Is NH4+ an electrophile?

An electrophile is a species that can accommodate additional electrons. Let us look at the structure of the ammonium ion (NH4+). Nitrogen has an atomic number of 7 and an electronic configuration of 1s2, 2s2, 2p3. In an ammonium ion, nitrogen is bonded to hydrogen atoms and shares electrons with them. This causes all the orbitals to be fully filled and hence, nitrogen does not have space for any additional electrons. Thus, the ammonium ion is not an electrophile. 

Having said that, ammonium still participates in reactions. What really happens is that the ammonium ion gets rid of the proton (H+) to achieve more stability. It is this hydrogen ion that seeks electrons and gains them during bonding with other species. Hence the hydrogen ion is the electrophile, not the ammonium ion. 

Take a look at this reaction:

`NH_4^+ + OH^(-) -> NH_3 + H_2O`

Hope this helps.

What colors or elements of nature does the Friar discuss in his monologue?

Friar Lawrence delivers a monologue (a speech that he says aloud to just himself -- so, really, a speech given directly to the audience) in Act II, Scene 3, before Romeo walks in. The Friar talks a little more, finishing up his monologue, and then greets Romeo. This whole monologue is about nature, especially the power of natural herbs to heal and hurt the body.

He starts by talking about the clouds, the sun and its morning light, and the dew, as well as the disappearing night:

"The gray-eyed morn smiles on the frowning night,

Checkering the eastern clouds with streaks of light,

And fleckled darkness like a drunkard reels

From forth day’s path and Titan’s fiery wheels.

Now, ere the sun advance his burning eye,

The day to cheer and night’s dank dew to dry,"

Then he talks about filling up the basket he's carrying with both poisonous weeds and healing flowers:

"I must upfill this osier cage of ours

With baleful weeds and precious-juicèd flowers."

Next, he compares the earth to a grave and a mother's womb. He talks more about the herbs that come out of the earth, which, like children, are both useful and diverse:

"The earth, that’s nature’s mother, is her tomb.

What is her burying, grave that is her womb.

And from her womb children of divers kind

We sucking on her natural bosom find,

Many for many virtues excellent,

None but for some and yet all different."

He mentions the power and grace of "herbs, plants, [and] stones," and then says that any herb growing in the earth that seems poisonous also has some good quality, but that helpful herbs can also be used for harm:

"For naught so vile that on the earth doth live

But to the earth some special good doth give.

Nor aught so good but, strained from that fair use

Revolts from true birth, stumbling on abuse."

After Romeo comes in, as if finishing his thoughts, the Friar gives an example of a plant with both good and bad qualities. He talks about a particular flower he's holding, saying it can either be poison or medicine depending on whether you smell it or taste it:

"Within the infant rind of this small flower

Poison hath residence and medicine power.

For this, being smelt, with that part cheers each part;

Being tasted, stays all senses with the heart."

Although the Friar mentions many descriptions of shade and light (such as darkness and murkiness), the only color he directly mentions is gray:

"The gray-eyed morn smiles on the frowning night"

That's how the Friar starts his monologue. What he's really saying is that the sun is rising because it's early morning, but he's expressing that thought by imagining that the morning, which has gray eyes, is smiling at the night, which frowns.

Mentioning that the morning has gray eyes focused on the outgoing nighttime, and observing "streaks of light" and "fleckled darkness" helps the Friar express the dual, competing elements of nature, which is appropriate considering how he keeps coming back to the idea that all herbs (and people) have both good and bad inside them.

All of this figurative speech about nature -- especially the reverence with which he shows the natural world -- helps to characterize the Friar as an unusually insightful character, deeply connected to the earth, and knowledgeable about ways to heal and poison people. 

What are the weekend preparations needed for a party to take place at Gatsby's mansion?

Nick describes the ambitious and elaborate preparations for Gatsby's parties in chapter three. Caterers come and set up enormous canvas tents and a dance floor and decorate with colored lights and flowers. Oranges and lemons arrive by the crate and are juiced by Gatsby's butler. Buffet tables are generously filled with food, and Gatsby has a fully stocked bar set up even though Prohibition is in effect. He hires a full orchestra, and performers from New York come to entertain. Waiters are brought in to serve his guests. Gatsby employs gardeners and handymen to prepare his lawn and gardens and then clean and repair damage after the parties. He sends a station wagon to pick up guests at the train station, and some arrive chauffeured by Gatsby's Rolls Royce. He has two motorboats and a seaplane and a raft with a tower for swimmers on his beachfront.

Fitzgerald, F. Scott. The Great Gatsby. Charles Scribner's Sons, 1925.

Which quotes about deception can one find in the first and second scenes of Macbeth?

In scene 1, we encounter the witches who are planning to meet Macbeth on the heath later, before sunset, when all the fighting is over. In the last lines of the scene, they say the following:

Fair is foul, and foul is fair:
Hover through the fog and filthy air.

This seeming contradiction is an obvious indication of their purpose later. Their reference to 'foul' suggests something disgusting or evil, whilst 'fair' suggests goodness and something wholesome. They equate the two—the one is the other. They intend using deception to lead Macbeth into committing vile deeds whilst he believes they are good in the sense that he will benefit from them. Their deliberate use of such equivocal statements is what will eventually lead him to his doom.

