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Professor, Charles R. Drew University of Medicine and Science College of Medicine
The anterior fifth of the inner layer medications with aspirin generic dramamine 50 mg mastercard, the pars ceca retinae medications kidney damage buy dramamine visa, remains one cell layer thick bad medicine generic 50mg dramamine otc. It later divides into the pars iridica retinae medicine qhs discount 50 mg dramamine free shipping, which forms the inner layer of the iris, and the pars ciliaris retinae, which participates in formation of the ciliary body. Meanwhile, the region between the optic cup and the overlying surface epithelium is filled with loose mesenchyme. In the adult, the iris is formed by the pigment-containing external layer, the unpigmented internal layer of the optic cup, and a layer of richly vascularized connective tissue that contains the pupillary muscles. Contraction of the ciliary muscle changes tension in the ligament and controls curvature of the lens. Chapter 20 Eye 333 Suspensory ligament Conjunctival sac Sclera Pigment layer Neural layer of the retina Anterior chamber Iridopupillary membrane Cornea Choroid Vitreous body Hyaloid artery Dura Ectoderm Eyelid Posterior chamber Iris Ciliary body Outer vascular layer Inner vascular layer Optic nerve Figure 20. By the end of the seventh week, these primary lens fibers reach the anterior wall of the lens vesicle. Growth of the lens is not finished at this stage, however, since new (secondary) lens fibers are continuously added to the central core. The inner layer later forms a highly vascularized pigmented layer known as the choroid; the outer layer develops into the sclera and is continuous with the dura mater around the optic nerve. The anterior chamber forms through vacuolization and splits the mesenchyme into an inner layer in front of the lens and iris, the iridopupillary membrane, and an outer layer continuous with the sclera, the substantia propria of the cornea. Hence, the cornea is formed by (1) an epithelial layer derived from the surface ectoderm, (2) the substantia propria or stroma, which is continuous with the sclera, and (3) an epithelial layer, which borders the anterior chamber. The anterior and posterior chambers communicate with each other through the pupil and are filled with fluid called the aqueous humor produced by the ciliary process of the ciliary body. The interstitial spaces of this network later fill with a transparent gelatinous substance, forming the vitreous body. The hyaloid vessels in this region are obliterated and disappear during fetal life, leaving behind the hyaloid canal. During the seventh week, the choroid fissure closes, and a narrow tunnel forms inside the optic stalk. As a result of the continuously increasing number of nerve fibers, the inner wall of the stalk grows, and the inside and outside walls of the stalk fuse. Its center contains a portion of the hyaloid artery, later called the central artery of the retina. Drawings of the cranial neural plate region depicted in A showing the initial stages of eye development. Through a groove at the inferior aspect of the optic vesicle, the choroid fissure, the hyaloid artery (later the central artery of the retina) enters the eye. The cornea is formed by (a) a layer of surface ectoderm, (b) the stroma, which is continuous with the sclera, and (c) an epithelial layer bordering the anterior chamber. Epidermis Initially, the embryo is covered by a single layer of ectodermal cells. Finally, at the end of the fourth month, the epidermis acquires its definitive arrangement, and four layers can be distinguished. The horny layer, forming the tough scalelike surface of the epidermis, is made up of closely packed dead cells containing keratin. During the first 3 months of development, the epidermis is invaded by cells arising from the neural crest. Ectoderm Mesenchyme A Periderm Basal layer Horny layer Granular layer B Intermediate layer Spinous layer Melanocyte Germinative layer Corium C D. Soon, cells in the center of the hair buds become spindle-shaped and keratinized, forming the hair shaft, while peripheral cells become cuboidal, giving rise to the epithelial hair sheath. A small smooth muscle, also derived from mesenchyme, is usually attached to the dermal root sheath. The first hair that appears, lanugo hair, is shed at about the time of birth and is later replaced by coarser hairs arising from new hair follicles. Cells from the central region of the gland degenerate, forming a fat-like substance (sebum) secreted into the hair follicle, and from there, it reaches the skin. Epidermis Sebaceous gland Smooth muscle fibers Hair bud Dermal root sheath A Hair shaft Epithelial hair sheath Hair papilla Blood vessel B C Figure 21.
