Dannielle C. O’Donnell, BS, PharmD

• Clinical Assistant Professor, College of Pharmacy, The University of Texas at Austin
• Principal Medical Science Liaison, Immunology, US Medical Affairs, Genentech, Austin, Texas

An avid traveler medicine natural buy discount brahmi 60caps, she finds that the humanoid races simply astound her with the amount of knowledge and wisdom they can collect in such short life spans medicine lodge ks order 60caps brahmi with amex. While she spends much of her time in humanoid form (usually blending in seamlessly with any race or culture) medicine 7253 pill trusted 60caps brahmi, she has been known to assume other shapes in the pursuit of knowledge treatment action group 60 caps brahmi sale. Recently symptoms strep throat discount brahmi 60caps, Stratiglynculcies has taken to accompanying good-aligned parties of adventurers in expeditions to unexplored lands or ruined settlements treatment yeast infection nipples breastfeeding generic brahmi 60 caps visa. She often forgets what a "rush" these shorterlived creatures are in, however, and can be left behind when she spends weeks or even months studying a new find. Lothirlondonis Young Adult Silver Dragon In his earliest youth, Lothirlondonis found he could not change shape as freely as his hatchmates. A kindly druid took him in and helped the silver hatchling develop his shapechanging skills. Ever since, Lothirlondonis has had a love for the forest and for forest creatures. He even pays homage to several nondraconic deities of the woodlands (such as Ehlonna) though he does not worship them. Lothirlondonis still spends most of his time in silver dragon shape but sometimes polymorphs into a fey creature and observes travelers who pass through his woods. If they show respect and tend toward conservation, he may aid them or protect them. Sallahtuwlishion Adult Silver Dragon When Sallahtuwlishion entered adulthood, she resisted putting aside her favorite nondraconic guise, that of a village innkeeper. Now, she still maintains the Silver Goblet Inn but spends only a few days a month there. Because of her willingness to mediate disputes and hold messages (useful talents for an innkeeper), she often finds herself speaking on behalf of older or more powerful dragons and other good or neutral beings. Livezzenvivexious Mature Adult Silver Dragon An unusually "draconic" silver dragon, Livezzenvivexious has little use for other forms. While he takes different shapes for short times, he does nearly all his fighting in dragon form- and Livezzenvivexious does a lot of fighting. Livezzenvivexious loathes evil creatures (particularly demons and devils) and despises evil dragons. Those creatures who worship evil deities also make Livezzenvivexious their enemies. Aesthyrondalaurai Old Silver Dragon Known throughout the planes as a master of lore and healing, Aesthyrondalaurai shares her insights with those who can find her. Legend has it that this old silver dragon always takes on a matronly form but seldom stays in one place for long. Still, she does maintain her own lair, high in the mountains, and keeps a strong friendship with eagles, pegasi, and other airborne creatures. When someone seeks knowledge, Aesthyrondalaurai often sends out her friends with clues to her location. If a seeker is persistent enough, he or she can find Aesthyrondalaurai, but it is never easy. Freilaclanbarin Very Old Silver Dragon Nearly eight hundred years old, Freilaclanbarin has yet to reach his full strength and maturity, but he has a ready wit and a clever tongue. Freilaclanbarin keeps a hoard (as almost all dragons do), but he despises overt greed. Freilaclanbarin often trades with good and neutral creatures, charging a fair price for his knowledge or his treasures, and he builds his hoard through rewards and trade. Asaduanaivakka Ancient Silver Dragon Asaduanaivakka Silverstar considers herself a front-line warrior against the forces of evil. She has spent many of her considerable years traveling the world and the planes learning about the constant war between good and evil and she feels it is her time to step up and "do something about it. She has been known to employ lower-level adventurers to battle lesser evils, in the hope that they grow into powerful heroes, but more often, she joins a party of strong crusaders in climactic struggles. She has no compunctions about revealing her draconic nature and often uses her considerable reputation as leverage when seeking to join a party. Kuulvaysheniruss Wyrm Silver Dragon It is hard to think of one of the oldest dragons in the world as a sad, old man, but Kuulvaysheniruss the Venerated has earned that description. For more than a hundred years, Kuulvaysheniruss was the cohort of a mighty paladin in the service of Heironeous, but the paladin was destroyed and attempts to revivify her failed. He never takes humanoid form anymore, preferring to battle as he did beside his paladin friend, breathing blasts of paralyzing gas and cones of frigid air. Improved Snatch (Ex): Against Large or smaller creatures, bite for 4d6+14/round or claw for 2d8+7/round. Spell-Like Abilities: 3/day-control winds, fog cloud; 2/day-feather fall; 1/day-control weather. Nymbryxion Great Wyrm Silver Dragon Nymbryxion the