In scene 2, King Duncan refers to the traitorous thane of Cawdor after his defeat and eventual arrest:

No more that thane of Cawdor shall deceive
Our bosom interest: go pronounce his present death,
And with his former title greet Macbeth.

The thane has deceived his king by probably feigning loyalty but actually plotting against him by assisting the traitor, Macdonwald, and Sweno, the Norwegian king. Duncan declares that Cawdor will nevermore have an opportunity to mislead him and thus thwart what is good for him, his countrymen, and the country itself. Now that he and the other two have been vanquished, to a great extent because of Macbeth's relentless pursuit and his courage, the king commands that he be executed and his title bestowed on Macbeth.

It is ironic that Duncan awards the traitor's title to Macbeth because it is this honour which actually provides Macbeth with an incentive to undertake his road to ruin. Furthermore, Cawdor's deception and betrayal foreshadow Macbeth's similar acts later, only with much more devastating outcomes.

What are natural treatments for osteoarthritis?

Introduction

In osteoarthritis, the cartilage in joints has become damaged,
disrupting the smooth gliding motion of the joint surfaces. The result is pain,
swelling, and deformity. The pain of osteoarthritis typically increases with joint
use and improves at rest. Although X rays can find evidence of arthritis, the
level of pain and stiffness experienced by people does not match the extent of
injury noticed on X rays.

Many theories exist about the causes of osteoarthritis, but no one really knows
what causes the disease. Osteoarthritis is often described as wear-and-tear
arthritis, but evidence suggests that this simple explanation is not correct. For
example, osteoarthritis frequently develops in many joints at the same time, often
symmetrically on both sides of the body, even when there is no reason to believe
that equal amounts of wear and tear are present. Another intriguing finding is
that osteoarthritis of the knee is commonly (and mysteriously) associated with
osteoarthritis of the hand. These factors, and others, have led to the suggestion
that osteoarthritis may actually be a body-wide disease of the cartilage.

During one’s lifetime, cartilage is constantly being turned
over by a balance of forces that both break down and rebuild it. One prevailing
theory suggests that osteoarthritis may represent a situation in which the
degrading forces become chaotic. Some of the proposed natural treatments for
osteoarthritis described here may inhibit enzymes that damage cartilage.

When the cartilage damage in osteoarthritis begins, the body responds by building
new cartilage. For several years, this compensating effort can keep the joint
functioning well. Some natural treatments appear to work by assisting the body in
repairing cartilage. Eventually, however, building forces cannot keep up with
destructive ones, and what develops is end-stage osteoarthritis. This is the
familiar picture of pain and impaired joint function.

The conventional medical treatment for osteoarthritis consists mainly of
anti-inflammatory drugs, such as naproxen and Celebrex. The
main problem with anti-inflammatory drugs is that they can cause ulcers.
Another possible problem is that they may actually speed the progression of
osteoarthritis by interfering with cartilage repair and by promoting cartilage
destruction. In contrast, two of the treatments described here might actually slow
the course of the disease, although this has not been proven.

Principal Proposed Natural Treatments

Several natural treatments for osteoarthritis have a meaningful, though not definitive, body of supporting evidence indicating that they can reduce pain and improve function. In addition, there is some evidence that glucosamine and chondroitin might offer the additional benefit of helping to prevent progressive joint damage.

Glucosamine. Inconsistent evidence hints that glucosamine
can reduce symptoms of mild to moderate arthritis; a small amount of evidence
indicates that regular use can slow down the gradual worsening of arthritis that
normally occurs with time.

Glucosamine appears to stimulate cartilage cells in the joints to make proteoglycans and collagen, two proteins essential for the proper function of joints. Glucosamine may also help prevent collagen from breaking down.

Glucosamine is widely accepted as a treatment for osteoarthritis. However, the supporting evidence that it works is somewhat inconsistent, with several of the most recent studies failing to find benefit. Two types of studies have been performed: those that compared glucosamine with placebo and those that compared it with standard medications.

In the placebo-controlled category, one of the best trials was a three-year double-blind study of 212 people with osteoarthritis of the knee. Participants receiving glucosamine showed reduced symptoms compared to those receiving placebo. Benefits were also seen in other double-blind, placebo-controlled studies, enrolling more than eight hundred people and ranging in length from four weeks to three years. Even more double-blind studies enrolling more than four hundred people compared glucosamine with ibuprofen and found glucosamine just as effective as the drug.

Most recent studies, however, have not shown benefit. In four studies involving
almost five hundred people, the use of glucosamine failed to improve symptoms to
any greater extent than placebo. In a study involving 222 participants with hip
osteoarthritis, two years of treatment with glucosamine was no better than placebo
at improving pain or function. Another study involving 147 women with
osteoarthritis found glucosamine to be no more effective than home exercises over
an eighteen-month period. A third study evaluated the effects of stopping
glucosamine after it was taken by participants for six months. In this
double-blind trial of 137 people with osteoarthritis of the knee, participants who
stopped using glucosamine (and unknowingly took placebo instead) did no worse than
people who stayed on glucosamine. In a fourth, large (1,583-participant) study,
neither glucosamine (as glucosamine hydrochloride) nor glucosamine plus
chondroitin was more effective than placebo. Another study also failed to find
benefit with glucosamine plus chondroitin. Finally, in a systematic review
including randomized trials involving 3,803 persons with osteoarthritis of the hip
or knee, researchers found that neither glucosamine alone, chondroitin alone, nor
the combination of glucosamine and chondroitin relieved pain. It appears that most
of the positive studies were funded by manufacturers of glucosamine products. Most
of the studies performed by neutral researchers failed to find benefit.