Let me conclude this portion of my discourse with a few remarks on the insular portion of this continent medications in mexico buy dramamine with paypal, and on those regions in the north which still own the sovereignty of Britain treatment trichomoniasis effective dramamine 50 mg. They had medications with codeine buy genuine dramamine line, and they have yet treatment centers for depression buy dramamine 50mg amex, their seigniories and their laws of primogeniture; their natural indolence,and good taste; their habits of clinging to each other and leaving the country desolate; they huddled themselves in villages, seemingly terri fied to locate in the open country; they had no self-dependence, no go-ahead notions; and so they all but stood still, waiting the arrival of the latest fashions from Paris. Then poured in the Saxon upon them; seized their territory, and advised them to become English. This struggle can only cease when the Saxon has become the preponderating race in Lower ` Canada, which can never happen until the laws of entail and primogeniture are abolished. Now it is easy to see which goes first to the wall; the laws of entail, after a severe struggle, will be abolished in both countries, and then the Saxon steps in with his self-dependent, go-ahead principle; then flourish commerce, manufacture, agriculture, and every useful speculation; then will Ireland be come Saxon, but not till then. So will " Le bas Canada," as it is called, soon, under such circum-, In the meantime we must not suppose that the Celtic struggle will end here. Some ten years ago I ventured to hint that whenever the Celtic race became sufficiently numerous in any part of the Union, the Saxon would be disposed to notice them. I allowed some half century, however, to elapse before the war of race might show itself; but in this I was wrong, for it has already appeared in one of the northern states, the Saxons assembling tumultu ously, and burning a Roman-catholic church, with other acts of violence towards the frequenters of that church, who of course are Celtic. We shall see: time unfolds all events; the war of race will some day shake the Union to its founda tion. Though using the same language, they apply to some most important words totally different meanings. It is not that he is more savage or more brutal (the term in no shape applies to him) or less a lover of justice than others; but his temper is quicker, and he flies to the sword, to arms, as his natural instinct. Both races talk of republican institutions, and the Saxon may well boast that pure democracy prevails through out the Union; that it forms a large element in Britain; that it is not quite extinct in Holland and Norway, though ground to the dust in France and throughout the rest of Europe. See forty millions of people, warlike and courageous, submit to become the mere tools of a miserable dynasty. The journalists of France inform us, no doubt, of a republic which is said to exist somewhere in France; be it so: in the mean time I beg leave to hint at the following facts. Paris is in a state of siege; walled and fortified round about; the passport system continues in full force. One great section, Hayti, has shown the white man that he cannot colonize a tropical country; it must revert to those races on whom nature has bestowed a constitution adapted to labour under a tropical sun. Cuba and Jamaica will follow; they will become black spots in the history of civilization, for nothing in the history of mankind permits us to believe in the perfect civilization of the Negro race. The policy of European races would be to expel the Negro and transplant the Coolies, Hindoos, Chinese, or other feeble races, as labourers and workmen,-bondmen, in fact. I am disposed to ascribe to the element of race a circumstance which has occurred oftener than once in the delivery of these lectures in various institutions-literary, scientific, and popular. The attention of the audience could not be so com pletely secured as when I spoke to them of the fair races. I will not say that this was ex pressed, but I think it was understood; it seemed to be felt that black and coloured men differ very much from fair men, like ourselves. Practically, all men believe in the element of race; it is denied only theoretically; thus theory and practice seldom coincide: profession is not conduct; fair words do not always imply straightforward actions. Even the daily press, so powerful an agent for the ex posure of such hypocrisy, must look to those who support it; Negroes and Red Indians, Hottentots and Kaflirs, neither read nor pay for daily jour rials. The anatomical structure of the dark races of men is but imperfectly known; I may venture to say it is not known at all. The details have not been observed and described by anatomists of reputation: few anatomists go abroad to sojourn in tropical countries, and opportunities for the dissection of the dark races are comparatively rare in the seats of learning and science in Europe. The Hottentot Venus, who died in Paris, was examined there, and some most dis tinguished men took part in the examination. But I can find no detailed account of the struc tures deserving the name of a report. It is known that the Hottentot and Bosjeman race have, in as far as regards the female, the reproductive organs singularly formed; but these singularities are thought not to be peculiar to these races. Andrew Smith, the first of all authorities, how ever, in respect of the natural history of extra tropical Southern Africa. The nasal bones are narrow and short, they usually coalesce; the ascending branches of the upper maxillary bones are broad, and the breadth between the eyes correspondingly remarkable. The power of vision is most admir able, but it is lost by a single cross with the white race. So also are the elastic fatty cushions over the glutei muscles and on the haunches generally, `so characteristically marked in the Hottentot Venus.
