states that God had a will and purpose for creation and that creation only exists for the sake of God's purpose. Creation is of God and for God. The Israelites, says Brueggemann, had a "new thought," a fresh intellectual exercise, that included mythology—a creation story—but still allowed humans a place in shaping the ongoing story of creation. Creator and creation interact. The creator speaks to its creation: "Language is decisive for the being of the world" (18). Further, God's call on creation is a command, but it is also "evocative" rather than "coercive" (18). As we see in the stories told in Genesis, humans can and do deny God's call.

A second important feature of Genesis to ancient Israelites was in its emphasis on covenants. God makes a specific call to Abraham and Sarah in history, wanting them to enter into a community with him and create Israel, a society that is "to fashion an alternative community in [a] creation gone awry" (105). Through his covenant with Israel, God, who is the same God who created the world, will use Israel to redeem the world and bring it back in alignment with his will. God enters into a covenant (mutual obligation) with Abraham and Sarah because they are receptive to his will and his promises (106). They will obey him and he will bless them and their descendants. The ancient Israelites expected to obey but also to be rewarded for their obedience.

In sum, ancient Israelite theologians in Genesis affirmed that God created the world, that material creation was good, that God created the world for a purpose and was involved in his creation through speaking to his creatures, that his creatures were expected but not forced to obey him, and  that God entered into a covenant relationship with Abraham and his descendants so they would be God's chosen people to redeem the world.

How does colonization change Nwoye in Things Fall Apart?

In Chinua Achebe's novel Things Fall Apart, Nwoye is the son of the protagonist Okonkwo. Nwoye initially idolizes his father, who is perceived as the height of Igbo masculinity. This idolatry is compounded by the fact that Okonkwo is extremely derisive of Nwoye, dismissing him as weak and effeminate. Okonkwo's violent rejection of Nwoye makes Nwoye simply love him more and work harder for his approval. 

This relationship is undermined by Okonkwo's role in the death of Ikemefuna, his adoptive son. Unlike Nwoye, Ikemefuna was developing into a promising young man, and he and Nwoye became very close. Okonkwo himself remarks on the positive effects that Ikemefuna has on Nwoye's masculine development. 

With Ikemefuna's death, Nwoye is sent reeling without either role model. He cannot model his own growth on Ikemefuna's, and so retreats into his status as an outlier of Igbo society. He also can no longer truly model himself after his father, whose actions he finds so deplorable. 

As such, with the arrival of the missionaries and European colonization, Nwoye takes advantage of an opportunity to belong to a community. He fully embraces Christianity, a society in which many of his characteristics, perceived as weaknesses by the Igbo, are strengths. He goes so far as to change his name, reject his culture, and leave his home. As strongly as Okonkwo fights against colonization, Nwoye embraces it. 

Why might the audience feel disgusted by Macbeth's behavior throughout Shakespeare's play Macbeth?

Although Macbeth is an intelligent man who seems to have upheld the morals of society up to this point in his life, the advent of the three witches’ prophecy that Macbeth will be king sets him on a morally downward spiral. Macbeth's gut reaction upon hearing the prophecy that he will be promoted to Thane of Cawdor and then become king is to justify to himself that this is not a bad thing.  As soon as Macbeth greets King Duncan in Act I, Scene 4, he fawns over the king, speaking of “The service and the loyalty I owe / ...by doing every thing / Safe toward your love and honor.”  In his heart, however, Macbeth vows to keep his “black desires” hidden. This takes “two-faced” to a whole new level.

To his credit, once the king is at Macbeth’s castle in Act I, Scene 7, Macbeth decides not to harm him.  After all, Macbeth reasons, the king is his cousin and trusts Macbeth as one of his thanes and military leaders. Macbeth feels Duncan has been a truly good king and, if he were murdered, all of Scotland and Heaven’s angels would mourn. The minute Lady Macbeth calls Macbeth “a coward in thine own esteem” for refusing to shed blood to become king, Macbeth caves and lets her manipulate him into committing bloody treason.

Although Macbeth's conscience haunts him, he stabs King Duncan in his sleep and lets his wife cover up the murder.  After this, Macbeth’s conscience seems to fade quickly.  Enjoying the power of kingship, his main concern is his competition—Banquo and his son Fleance—since the witches prophesy that the sons of Banquo are to be kings, not Macbeth’s.  In Act III, Scene 1, now-King Macbeth questions Banquo about his afternoon riding plans with Fleance, even telling his friend, “I wish you well on your journey.” Macbeth then sends three hired assassins to murder them.  That night at the banquet, knowing full well he’s had Banquo murdered, Macbeth says to his guests, “I drink to the joy of .../ our dear friend Banquo.../ I wish he was here.”  What a duplicitous hypocrite!  It is disgusting that murder has become Macbeth’s go-to option for any obstacle to his power.