Many popular glucosamine products combine this supplement with methylsulfonylmethane (MSM). One study published in India reported that both MSM and glucosamine improved arthritis symptoms compared with placebo but that the combination of MSM and glucosamine was even more effective than either supplement separately.

Two studies reported that glucosamine can slow the progression of osteoarthritis. However, as with the positive studies of glucosamine for reducing symptoms, both of these studies were funded by a major glucosamine manufacturer.

Osteoarthritis results when irregular bone growth occurs at the edge of a joint, causing impaired movement of the joint and pressure on nerves in the area.

A three-year, double-blind, placebo-controlled study of 212 persons found indications that glucosamine may protect joints from further damage. Over the course of the study, persons given glucosamine showed some actual improvement in pain and mobility, while those given placebo worsened steadily. Furthermore, X rays showed that glucosamine treatment prevented progressive damage to the knee joint. A separate three-year study enrolling 202 people found similar results.

A follow-up analysis five years after the conclusion of the foregoing two studies found suggestive evidence that the use of glucosamine reduced the need for knee replacement surgery. However, the aforementioned study involving 222 persons with osteoarthritis of the hip failed to show any significant change on X ray findings following two years of glucosamine treatment compared with placebo.

Chondroitin sulfate. The supplement chondroitin
is often combined with glucosamine. Several studies also have evaluated
chondroitin used alone, with some positive results, both for improving symptoms
and for slowing the progression of the disease. On balance, however, the evidence
for chondroitin’s effectiveness for osteoarthritis remains inconsistent.

According to some double-blind, placebo-controlled studies, chondroitin may relieve symptoms of osteoarthritis. One study enrolled eighty-five people with osteoarthritis of the knee and followed them for six months. Participants received either 400 milligrams (mg) of chondroitin sulfate twice daily or a placebo. At the end of the trial, doctors rated the improvement as good or very good in 69 percent of those taking chondroitin sulfate but in only 32 percent of those taking placebo.

Another way of comparing the results is to look at maximum walking speed among participants. Whereas persons in the chondroitin group were able to improve their walking speed gradually over the course of the trial, walking speed did not improve in the placebo group. Additionally, there were improvements in other measures of osteoarthritis, such as pain level, with benefits seen as early as one month. This suggests that chondroitin was able to stop the arthritis from gradually getting worse. Good results were seen in a twelve-month double-blind trial that compared chondroitin with placebo in 104 persons with arthritis of the knee, and in a twelve-month trial of 42 participants.

Another study evaluated the intermittent or “on and off” use of chondroitin. In this study, 120 people received either placebo or 800 mg of chondroitin sulfate daily for two separate, three-month periods in one year. The results showed that even when it was taken intermittently, the use of chondroitin improved symptoms. Benefits were also seen in two short-term trials involving about 240 persons.

Generally positive results were also seen in other studies, including one that found chondroitin about as effective as the anti-inflammatory drug diclofenac. However, a large (1,583-participant) and well-designed study failed to find either chondroitin or glucosamine plus chondroitin more effective than placebo. When this study is pooled together with the two other best-designed trials, no overall benefit is seen. It has been suggested that chondroitin, like glucosamine, may show benefit primarily in studies funded by manufacturers of the product being tested.

Some evidence suggests that, like glucosamine, chondroitin might slow the progression of arthritis. An important feature of the foregoing study of forty-two persons was that the persons taking a placebo showed progressive joint damage over the year, but among those taking chondroitin sulfate, no worsening of the joints was seen. In other words, chondroitin sulfate seemed to protect from further damage the joints of those with osteoarthritis.

A longer and larger double-blind, placebo-controlled trial also found evidence that chondroitin sulfate can slow the progression of osteoarthritis. The study enrolled 119 people and lasted three years. Thirty-four of the participants received 1,200 mg of chondroitin sulfate per day; the rest received placebo. Over the course of the study, researchers took X rays to determine how many joints had progressed to a severe stage.

During the three years of the study, only 8.8 percent of those who took chondroitin sulfate developed severely damaged joints, whereas almost 30 percent of those who took placebo progressed to this extent. Similar long-term benefits were seen in two other studies, enrolling more than two hundred people.

Additional evidence comes from animal studies. Researchers measured the effects of chondroitin sulfate (administered both orally and via injection directly into the muscle) in rabbits, in which cartilage damage had been induced in one knee by the injection of an enzyme. After eighty-four days of treatment, the damaged knees in the animals that had been given chondroitin sulfate had significantly more cartilage left than the knees of the untreated animals. Taking chondroitin sulfate by mouth was as effective as taking it through an injection.

Looking at the sum of the evidence, it does appear that chondroitin sulfate may actually protect joints from damage in osteoarthritis. However, the scientific record suffers from a paucity of truly independent researchers.

S-adenosylmethionine. A substantial body of scientific evidence
indicates that S-adenosylmethionine (SAMe) can relieve symptoms of
arthritis. Numerous double-blind studies involving more than one thousand
participants suggest that SAMe is approximately as effective for this purpose as
standard anti-inflammatory drugs. However, there is no meaningful evidence that
SAMe slows the progression of the disease.