Their object must be to mislead treatment zoster ophthalmicus cheap 50mg dramamine, else why so sys tematically and habitually pervert the truth Had India medicine vocabulary purchase dramamine 50 mg overnight delivery, or Australia medications causing thrombocytopenia 50mg dramamine, or Northern America medication 3 checks cheap dramamine 50mg fast delivery, been peopled by Arabs and Mauritanians, our position in these countries might now have been widely different. Shortly after the seizure of Algeria by France, it must have become evident that no amalgama tion of the races was practicable: was not even desirable. It must have been evident that, to make Algeria French, it must be peopled and cultivated by Frenchmen, there being no slave population; no lIindoo; no Negro; no labouring class. It is called a question of acclimatation; for it has been sup posed that in countries like Algeria, Lower Egypt, Morocco, which are extra-tropical, the fair races of men might with time become so accustomed to the climate, or acclimatized, as the phrase is, as thoroughly to occupy the ter ritory. French troops stationed in these coun tries during the Empire suffered nearly as we did; the natives themselves seemed to think the country healthy enough, and were surprised at our losses! Their immunity has been usually ascribed to a long acclimatation; our destruction, to the want of it. It is not my intention to discuss here generally this great question of acclimatation: I disbelieve partly in its power, at least for many generations. Let us consider merely Northern Africa, for on the decision of this question must depend the extension of the Celtic race into Africa: it is the safety-valve of Europe; a successful colonization of Algeria, or a war on the Rhine. The conti nental and insular Saxons, Russ, and Slavonian (the other three great races) have their choice. Give Northern Africa to France, to the Celtic race: there is no avoiding the question; it is an act of mere justice due to the race; but, as might is right, the question will no doubt be decided by the sword. Another affair in Morocco, and one or two at the base of the Pyramids, will decide the matter for a few centuries. The invasion of Algeria by France, and its at tempted occupation by that country as a colony or a province, or an integral part of the empire, was viewed in this country and throughout Europe (I use the language of the press as inter preters of the feelings of the people and of the wishes of their governments) as a wanton aggres sion on the part of the people called French, on some of their peaceable neighbours, our allies, the Dey of Algiers and Emperor of Morocco! In viewing France as a nation, it was forgotten that she was peopled by a race of men, which, if not identical throughout, was more nearly so than, perhaps, any other on the globe. To the principle of nationality, that is, of political inde pendence, she added the most glorious recollec tions of all times; from Brennus to Charles Martel, from Martel to Napoleon, she had never been beaten but by a world in arms. As a nation, then, though a nation be a mere accidental political as semblage of people-a human contrivance based on no assurance of perseverance,on no bond of nature, but on protocols and treaties, on the mockery of words called constitutions and laws of nations, made to bind the weak, to be broken by the strong-was it to be expected that France, all powerful, was to remain "cribbed up, cabined, and confined" within that territory which chance and the fate of war had assigned to her But Northern Asia had been seized on by the Sarmatian race; Southern Asia, or India, by the Saxon-English, not, it is true, to hold as acolony, but a mere military dependence; America, Aus tralia, and a hundred oceanic islands were also in the hands of the "men of commerce and of peace;" the men of traffic, of manufacture, and of ships; Anglo-Saxon,or Holland-Saxon had extended his race nearly over the world, losing, it is true, his colonies nearly as fast as he ac quired them, but peopling them with his race, language, modes of thought, manner of civiliza tion. To the Celtic race of France there remained but Northern Africa-Africa to the north of the equator. Colonize Africa or march to the Rhine; extend the race into Italy or Germany, or colonize Algeria: these were the alternatives left to France in 1830. Let me now examine, then, with care, this great queStion, for such I esteem it-not whether Algeria can be made a mere colony of France, that is not the question. Can the Celtic French man be acclimatized in Northern Africa, Algeria, Morocco, Tunis, Tripoli, Barca, Syrene, and Egypt, so that these countries may ultimately form an integral portion of the French empire Its importance will, I trust, excuse the details into which I shall be necessitated to enter. The country of Algeria, as at first viewed by France, was deemed likely to prove an important acquisition to the empire. Its proximity to Old France; its Mediterranean coast line; its proxi mity to Morocco on one hand, and Tunis`on the