Perhaps as expected, Macbeth and Lady Macbeth become rather distant from each other.  When his chief servant Seyton reports to Macbeth in Act V, Scene 5 that Lady Macbeth is dead, Macbeth's appalling response is that his wife should have died at a more convenient time.  Although Macbeth initially has some redeeming qualities, he systematically rejects each one. When Macduff produces Macbeth's severed head, the audience hardly mourns at all.

How can firms and governments use price elasticity of demand (PED) when making decisions?

The use of economic theory in decision-making by firms and governments is very important. Its use ensures that firms choose the quantities of goods they produce and their selling price (in the case of firms operating in imperfect competition) at a level where the profit earned is maximized.

Similarly, its use ensures that the benefits of government policies such as price controls (price floors and price ceilings) are greater than the deadweight loss experienced by the economy.

Price elasticity of demand (PED) measures the level of responsiveness of the demand for a good when there is a 1-percent change in the price of the good. When PED is less than 1, demand is inelastic. PED greater than 1 indicates that demand is elastic, and PED equal to 1 is unitary.

PED and The Firm

a) When demand is elastic, firms should choose to reduce their selling prices in order to increase their profits. This is because elastic demand is very sensitive to price changes, and according to the demand theory demand increases as price decreases. Therefore, the price reduction would be outweighed by the rise in demand, so the firm would earn increased revenue. Products with an elastic demand include luxury items, movie tickets, beverages, and food items.

b) In contrast, when demand is inelastic, firms should choose to increase their selling prices in order to increase their profits. This is because inelastic demand is not very sensitive to price changes, as such demand would decrease (due to the demand theory), but only slightly. Therefore, the price increase would outweigh the slight decrease in demand, so the firm would earn increased revenue. Products with an inelastic demand include most medications.

c) In the case of unitary demand, any price change is met with a proportional change in demand. Simply, the percentage changes in both price and demand are equal. 

PED and Governments

In some markets, such as farming and real estate, government enforces price controls. Such controls may result in excess demand or excess supply; however, the government can prevent these excesses with the use of PED knowledge.

d) When demand is inelastic, the government should set a price floor (the minimum price at which a good can be sold). This would cause firms operating in this market to increase their offering price above the original equilibrium price, which is similar to the firms' action mentioned above in part b.

e) When demand is elastic, the government should set a price ceiling (the maximum price at which a good can be sold). This would cause firms operating in this market to offer a reduced price that is below the original equilibrium price, which is similar to the firms' action in part a.

What are colonoscopies and virtual colonoscopies?

Cancers diagnosed: Cancers of the large intestine and rectum, precancerous adenomas, polyps

Why performed: These procedures are intended for the prevention and early detection of colon cancer for people over the age of fifty, or earlier when indicated. They are also a necessary component in the management of inflammatory bowel diseases (Crohn's disease and ulcerative colitis) or for individuals who have a family history of polyps or diseases of the large intestine. As of 2014, the American Cancer Society advises everyone at average risk of colorectal cancer to have a traditional colonoscopy procedure performed every ten years; a virtual colonoscopy should be performed every five years.

Many patients resist the procedure as a result of embarrassment and/or concern over the bowel preparation, which is the same for both traditional and virtual colonoscopy. Neither procedure replaces the need for yearly testing for blood in the feces with a fecal occult blood test (FOBT) or a fecal immunochemical test (FIT). There are several considerations in deciding on the appropriate procedure. Patients should discuss family history of any bowel disease, increasing age, existing medical problems, and other personal issues with a physician when deciding the most appropriate procedure. Both forms of colonoscopy are considered the most thorough and accurate in examining the entire large intestine, but there are differences in how they are performed and what happens if a test is abnormal.

Patient preparation: Patients should not stop taking any medications (such as insulin, aspirin, or blood thinners) to prepare for a colonoscopy unless approved by their physicians. Three days before either procedure, the patient should stop eating a high-fiber diet or taking fiber supplements and iron-containing vitamins or iron tablets. The day before the procedure, all three meals should consist only of clear liquids, such as tea, broth, gelatin, clear juices, tea, or coffee.