One of the best double-blind studies enrolled 732 persons and followed them for four weeks. Over this period, 235 of the participants received 1,200 mg of SAMe per day, while a similar number took either placebo or 750 mg daily of the standard drug naproxen. The majority of the participants had experienced moderate symptoms of osteoarthritis of either the knee or the hip for an average of six years.

The results indicate that SAMe provided as much pain-relieving effect as naproxen and that both treatments were significantly better than placebo. However, differences did exist between the two treatments. Naproxen worked more quickly, producing readily apparent benefits at the two-week follow-up, whereas the full effect of SAMe was not apparent until four weeks. By the end of the study, both treatments were producing the same level of benefit.

In a double-blind study that compared SAMe with the newer anti-inflammatory drug Celebrex, the drug worked faster than the supplement, but in time both were providing equal benefits.

Evidence regarding slowing the progression of arthritis is limited to studies involving animals rather than people.

Avocado-soybean unsaponifiables. Special extracts of avocado and soybeans called avocado-soybean unsaponifiables (ASUs) have been investigated as a treatment for osteoarthritis with promising results in studies enrolling several hundred people.

For example, in a double-blind trial, 260 persons with arthritis of the knee were given either placebo or ASU at 300 or 600 mg daily. The results over three months showed that the use of ASU significantly improved arthritis symptoms compared with placebo. There was no significant difference seen between the two doses tested. It does not appear that ASU can slow the progression of osteoarthritis.

Cetylated fatty acids. A type of naturally occurring fatty acid
called cetylated
fatty acids have shown growing promise for osteoarthritis.
They are used both as topical creams and as oral supplements. Three double-blind
placebo-controlled studies have found cetylated fatty acids helpful for
osteoarthritis. Two involved a topical product and one used an oral
formulation.

In one of the studies using a cream, forty people with osteoarthritis of the knee applied either cetylated fatty acid or placebo to the affected joint. The results over thirty days showed greater improvements in range of motion and functional ability among people using the real cream than among those using the placebo cream. In another thirty-day study, also enrolling forty people with knee arthritis, the use of cetylated fatty acid cream improved postural stability, presumably because of decreased pain levels. In addition, a sixty-eight-day, double-blind, placebo-controlled study of sixty-four people with knee arthritis tested an oral cetylated fatty acid supplement (the supplement also contained lesser amounts of lecithin and fish oil). Participants in the treatment group experienced improvements in swelling, mobility, and pain level compared to those in the placebo group. Inexplicably, the study report does not discuss whether or not side effects occurred. While this is a promising body of research, it is far from definitive.

Advertising claims for cetylated fatty acids go far beyond the existing evidence. For example, a number of Web sites claim that cetylated fatty acids are more effective than glucosamine or chondroitin. However, no comparison studies have been performed upon which such a claim could be rationally based.

Acupuncture. Acupuncture has shown inconsistent
benefit as a treatment for osteoarthritis. A 2006 meta-analysis (systematic
statistical review) of studies on acupuncture for osteoarthritis found eight
trials that were similar enough to be considered together. These studies enrolled
2,362 people. The authors of the meta-analysis concluded that acupuncture should
be regarded as an effective treatment for osteoarthritis.

However, one study comprised almost one-half of all the people considered in this meta-analysis, and it failed to find real acupuncture more effective than sham acupuncture. In this study, published in 2006, 1,007 people with knee osteoarthritis were given either real acupuncture, fake acupuncture, or standard therapy over six weeks. Though both real acupuncture and fake acupuncture were more effective than no acupuncture, there was no significant difference in benefits between the two acupuncture groups. In general, larger studies are more reliable than small ones. For this reason, it is always somewhat questionable when meta-analysis combines one large negative study and a number of smaller positive ones to come up with a positive outcome.

Another review, published in 2007, concluded that real acupuncture produces
distinct benefits in osteoarthritis compared to no treatment but that fake
acupuncture is effective for osteoarthritis too. When comparing real acupuncture
to fake acupuncture, the difference in outcome (while it might possibly be
statistically significant) is so trivial as to make no difference in real life. In
other words, virtually all of the benefit of acupuncture for osteoarthritis is a
placebo
effect.

Other Proposed Natural Treatments

A six-week, double-blind, placebo-controlled study of 247 persons with osteoarthritis of the knee evaluated a combination herbal product containing ginger and the Asian spice galanga (Alpinia galanga). The results showed that participants in the ginger and galanga group improved to a significantly greater extent than those receiving placebo. However, despite news reports claiming that this study proves ginger effective for osteoarthritis, this study only provides information on the effectiveness of the herbal combination. The two double-blind studies performed on ginger alone were small and produced contradictory results. Furthermore, another study found that massage combined with the topical application of essential oils made from ginger and orange was no better than massage plus olive oil in persons with osteoarthritis of the knee.

A three-week double-blind study of 220 people with osteoarthritis of the knee
found that the use of a cream containing the herb comfrey
reduced symptoms significantly more than a placebo cream.

The herb white
willow contains the aspirin-like substance salicin. A
two-week, double-blind, placebo-controlled trial of seventy-eight persons with
arthritis found evidence that willow extracts can relieve osteoarthritis pain.
However, another double-blind study enrolling 127 people with osteoarthritis found
white willow less effective than a standard anti-inflammatory drug and no more
effective than placebo. The likely explanation for these contradictory results is
that white willow at usual doses provides relatively modest benefits.