other; moreover, its extra-tropical position, seemed to combine in proving its political im portance to France, and its capability of being colonized by European men of the French or Celtic race. En- deavours, no doubt, have been and will continue to be made to show that the destructive climate of Northern Africa depends more on accidental circumstances than on its geographical position; that a want of culture has rendered the climate pestilential, destructive to the European. It would be consolatory to France to believe in its truth- advantageous to Europe were it really true; all this I admit. Let me examine the opposing circumstances, for a knowledge of which I am mainly indebted to M. This is not merely a medical question: it involves the aban donment of Algeria, and, as a. Abandon Algeria, says the political French physician, obeying his own impulses or acting on those which he conceives now influence his employers; hold Algeria, and colonize it as soon as possible, says the social physician, looking, no doubt, as he thinks, towards the advancement of his country. These terms are not mine: they argue two conflicting parties, between whom truth is sure to be sacrificed.
Gross cardiomegaly medications erectile dysfunction generic 50mg dramamine otc, particularly of the left atrium and left ventricle rust treatment cheap 50 mg dramamine with mastercard, was seen on chest X-ray medications ending in ine cheap dramamine online. The echocardiogram showed a strikingly echogenic endocardium treatment lung cancer order on line dramamine, left ventricular enlargement, decreased systolic function, and mitral regurgitation. It is caused by an incessant tachyarrhythmia, either ventricular or 274 Pediatric cardiology "supraventricular" (see Chapter 10). Following elimination of the tachyarrhythmia, normal cardiac function usually recovers, although some degree of left ventricular dilation may persist. The hypertrophy may be concentric, involving the ventricular walls diffusely, or asymmetric, unevenly affecting portions of the wall usually the ventricular septum. In contrast to dilated cardiomyopathy, the left ventricular cavity has a normal or decreased size. During systole, the hypertrophied myocardium bulges into the left ventricular outflow tract and may result in subaortic obstruction. Other names for this condition are hypertrophic obstructive cardiomyopathy and asymmetric septal hypertrophy. The disease may be caused by mutations of genes coding for various contractile proteins. This condition frequently occurs as an autosomal dominant or sex-linked condition (occurring in males). The natural history and prognosis are variable; sudden death is not uncommon, even in patients who have no important obstruction or sentinel arrhythmia. History Syncope may be present, but congestive cardiac failure is rare unless significant diastolic dysfunction is present. The family history may reveal other members with similar diagnosis or a history of sudden death. Physical examination the peripheral pulses are brisk, and palpation of the apex may reveal a double impulse. A long systolic ejection murmur is present along the left sternal border 9 the cardiac conditions acquired during childhood 275 and faintly radiates to the base. Chest X-ray Chest X-ray does not usually show cardiac enlargement related to the left ventricle and left atrium because hypertrophy alone may not alter the external silhouette. In contrast to other forms of aortic stenosis, the ascending aorta is usually of normal size. This creates low pressure that "pulls" the valve leaflet towards the interventricular septum during systole. Color Doppler reveals disturbed flow within the left ventricular outflow tract, beginning proximal to the aortic valve. Spectral Doppler allows estimation of the systolic gradient by measurement of the maximum velocity; this may change from beat to beat because of the dynamic nature of the muscular obstruction. Management Because the subsequent therapies increase the gradient, the use of digoxin or other inotropes is contraindicated in these patients. Beta-blockers, calcium channel blockers, and other "negative inotropes" have been advocated for these patients but do not necessarily prevent sudden death. Surgical excision of portions of the septal myocardium (myomectomy) has been helpful in some patients with obstruction. Alcohol injected via a coronary artery catheter can achieve a form of nonsurgical myomectomy by selectively destroying obstructing myocardium. Ventricular pacing via a transvenous right ventricular 276 Pediatric cardiology electrode may reduce the gradient in some patients, presumably by altering the activation sequence of the left ventricular myocardium; but the response varies, and there have been few long-term studies of the procedure. Restrictive cardiomyopathy This, the rarest of the three general types of cardiomyopathy, is characterized by poor ventricular compliance and limited filling. Some patients have a mutation of myocardial regulatory proteins, such as troponin, but most forms are idiopathic.