The doctor will provide bowel preparation information and laxatives, either tablets or liquid, to take the day before the procedure and possibly again four hours before the procedure. The large intestine must be completely empty and free of all fecal matter in order to clearly see any abnormal growths or changes in the wall of the intestine. The patient may not eat or drink anything after midnight before the procedure unless it is water to take approved medication.

Steps of the procedure: Traditional colonoscopy is usually performed in an outpatient surgery suite. Patients are moderately sedated and given pain medication through an intravenous catheter. It is common for patients to sleep through the procedure, which can take thirty to sixty minutes.

The patient lies on the left side, and a colonoscope is inserted through the anus and rectum. The doctor watches a video screen as the tube is guided through the large intestine. Examination includes visualization during slow withdrawal of the tube, as some growths can be hidden in folds in the intestine. The gastroenterologist is looking at the actual lining of the intestine, not a computerized image.

The following can be done during this procedure: removal of polyps, sampling of abnormal tissue (biopsy), removal of small growths, stopping of small areas of bleeding, laser treatment of abnormal tissue or growths, and the introduction of certain medicines.

Virtual colonoscopy is performed by a radiologist in a radiology suite. No sedation is necessary. The patient is asked to lie on the back on a table. A thin tube is inserted into the rectum introducing air to inflate the large intestine for better visualization. The table passes through the scanner as three-dimensional computerized images of the large intestine are made and immediately viewed on a video screen. The patient is instructed to periodically hold the breath to be sure that the images taken are clear. The procedure is repeated with the patient lying on the stomach and is completed in ten to fifteen minutes.

Identification of anything abnormal might require traditional colonoscopy. Repeat bowel preparation will be necessary if the procedure cannot be performed the same day.

After the procedure: The patient will need to be driven home after traditional colonoscopy, as the sedation used during the procedure makes it unsafe to drive. It can take one to two hours after traditional colonoscopy for the patient to be alert enough to be driven home. There can be some abdominal cramping and feelings of gas. Normal activities can be resumed the following day.

Virtual colonoscopy does not require medication, and patients are free to leave immediately after the procedure. Some cramping might occur following virtual colonoscopy because of the introduction of air during the procedure.

Risks: Perforation and/or infection of the large intestine, while very uncommon, is a possible complication from traditional colonoscopy. The doctor will provide an information sheet that describes what is normal and not normal following colonoscopy. Symptoms that should indicate calling the doctor include bloody diarrhea, blood coming from the rectum, dizziness, fever, severe abdominal pain, and weakness. There is radiation exposure with virtual colonoscopy.

Results: Both procedures are considered the most thorough in examining the entire large intestine. Traditional colonoscopy is better at finding growths smaller than 10 mm and has the advantage of permitting biopsies of abnormal growths, removal of polyps, treatment of inflammation or disease, and laser treatment during the examination. Virtual colonoscopy is a much newer procedure and has been widely embraced by those who are fearful of traditional colonoscopy. Traditional colonoscopy is required following virtual colonoscopy if any abnormalities are found. Some studies have found that certain abnormalities on virtual colonoscopy were normal when traditional colonoscopy followed. Studies continue comparing the benefits and drawbacks of each procedure.

"American Cancer Society Recommendations for Colorectal Cancer Early Detection." American Cancer Society. Amer. Cancer Soc., 31 Jan. 2014. Web. 11 Sept. 2014.

Cotterchio, Michelle, et al. “Colorectal Screening Is Associated with Reduced Colorectal Cancer Risk: A Case-Control Study Within the Population-Based Ontario Familial Colorectal Cancer Registry.” Cancer Causes & Control 16.7 (2005): 865–75. Print.

Kahi, Charles J., ed. Gastroenterology Clinics of North America: Colonoscopy and Polypectomy 42.3 (2013): 429–700. Print.

Waye, Jerome D., et al, eds. Colonoscopy: Principles and Practice. 2nd ed. Malden: Wiley, 2009. Print.

Waye, Jerome D., et al. Practical Colonoscopy. Malden: Wiley, 2013. Print.

Yee, Judy. Virtual Colonoscopy. Philadelphia: Lippincott, 2008. Print.

Zauber, Ann G., et al. "Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths." New England Journal of Medicine 366.8 (2012): 687–96. Print.

How does Arthur Conan Doyle present Irene Adler in "A Scandal in Bohemia"?