The supplement MSM, as described in a foregoing study, has shown promise for osteoarthritis when taken with glucosamine. Benefits were also seen in a twelve-week, double-blind, placebo-controlled trial of fifty people with osteoarthritis, utilizing MSM at a dose of 3 grams twice daily. However, in a comprehensive review of six studies involving 681 persons with osteoarthritis of the knee, researchers concluded it is not possible to convincingly determine whether or not MSM is beneficial.

Other treatments with incomplete supporting evidence from double-blind trials include Ayurvedic herbal combination therapy, boswellia, cat’s claw, a proprietary complex of minerals with or without cat’s claw, devil’s claw, proteolytic enzymes, rose hips, soy protein, and vitamin B3.

Traditional
Chinese herbal medicine has also shown some promise for
osteoarthritis. However, one study that compared a commonly used Chinese herbal
product (Duhuo Jisheng Wan) to the drug diclofenac found that the herb worked more
slowly than the drug, yet produced about an equal rate of side effects.

Growing but definitive evidence suggests that the natural substance hyaluronic acid may help reduce osteoarthritis symptoms when it is injected into an affected joint. However, there is absolutely no reason to believe that oral hyaluronic acid should help, and one study failed to show any significant benefit.

Incomplete and inconsistent evidence from human and animal studies only weakly
suggests that green-lipped mussel might alleviate osteoarthritis symptoms.
A badly designed human study hints that krill oil might be helpful as well. One
double-blind study involving dogs found some evidence of benefit with elk velvet
antler.

Numerous other herbs and supplements sometimes recommended for osteoarthritis include beta-carotene, boron, cartilage, chamomile, copper, dandelion, D-phenylalanine, feverfew, molybdenum, selenium, turmeric, and yucca. However, there is little to no evidence that these treatments are effective.

Other studies provide limited evidence that certain supplements proposed for osteoarthritis do not work. For example, a two-year double-blind study of 136 people with knee arthritis found vitamin E ineffective for either reducing symptoms or slowing the progression of the disease. In addition, a six-month, double-blind, placebo-controlled trial of seventy-seven people with osteoarthritis failed to find any symptomatic benefit with vitamin E. Similarly, in a large (almost four-hundred-participant), five-year, double-blind, placebo-controlled study, the use of injected mesoglycan failed to slow the progression of osteoarthritis. A fairly small study failed to find the enzyme bromelain helpful for reducing symptoms.

Prolotherapy is a special form of injection therapy that is
popular among some alternative practitioners. A double-blind, placebo-controlled
study evaluated the effects of three prolotherapy injections (using a 10 percent
dextrose solution) at two-month intervals in sixty-eight people with
osteoarthritis of the knee. At six-month follow-up, participants who had received
prolotherapy showed significant improvements in pain at rest and while walking,
reduction in swelling, fewer episodes of “buckling,” and better range of flexion,
compared to those who had received placebo treatment. The same research group
performed a similar double-blind trial of twenty-seven persons with osteoarthritis
in the hands. The results at six-month follow-up showed that range of motion and
pain with movement improved significantly in the treated group compared with the
placebo group.

Several double-blind, placebo-controlled studies suggest that pulsed
electromagnetic field therapy, a special form of magnet therapy, can improve
symptoms of osteoarthritis. One small study provides extremely weak supporting
evidence for the more ordinary form of magnet therapy: static magnets. A
subsequent, much larger study of static magnets failed to find real magnets more
effective than placebo magnets, but a manufacturing error may have obscured
genuine benefits (some people in the placebo group were accidentally given active
magnets). In another placebo-controlled trial, the use of a magnetic knee wrap for
twelve weeks was associated with a significant increase in quadriceps (thigh
muscle) strength in persons with knee osteoarthritis.

Limited evidence supports the use of bee venom injections for osteoarthritis. Hot
water therapy (balneotherapy), relaxation therapies, and various forms
of exercise, including hatha yoga and Tai Chi, have
also all shown some promise. However, for none of these therapies is the
supporting evidence convincing.

Herbs and Supplements to Use with Caution

Various herbs and supplements may interact adversely with drugs used to treat osteoarthritis, so one should be cautious when considering the use of herbs and supplements.

Bibliography

Arjmandi, B. H., et al. “Soy Protein May Alleviate Osteoarthritis Symptoms.” Phytomedicine 11 (2005): 567-575.

Brien, S., et al. “Systematic Review of the Nutritional Supplements Dimethyl Sulfoxide (DMSO) and Methylsulfonylmethane (MSM) in the Treatment of Osteoarthritis.” Osteoarthritis and Cartilage 16 (2008): 1277-1288.

Brismee, J. M., et al. “Group and Home-Based Tai Chi in Elderly Subjects with Knee Osteoarthritis.” Clinical Rehabilitation 21 (2007): 99-111.

Chen, C. Y., et al. “Effect of Magnetic Knee Wrap on Quadriceps Strength in Patients with Symptomatic Knee Osteoarthritis.” Archives of Physical Medicine and Rehabilitation 89 (2008): 2258-2264.

Clegg, D. O., et al. “Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis.” New England Journal of Medicine 354 (2006): 795-808.

Deutsch, L. “Evaluation of the Effect of Neptune Krill Oil on Chronic Inflammation and Arthritic Symptoms.” Journal of the American College of Nutrition 26 (2007): 39-48.