Afterload reduction Natural mechanisms produce vasoconstriction and redistribution of organ blood flows in patients with hypotension treatment hiatal hernia 50mg dramamine with mastercard. Although such events may be beneficial during acute hemorrhage medications during pregnancy safe 50mg dramamine, for example treatment quality assurance unit buy dramamine line, vasoconstriction may be disadvantageous in chronic heart failure symptoms 6 dpo buy dramamine 50mg low price. Vasoconstriction increases the impedance to arterial blood flow that myocytes must overcome to propel blood from the heart. The mechanical load on the myocytes, known as afterload, is increased in heart failure. Reducing the afterload on failing myocardial cells may improve their performance, lessen ongoing myocyte injury, and allow for recovery of injured myocytes, depending on the mechanism of the heart failure. Afterload reduction is achieved by the administration of vasodilator drugs, which relax smooth muscle in systemic arterioles and decrease systemic vascular resistance. These drugs may also partially redistribute blood flow towards more normal patterns. Increasing renal blood flow may lessen the overproduction of renin, a factor in elevated afterload. In infants with a ventricular septal defect and a large left-to-right shunt, reduction of systemic vascular resistance (provided that the pulmonary vascular resistance does not fall to a similar extent) decreases the volume of blood shunted and relieves cardiac failure by lessening the left ventricular volume overload. The authors use a solution of captopril for treating infants, but care must be taken in its preparation and storage, since the drug degrades rapidly in solution. Oral enalapril can be 322 Pediatric cardiology used once daily in children able to take tablets. These drugs have an antialdosterone renal effect, so they are used with caution with potassium-sparing diuretics or potassium supplements. Beta-blockers may reverse some neurohumoral derangements of chronic heart failure, especially the detrimental cardiac effect of high levels of endogenous catecholamines. Short-term treatment of heart failure may require an inotrope, including a beta-agonist. Identifying patients who do not depend on high levels of catecholamines and will benefit from beta-blockers can be challenging. These drugs are not useful for and may have adverse effects in children with high-output-type heart failure, as in a left-to-right shunt. The specific drug literature should be consulted for precautions, contraindications, and details of use, including maximum doses. Supportive measures Other therapeutic measures may be useful in the treatment of children with congestive cardiac failure. Long-term use of oxygen may be counterproductive, perhaps because of its effect as a systemic vasoconstrictor (thereby increasing afterload). Oxygen is administered using a rigid plastic hood in neonates and nasal cannulae in older children. The least aggravating method of delivery should be sought, since increased patient agitation in the presence of limited cardiac output will be counterproductive. In the acute management of severe cardiac failure, endotracheal intubation and mechanical ventilation may be indicated. Children may present in extremis with respiratory failure due to fatigue of overworked 11 Congestive heart failure in infants and children 323 Table 11. One or more of the following classes of drugs are employed for management of acute heart failure, with examples of commonly used agents shown. Consult specific drug literature for precautions, contraindications, details of use including maximum doses, etc. On the other hand, sedation may result in apnea in children who have impending respiratory failure from fatigue and in those with underlying pulmonary disease. Close monitoring and preparations for emergency intubation are warranted if sedatives are used. Conditions associated with increased pulmonary blood flow have an increased incidence of pneumonia. Atelectasis occurs more commonly in children because of bronchial compression from enlarged pulmonary arteries or cardiac chambers.
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