In "A Scandal in Bohemia," Doyle presents Irene as a mysterious character who is very different from other women:

To Sherlock Holmes, she is always the woman…In his eyes she eclipses and predominates the whole of her sex.

This quote also suggests that she exerts a powerful influence over the men in her life and this power derives from a combination of her wit and beauty. The King of Bohemia, for example, says that "she has the face of the most beautiful of women," while Sherlock calls her "the daintiest thing under a bonnet." But her wit is, perhaps, her most striking feature because she is able to outwit both the King of Bohemia and Sherlock himself. In a clever twist, she uses some of Sherlock's own methods to achieve this, notably the use of disguise, as we learn from her letter:

But, you know, I have been trained as an actress myself. Male costume is nothing new to me. I often take advantage of the freedom which it gives.

Part of Irene's appeal is her ability to act outside the boundaries of accepted gender roles. On the surface, she acts like any other woman, as Sherlock comments:

She lives quietly, sings at concerts, drives out at five every day, and returns at seven sharp for dinner.

But, below this ordinary exterior lies a power which makes Sherlock completely rethink his ideas about women, as Watson comments in the closing lines:

He used to make merry over the cleverness of women, but I have not heard him do it of late. 

What is the summary of "Tobermory" by Saki?

"Tobermory" is a half-comical, half-sinister story published in 1911 in the Chronicles of Clovis. It is, primarily, the story of an incident concerning a cat named Tobermory, who has the curious ability of being able to speak perfect English. 

The story is set at the country estate of Lady Blemley, where guests gathered and met Cornelius Appis, a man who had also been staying at the estate and claims that he taught the family cat, Tobermory, how to speak like humans.

Upon bringing out the cat, the guests begin to ask it questions, which he answers quite arrogantly. He is not only a smart-mouth, but he has no filter when he speaks, as he starts to tell information about the guests, which he had been observing as a casual passer-by of the household, the way cats tend to do. 

Noticing how dangerous the cat and his knowledge of their private goings-on is, the guests start feeling uneasy and plot to poison the cat at some point. Meanwhile, Tobermory is still a feline with animal instincts. He continues to behave and react like a cat in other aspects, especially when it comes to his penchant to chase and fight with his rival, the other neighborhood tomcat. 

When Tobermory notices the presence of the other cat, he runs after it and they get in a deadly fight that leaves Tobermory dead. Upon discovering his body, Lady Blemley writes an angry letter to the Rectory because it was that cat who killed Tobermory. At the end of the story, it is discovered that Appis was killed by an elephant in Dresden, Germany, as he tried to teach the animal how to talk.

How is lipstick produced?

Lipstick is composed of wax, oil, moisturizer and pigment. The exact recipe varies from manufacturer to manufacturer. However, a mixture of several different types of waxes is normally used, including beeswax, carnauba wax and paraffin. The ratio of the ingredients is carefully formulated so that the lipstick has a high enough melting point so it won't melt on hot days. 

First, the various ingredients are measured and added to a mixer. Heat is applied and the ingredients are mixed until a uniform consistency is achieved. The molten mixture is then transferred into molds in the shape of the individual sticks. The molds are cooled until the mixture solidifies. The sticks are then removed from the molds and placed inside plastic lipstick containers. 

Animal Farm: Why was comrade Napoleon "dying"? What really happened? Was this surprising? Why?

Just after the Battle of the Windmill, Napoleon gives himself a medal. Even though the battle had been a defeat, with the windmill destroyed, several animals killed and Boxer severely wounded, the pigs make out as if it was actually a victory. Not many days after the battle the pigs discover a case of whiskey in the cellar of the farmhouse. That night riotous singing goes on in the farmhouse among the pigs, but the next morning Squealer tells the animals that Napoleon is dying.

In reality, Napoleon suffers from a hangover after a drunken night during which he even donned one of Farmer Jones's hats and ran around the farm yard. Not surprisingly, he has become just like the farmer. He lives in his house, the pigs start to wear ribbons in their tails (two commandments broken), and Napoleon even sells Boxer to the glue factory. Not long after the sale, the pigs again have procured a case of whiskey. The plight of the animals is basically the same as it was under Jones. They work harder for less, with rations continually cut, despite the fact that the farm is successful and the pigs seem to be living better than ever.  

Does Kino choose his destiny or his fate, and how does this fate affect his life in The Pearl?