Kawasaki, T., et al. “Additive Effects of Glucosamine or Risedronate for the Treatment of Osteoarthritis of the Knee Combined with Home Exercise.” Journal of Bone and Mineral Metabolism 26 (2008): 279-287.

Lee, M. S., M. H. Pittler, and E. Ernst. “Tai Chi for Osteoarthritis.” Clinical Rheumatology 27 (2008): 211-218.

Manheimer, E., et al. “Meta-analysis: Acupuncture for Osteoarthritis of the Knee.” Annals of Internal Medicine 146 (2007): 868-877.

Reichenbach, S., et al. “Meta-analysis: Chondroitin for Osteoarthritis of the Knee or Hip.” Annals of Internal Medicine 146 (2007): 580-590.

Tishler, M., et al. “The Effect of Balneotherapy on Osteoarthritis: Is an Intermittent Regimen Effective?” European Journal of Internal Medicine 15 (2004): 93-96.

Wandel, S., et al. “Effects of Glucosamine, Chondroitin, or Placebo in Patients with Osteoarthritis of Hip or Knee.” British Medical Journal 341 (2010): c4675.

How does Shakespeare present Juliet after the balcony scene?

The next time the audience sees Juliet after the balcony scene is when her nurse returns from a meeting with Romeo to learn what provisions he has made for his marriage to Juliet.  Juliet is excited, hopeful, and impatient, especially because the nurse is purposely delaying and teasing her.  Juliet says, exasperatedly, "How are thou out of breath, when thou hast breath / To say to me that thou art out of breath?" (II.5.33-34).  The nurse makes all manner of excuses to prolong Juliet's suspense: complaining about her aching head and back, talking about how handsome Romeo is, asking about the location of Juliet's mother.  Poor Juliet begins to lose patience with her, but recovers herself once she learns Romeo has sent word of their wedding.

Later, though Juliet seems to mourn the death of Tybalt sincerely, she also understands she owes her love to her husband.  She is quite thoughtful in Act III, Scene 2, when she wonders how "deceit should dwell / In such a gorgeous palace" (III.2.90-91).  Juliet knows she should hate the man who murdered her cousin, but also knows she ought to love the man who is her husband.  It's a terrible situation for her to be in, and her thoughtfulness (and even her wordplay and use of oxymora to describe Romeo's simultaneous treachery and beauty) conveys a sense of Juliet's maturity, even though she is but thirteen.

Still later, it is Juliet who visits Friar Lawrence's cell and commits to the plan to fake her own death as a means of escaping the wedding her father has planned for her to County Paris.  She is brave and independent, acting outside of her nurse's advice for what seems to be the first time in her life.  

What are spine, vertebrae, and disks?

Structure and Functions

The spinal column undergoes developmental changes from infancy to the adult state and then degenerative changes with aging. The alignment of the spinal column at birth is in the shape of a C curve, the fetus having been curled up. This forward-tilted curve is retained except in the neck and lower back. As the infant raises its head and attempts to see things, head control and vision gradually require the head to tilt back, resulting in a posterior curve at the neck. As children progress to standing and walking, the lower spine also develops a posterior curve (a normal lumbar lordosis). As individuals increasingly use the predominant upper extremities, these muscles become stronger and increase the pull on that side of the spine, resulting in a lateral curve (a normal scoliosis).

Humans generally have thirty-three vertebrae, but abnormalities can occur in their numbers, shape, alignment, density, and maturation. There are seven vertebrae in the neck or cervical area, twelve in the chest or thoracic area, five in the lower back or lumbar area, five usually joined together in the pelvic region to form the sacrum, and three or four rudimentary vertebrae partially fused to form the coccyx. The typical vertebra develops embryologically from two bone growth centers. The front of one bone growth center becomes the body and part of the arch, while the other bone growth center evolves into the spinous processes, the transverse processes, the articular processes, and the back portion of the arch.

The thirty-three vertebrae of the spine have various defined parts and characteristics. The oval or round vertebral body has a spongy center surrounded by a dense bone. Above and below it are layers of cartilage. Lack of the mineral calcium reduces the density of the bone, resulting in osteoporosis. This condition may occur in postmenopausal women, causing pain, fractures, and kyphosis (a thoracic humpback). The pedicle portions of this anterior arch have an upper and lower notch called the intervertebral foramina, through which the spinal nerves exit from the spinal canal. At the junction of pedicle and lamina are projections upward and downward that form the articular processes, or joints. The alignment and direction of these joints vary with the spinal region and serve to control spinal motion. The transverse processes assist in the movement of muscles and at the chest level act as links between the ribs. There are generally twelve thoracic vertebrae and twelve ribs. On occasion, an extra cervical rib may be present; this extra rib narrows the exit space at the neck and can pinch the cervical nerves and blood vessels.

The upper two cervical processes are different from all other vertebrae. The first cervical vertebra supports the head and is called the atlas. Instead of a body, it has an enlarged anterior arch and a groove on which the head rests. Its transverse processes are long, but its spinous process is a little knob. The second cervical vertebra is also unique, with an upward projection called the dens that is like a pole fitting into the ring of the first cervical vertebral arch. It represents the body of the first cervical vertebra. This pole and ring permit the head to rotate.

The cervical transverse processes or lateral projections have holes, the transverse foramina, through which the vertebral arteries send blood to the brain. As one progresses downward, the vertebrae become larger and bear more weight. The thoracic vertebrae have their joint surfaces in the frontal plane, and the transverse processes are solid. The ribs share half of the joint surfaces with the adjoining vertebrae, except for the first, tenth, eleventh, and twelfth vertebrae; these vertebrae join only their corresponding ribs. As one continues down the spine, the spinous processes become more slender and project downward, almost touching one another. The lower thoracic vertebrae are closer to the lumbar vertebrae in appearance.

The lumbar vertebrae are more massive, carry more stress, and support the weight of the body. The transverse processes in this region are thinner but longer, increasing the leverage action for muscles. The joint surfaces tilt upward, backward, and toward the center, opening the joint space when one bends forward. This action permits side bending, increasing the side pressures on the disks. The five sacral vertebrae are fused, with small ridges representing the sites of fusion. Small openings allow the upper four sacral nerves to exit the spine. The sacrum contributes the back portion of the pelvis. The coccyx, or tailbone, is composed of three or four rudimentary vertebrae, with the first distinct and separate from the other two or three, which are fused. The back of the spine is layered with muscles going to the upper extremities, with long vertical muscles underneath, intermediate-length muscles under these, and the deepest muscle groups closest to the spine and only two or three vertebrae in length.

Vertebrae are separated by washers called disks. The central portion of a disk is a gel-like substance, the nucleus pulposus, which offers hydraulic cushioning and allows some movement. This substance is enclosed in a ligamentous covering called the annulus fibrosis. Disks contribute approximately one-fourth of body length, can add about eight degrees in motion per vertebra, and can alter their shape to accommodate the solid vertebrae when the body is bent. The nucleus pulposus is 70 to 80 percent water, and about 14 kilograms (30 pounds) of pressure must be exerted constantly by ligaments to maintain the shape of the disk. Dehydration, aging, compressive forces, and simply a day of normal activity can temporarily reduce the amount of the watery nucleus pulposus, increase the bulging of the disks, and shorten one’s stature.

The spinal cord
connects the peripheral structures of the body to the brain and the nerve cells in the spinal cord itself. Until about the third month of life, the spinal cord occupies the entire length of the spinal canal. The vertebrae grow faster than the spinal cord, however, and later in life it occupies two-thirds of the length of the spinal canal (approximately 42 to 45 centimeters) and ends at about the second lumbar vertebra. The coverings on the cord continue as the filum terminale, which is attached to the sacral vertebrae.

There are three coverings of the spinal cord within the spinal canal. The outermost, toughest, and fibrous covering, called the dura, is separated from the bony surfaces by fat and blood vessels. The spinal cord is covered by a thin layer called the pia that enters into the spinal cord and separates various portions of the cord. Surrounding the pia is a protective fluid, the spinal fluid, which is held in place by the arachnoid layer; this fluid can be aspirated for analysis, as in a lumbar puncture, or spinal tap. The nerves exiting from the spinal cord are also segmental. There are only seven cervical vertebrae but eight cervical nerves. The eighth cervical nerve exits below the seventh cervical vertebra, and thereafter all roots from the vertebrae leave below the corresponding vertebra. These segmental nerves then join, divide, send messages to the brain and other organs, and control bodily functions and motion.

Ligaments run vertically in front of the vertebral bodies (the anterior longitudinal ligament) and in back of the vertebral bodies and within the spinal canal (the posterior longitudinal ligament). These ligaments support the vertebrae and disks and limit excessive motion forward and backward. The posterior longitudinal ligament ceases at about the fourth lumbar vertebra, and thus farther down the spine the fibrous rings about the disks are weaker, permitting herniations. Such leakages from the disks may press on nerve roots exiting at these levels and cause pain. These ruptures of the disks occur mostly when lifting with the trunk bent forward and sideways. There are additional ligaments between the spinous processes at the tips (the supraspinous ligament) and along the length of the spinous processes (the interspinous ligament). The portion of the arch between the spinous processes and the transverse processes is the lamina. Between the laminae are the ligamentum flavum. The interspinous ligament, ligamentum
flavum, and nucleus pulposus have no pain fibers. The laminae and disks may be removed when disk surgery is performed, and pieces of bone from the hip may be used to fuse and reduce motion at this level.

Motion between each vertebra is about eight degrees. Motion is enhanced by the facets, vertical bony projections with joint surfaces. They are structured like the other joints of the body, and thus are subject to irritation and arthritic changes. Flexion of the trunk opens the spaces in the lumbar joints and allows side bending and rotation in the same direction. Extension of the trunk compresses and limits motion in these facets.

The blood supply to the spinal cord and the surrounding tissues diminishes progressively downward. Excessive activity can lead to insufficient circulating blood to these nerves and give rise to symptoms in the lower extremity called intermittent claudication. The front portion of the spinal cord contains motor nerve cells, leading to the trunk and the muscles of the extremities, that can be inhibited or activated by impulses. The lateral areas of the spinal region contain messenger tracts and the autonomic nervous system. The back portion of the spinal cord has sensory structures that carry messages of pain, temperature, position, and touch to the brain. The different levels within the spinal cord connect to different segmental structures of the body. The fifth cervical nerve down to the first thoracic nerve connect to the upper extremities, and the second lumbar to second sacral roots connect to the lower extremities. Compression of these nerve roots at the spine may cause symptoms in areas distant from the spine.