It would seem that Kino does choose his fate. For, after the pearl dealers offer him far less than the Pearl of the World is worth, he refuses when Juana urges him to crush the pearl between two stones and cast it from his mind. 

When Kino refuses to destroy the pearl, he tells his Juana,

"I will fight this thing. I will win over it. We will have our chance...No one shall take our good fortune from us....I am a man."

This choice changes the lives of Kino and his family as from then on there is a reversal of fortune. On the night after Kino has gone to the pearl dealers, Juana sneaks outside and discovers the great pearl in the brush on the path behind a large rock. Kneeling, Juana ponders whether to take it and throw it into the sea, but as she does so, the moon reappears from behind a cloud, revealing "two dark figures" who are lying on the path just ahead of her. Juana leaps to her feet and discovers Kino over a stranger who is bleeding. Seeing this dead man, Juana knows that "the old life was gone." Kino believes his pearl has been stolen, but Juana returns it to him.

Now, they must flee their home. So, they head to the Sierra de la Giganta, hoping to go to Lorento, a town to the north, but trackers eventually find their trail. Kino and his family hide in a cave; in the night, Kino ventures out and sees a match flare down on the beach. Three men are there; two are asleep while one watches with a rifle. Kino sneaks down the rocks to try to grab the rifle away from the one holding it. But, as fate would have it, his baby cries out just as Kino is in midleap, and the man shoots because he thinks he hears a coyote. Coyotito (whose name is ironically similar) is shot in the head by this random bullet of fate. Kino lands on the man too late as he hears the "cry of death" from Juana.

Defeated by fate, Kino and Juana return to their home; they walk to the beach, and Kino pulls the pearl from his clothes. As he looks down at the pearl, it seems malignant and grey and distorted because in it he sees his dead baby and the tragedy of their lives. Drawing back his arm, he flings the pearl as far as he can into the sea.

  

What are blood cancers?

Risk factors: The risk factors and causes of many types of blood cancers are not well known, and most cases of blood cancer occur in individuals with no identifiable risk factors. However, for AML, which along with CLL is among the most common types of blood cancer seen in adults, these specific risk factors have been found: Down syndrome and other genetic disorders, chronic exposure to ionizing radiation and chemicals such as benzene in the workplace, high doses of radiation therapy and chemotherapy to treat lymphoma or other types of cancer, and tobacco smoke. Those who are immunocompromised by certain bacteria or human retroviruses, such as the Epstein-Barr virus (EBV), human immunodeficiency virus (HIV), or human T-cell leukemia virus (HTLV), are at greater risk of developing lymphomas. Familial clustering also has been associated with the development of lymphomas.

Etiology and the disease process: Cancer develops as a result of a variety of factors and over a number of years. Blood cancers differ widely by group and within each subtype in their progression, causes, and molecular presentation. The leukemias begin in two types of white blood cells: neutrophils and monocytes, which are germ-ingesting cells, and lymphocytes, which are immune-defense cells. Abnormal white blood cells in the bone marrow multiply and enter the bloodstream, crowding out normal cells. Lymphomas develop when these immune-defense cells multiply and cause tumors in the lymph nodes or other parts of the immune system. Development of blood cells through the hematopoietic process is arrested, and abnormal blood cells proliferate. Every stage of hematopoietic development can result in a particular type of cancer. Non-Hodgkin lymphoma (NHL) is manifested by well-differentiated cells with slow progression, while other forms are more aggressive with lymphocytes of limited differentiation. Tumors of the bone marrow are characteristic of myelomas. In myeloma, cells that are to become immune cells develop in the bone marrow from stem cells, as do all blood cells. B lymphocytes, which are a type of white blood cell that typically develop into plasma cells, undergo multiple genetic changes as they change into plasma cells, causing malignant plasma cells to develop. These myeloma cells travel throughout the bloodstream, reside in the bone marrow, and damage healthy tissue. The myeloma interferes with the plasma cell’s production of protective proteins called immunoglobulins or antibodies by producing M proteins or abnormal immunoglobulin, making those affected susceptible to infection.