Disorders and Diseases

The anatomy of the trunk regulates the erect, or standing, posture. It is influenced by the structure of the vertebrae and extremities and even by the tilt of the head. It is also influenced by cultural factors, emotion, habits, and occupation. Good posture involves standing straight with the head up, the shoulders back and up, the stomach in, and the hips and knees straight. This position also is most efficient in energy expenditure, since it requires the least amount of muscle activity in order to balance the weights in the front and back of the trunk, as well as the weights on the left and right sides of the body. Looking at the front of the body, the central gravitational, or weight-bearing, line falls in line with the nose and between the pelvis, knees, and ankles. From the back, the gravitational line follows the center of the head, the spinous processes, the gluteal fold between the buttocks, and between the knees and ankles. The weight stresses should be balanced between the right side and the left side of the body and between the front and the back. The head should be maintained so that the eyes and the labyrinth in the inner ear are level. Any deviations cause
imbalance in the trunk, resulting in muscle strain, ligament sprains, pain, and possibly deformities. Abnormalities in posture and gait may be attributable to muscle imbalance, deformities at birth, problems in development, disease, or surgical procedures.

There are several birth defects that affect the spine. Occasionally, during embryonic development
, the two bone growth regions that form a vertebra do not fuse together, causing an opening in the arch in the back called spina bifida. Spondylolysis occurs when the articular process remains unattached. Ligaments, muscles, and tendons are unable to attach to these areas securely, and the result is weakness in the vertebra and a reduction in stability. Occasionally, this weakness permits the upper vertebra to slide forward, a condition called spondylolisthesis. The misalignment and narrowing of the spinal canal can compress the nerve structures within it, a condition known as spinal stenosis. The lower cervical and lower lumbar regions, which need more nerve tissue to supply the extremities, are especially vulnerable to pressure symptoms.

Inequality in leg lengths or pain in the lower extremities, upper extremities, abdomen, chest, or neck can lead to compensatory reactions in the trunk. These may then cause misalignment in the spine with side deviations (scoliosis), backward deviations (kyphosis, or humpback, in the thoracic area), and forward deviations (lordosis in the low back). Other contributing factors are overuse, muscle spasm or weakness, birth defects, developmental abnormalities, diseases, aging, and trauma. Some misalignments occur after surgery on the chest, back, or abdomen. Idiopathic scoliosis (scoliosis of unknown cause) may occur in adolescent girls; when it is severe, lung and heart functions can be impaired. Temporarily increased lordosis can occur in pregnancy, to compensate for the extra weight in the abdomen. Lordosis may be permanent because of structural changes in the spine, pendulous abdomen and/or breasts, or poor muscle balance. Therefore, back problems may be caused by poor posture, behavior, occupation, and structural, neurologic, or muscular factors. Pain located only
in the back is generally attributable to poor posture, trauma, or inflammation. If pain extends below the knees, the cause may be nerve pressure at the fifth lumbar or first sacral nerve roots. Bladder and rectal sphincter disturbances may indicate sacral nerve or cord involvement and may require immediate surgical care.

The body’s center of gravity is in the front portion of the second lumbar vertebra. Thus, the compressive force of body weight is increased when one lifts an object with the arms in front of the trunk. The greater the distance of the object from the center of the body, the greater the need for the back muscles to contract. Lifting a 45-kilogram (100-pound) object may require a 545-kilogram (1,200-pound) muscle pull and compressive force. The posterior longitudinal support for the disks that is provided by ligaments narrows in the sides at the level of the fourth and fifth lumbar vertebrae. Herniations through the fibrous disk ring at these levels are more likely, and a ruptured disk can pinch the nerves exiting at these levels.

Stresses that bear on the spine are categorized as compressive, shearing, elongating, or rotational. Compressive forces may involve the muscles, disks (possible ruptures), vertebrae (fractures), and the facet joints. Shearing stress may lead to forward slippage of the fourth or fifth vertebra from the segment below. This is most common in individuals with incomplete bony union of vertebrae. Rotatory stress may affect the joints, the facets of the spine, the short spine muscles, or the ligaments. On rare occasions, an elongating stretch or traction may strain muscles and sprain or tear ligaments.

Perspective and Prospects

Examinations of the spine usually include the history of the problem: whether it is sudden or gradual and whether it is influenced by certain activities or climates. The physician checks the patient’s posture for abnormal curvatures and determines whether they are fixed or functional. Functional curves disappear when the patient is lying down. The gait should be evaluated for symmetry, balance, and deviations. The physician will measure leg lengths for inequalities, the circumference of the chest for rib flare, and the circumferences of extremities for swelling or shrinkage. Next, the trunk’s range of motion will be evaluated, followed by palpation to discover tender spots and muscle spasms.

With spinal problems, a full examination of the entire body is indicated since pain can be referred to the back from other organs. Changes in function, sensation, and motor strength can indicate spinal cord or nerve involvement. Simple X rays of the spine will indicate alignment of the vertebrae, bone density, fracture lines, extraneous bone growth, cartilage thickness, and unusual soft tissue densities caused by hemorrhage or calcification. For problems other than bone and cartilage tissue involvement, a computed tomography (CT) scan or magnetic resonance imaging (MRI) may be needed; these techniques provide images of the area to be examined that are at different levels or depths. In 2013, reserachers at the University of Zurich published a study showing that spinal cord injury can cause irreversible tissue loss within forty days of sustaining injury.

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