Incidence: As reported by the Leukemia & Lymphoma Society (LLS) in April 2014, the most common forms of leukemia seen in adults are chronic lymphocytic leukemia (CLL) and acute myelogenous leukemia (AML). The most common form in children and young adults is acute lymphocytic leukemia (ALL), accounting for 74 percent of new leukemia cases in the under-twenty population in 2010. The average median age at diagnosis for leukemia was sixty-six, with incidences of CLL and AML beginning to increase significantly at age fifty and older and incidences of chronic myelogenous leukemia (CML) increasing significantly above age sixty-five. Between 2006 and 2010, the age-adjusted incidence rate for leukemia was 12.8 per 100,000 men and women per year. In the United States in 2014, new cases of ALL were estimated to number 6,020; new cases of AML, 18,860; CLL, 15,720; and CML, 5,980. Overall, chronic leukemias accounted for an estimated 6 percent more cases than acute leukemias. Incidence rates for all types of leukemia are higher among men than women and higher among those of African descent than those of European descent.

The LLS reported that an estimated 79,990 cases of lymphoma would be diagnosed in the United States in 2014. The majority of these cases (70,800) were projected to be of the non-Hodgkin type. Incidence rates of both Hodgkin and non-Hodgkin lymphoma tend to be higher for men than women; between 2006 and 2010, the incidence among men was 3.2 per 100,000 for Hodgkin lymphoma and 23.9 per 100,000 for non-Hodgkin lymphoma, while incidence rates among women were 2.4 per 100,000 and 16.4 per 100,000, respectively. New cases of Hodgkin lymphoma peak in young adults between ages twenty and twenty-four, decrease throughout middle age, then begin to increase again after age sixty, while incidence rates of non-Hodgkin lymphoma remain low until age fifty and above. Non-Hodgkin lymphoma is the sixth most common cause of cancer deaths among men and the seventh most common among women.

It was estimated that 24,050 new cases of myeloma would be diagnosed in the United States in 2014. The LLS reported that between 2006 and 2010, the median age for diagnosis of myeloma was sixty-nine, with the highest incidence rates—39.7 per 100,000—occurring between ages eighty and eighty-four. The incidence rate of myeloma is higher for men than women across racial and ethnic groups: 7.5 per 100,000 among men, compared to 4.8 per 100,000 among women.

Symptoms: Signs and symptoms of blood cancers vary widely and may be similar to those of other, less severe illnesses. Symptoms vary based on the category and subtype of blood cancer; for example, symptoms of acute leukemia may include pallor, shortness of breath with exertion, lack of energy, night sweats or a mild fever, slow healing of cuts and bruises, unexplained weight loss, tiny red spots under the skin, bone and joint aches and pains, and low white blood cell count (especially neutrophils and monocytes). Although specific bone marrow and blood tests are needed to diagnose any type of blood cancer, some of those affected with certain subtypes of leukemia may have enlarged lymph nodes in the neck, groin, or armpit, and they may suffer from frequent infections.

Often individuals who have Hodgkin disease or non-Hodgkin lymphoma experience painless, swollen lymph nodes, loss of appetite, vomiting, bloating, abdominal pain, fullness (due to enlargement of the liver, spleen, or abdominal lymph nodes), pain in the lower back, bone pain, constant coughing, and unexplained lethargy.

Early symptoms of myeloma are bone pain, particularly with movement, and infections involving the skin, the urinary tract, the bronchial tract, or lungs. These symptoms may also be accompanied by pallor resulting from anemia, weakness, and exaggerated fatigue.

Screening and diagnosis: Blood tests and specific bone marrow tests are needed to diagnose blood cancer; however, individuals in early stages of the disease may not have symptoms suggesting cancer. Current evidence does not suggest that routine blood screening before the onset of symptoms will detect cases of blood cancer and lead to improved medical outcomes or be cost effective in those at average risk of developing cancer according to their medical, family, and occupational history. The first indication that a person has blood cancer may be the results of a blood test performed as part of an annual physical. The blood sample may reveal anemia or changes in white blood cells, a possible indicator of leukemia. If an individual has symptoms that suggest blood cancer, the physician will take a medical history and check for swelling of the liver, spleen, or lymph nodes in the armpits, groin, or neck. Urinalysis will also be performed to detect substances or cellular material in the urine. Other tests include a blood test to assess blood cell count, a cytogenetic exam to analyze the number and shape of chromosomes to check for genetic abnormalities, and bone marrow aspiration and biopsy to check for cancerous cells in liquid bone marrow or the bone specimen. If cancerous cells are present, additional tests may be ordered to ascertain if the disease has spread and to organs or systems. These tests may include tumor marker tests (immunophenotyping, based on the type of antigen or marker on the surface of the cell), a spinal tap or lumbar puncture to obtain a sample of cerebrospinal fluid, chest x-rays to look for signs of infection or lymph-node involvement, or ultrasound scans.

Staging is used to assess the extent or severity of the disease, to plan treatment, and to predict the outcome or prognosis. Classification of each type of blood cancer into stages is based on the site that is affected, the progression of the disease, and the appearance of the affected cells. For example, CLL is staged according to the risk-based Rai classification system, using symptoms such as blood lymphocyte count, presence of enlarged lymph nodes or organs, platelet count, and anemia. Other forms of leukemia, such as acute leukemia, are not staged because of acute onset, which typically means the cancer has spread to other organs at the time of diagnosis.

Although leukemic cancerous cells circulate in the blood and bone marrow, in lymphomas cells form tumors in lymphatic tissue. The Ann Arbor staging system is used for both Hodgkin disease and non-Hodgkin lymphomas on the basis of specificity of site of lymph-node involvement. The TNM (tumor/lymph node/metastasis) system may be used to stage the size of a tumor, lymph-node involvement, and existence or extent of spread through other parts of the body. The International Staging System (ISS) is used for staging multiple myelomas based on blood tests for two proteins, albumin and beta-microglobulin, which are markers for the disease.

Treatment and therapy: Blood cancers are typically treated with one or more of the following: chemotherapy, radiation therapy, stem-cell transplantation, and immunotherapy. The goal of chemotherapy, drugs given in combination and via different methods of delivery, is to destroy cancerous cells or to stop them from growing and multiplying, producing long-term remission or a cure. Radiation therapy may be used to treat localized cancers such as lymphomas and certain types of leukemia, or it may be used to relieve symptoms when cancerous growths cause pain or pressure on bones, nerves, or organs. However, chemotherapy and radiation therapy can cause long-term or late effects, affecting fertility or growth and causing learning disabilities or illnesses secondary to the primary cancer, such as leukemia.

Chemotherapy doses considered tolerable by most patients may not be sufficient to arrest, cause remission in, or cure acute leukemia, myeloma, or lymphoma. In patients who may be at high risk of relapse, who relapse after a successful course of treatment, or who do not respond as expected to conventional treatment, stem cell transplantation can enable production of normal blood cells such that intensive chemotherapy can bring about recovery. Immunotherapy, using antibodies from the patient or a donor, may be used alone or in combination with other therapies to attack cells that remain after chemotherapy and that may attach to antigens on the malignant cells. They also are used as vaccines to suppress malignant cells that remain in the body following therapy.

New chemotherapies, immunotherapies, vaccines, gene therapies, and types of bone marrow transplants to suppress the growth of cancerous cells and affect the course of the disease are always being developed and tested. Patients should be reminded that pain and uncomfortable symptoms arising from the toxic effects of cancer treatments can be managed by consulting with their physicians. Supportive care to improve functioning and quality of life, transfusions, antibiotics to protect against infection, and a healthy diet and lifestyle are critical for those undergoing cancer treatment.

Prognosis, prevention, and outcomes: Many factors affect the outcome of a patient’s blood cancer, including the type, location, and stage of disease, as well as individual and demographic factors such as the person’s general health, age, and response to treatment. A cancer survivor will undergo follow-up care, which includes frequent monitoring of blood counts, x-rays, urine tests, and imaging tests such as computed tomography (CT) or positron emission tomography (PET) scans. Those whose remission lasts five years are considered cured. Five-year survival rates for those with blood cancer have been rising since 1975 and the advent of more effective cancer treatments.

No specific guidelines for preventing blood cancer exist, as its causes are not known and many types are relatively rare. Limiting exposure to environmental toxins and leading a healthy lifestyle may help prevent blood cancers in those of average risk. The relative overall five-year survival rate of leukemia for those diagnosed between 2003 and 2009 was 59 percent—nearly double the rate for those diagnosed between 1975 and 1977 (34 percent), according to the LLS. Relative survival rates vary by age at diagnosis, race, gender, and type of leukemia. Of all types of leukemia, those with CLL had the highest relative survival rate during this period, at 83.1 percent.

Hodgkin disease is considered one of the most curable cancers, with many patients cured after their initial treatment. The five-year survival rate has increased substantially since the 1970s, from 72 percent to 88 percent. Similarly, due to advances in treatment of non-Hodgkin lymphoma, the five-year survival rate has increased from 47 percent in the 1970s to 71 percent in those diagnosed between 2003 and 2009.

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