Shield of Law seldom visits the Material Plane anymore, preferring instead the uninterrupted sky of the Elemental Plane of Air. If she does travel back to the plane of her birth, she does so in the form of an ageless elven woman with silver eyes. When she does speak, she cuts right to the heart of any matter and her voice has the power of persuasion behind it. Nymbryxion has been known to visit elder dragons of nearly every type-even chromatic-to advise them on their place in the world. Metallic dragons take her words to heart; chromatic dragons often fly into a rage at her presence but few dare attack her. Nymbryxion is an unbelievably powerful opponent and many creatures of many planes owe her favors. Spell-Like Abilities: 3/day-control winds, fog cloud; 2/day-feather fall; 1/day-control weather, reverse gravity. Skills and Feats: Hide +8, Listen +6, Move Silently +3, Search +4, Spot +9, Swim +17; Flyby Attack, Hover, Power Attack. Kalkol Young White Dragon Kalkol often takes to the water, skulking under ice floes and other places where ice meets open water. A tireless hunter, Kalkol also keeps a wary eye out for a band of frost giants that have been entering his territory and stalking him for months, the giants hope to capture Kalkol and force him to serve them as a guard. Still, he is too stubborn to abandon his territory to the giants, so he remains in the area, avoiding the giants as much as he can. Skills and Feats: Hide +7, Listen +12, Spot +12, Swim +22; Flyby Attack, Hover, Improved Initiative, Wingover. Haaldisath Juvenile White Dragon Brutal and direct, Haaldisath has survived for this long due primarily to her extreme cowardice. She has just enough wit to avoid capture or death at the hands of more powerful opponents and avoids protracted combat with any foe. She may return, if she has reason to believe her foes have sustained significant damage-or if they approach her lair-but she Detailed below are twelve sample white dragons, one of each age category. Icewalking (Ex): All white dragons can move on icy surfaces as though using spider climb (as the spell). Skills: A white dragon can move through water at its swim speed without making Swim checks. It has a +8 racial bonus on any Swim check to perform some special action or avoid a hazard. Rime Wyrmling White Dragon Rime takes savage joy in hunting and is happiest when closing in for a kill. His favorite prey includes polar bears and the occasional whale, provided he can catch the creature in shallow water where it cannot readily escape. Skills and Feats: Hide +22, Listen +3, Search +1, Sense Motive +3, Spot +3, Swim +19; Improved Initiative, Power Attack. Hrymgird Very Young White Dragon Hrymgird is equally at home in the air or the water. She loves foggy stretches of water, especially if they also have floating ice, protruding rocks, or other hazards. In such places, she alternately swims on the surface or flies just above it on silent wings, looking for prey. Hrymgird attacks just about anything she meets, except dragons bigger than herself. Skills and Feats: Concentration +8, Intimidate +14, Listen +15, Search +14, Sense Motive +12, Spot +12, Swim +11; Enlarge Breath, Flyby Attack, Hover, Power Attack, Wingover. The giants keep him on a leash of greed: they allow Nidhogrym to keep a portion of all the treasure he helps steal from their enemies, but he must keep it in their lair. Skills and Feats: Hide +14, Listen +18, Move Silently +18, Search +17, Spot +18, Swim +12; Flyby Attack, Hover, Improved Maneuverability, Power Attack, Power Dive, Recover Breath. Cealdia Adult White Dragon Cealdia has survived many years in the frozen northern world by knowing her limitations. She is not the strongest, smartest, or largest predator, and she realizes plenty of creatures exist that are ready and willing to destroy her for a variety of a reasons. She spends most of her time in her lair-a complex series of underground, icy tunnels-and often uses her small magical skills to lure enemies into traps or ambushes. When Cealdia must fight in the open, she prepares ahead of time and prefers fighting from above. She is a cautious opponent and is not above a little judicious bargaining if things do not appear to be going her way. Bestlaranathion Mature Adult White Dragon Though intelligent, Bestlaranathion proves as capricious as a winter wind and as savage as any wild animal. He has recently learned to speak Common, and has come to think of himself as something of a diplomat. Unfortunately, his efforts at diplomacy usually sink to the level of stark threats, and even when he is able to browbeat an unfortunate creature into some kind of agreement, Bestlaranathion seldom contains his baser instincts for very long and he usually winds up attacking his reluctant allies. About half the time, Bestlaranathion simply tries to ambush characters, hoping for a quick kill. He might demand to know their business, try to extort treasure, or simply converse. Skills and Feats: Concentration +19, Hide +13, Intimidate +15, Knowledge (nature) +15, Listen +22, Move Silently +21, Search +22, Spellcraft +11, Spot +22, Swim +16; Flyby Attack, Hover, Improved Snatch, Power Attack, Shape Breath, Snatch, Spreading Breath, Wingover. Improved Snatch (Ex): Against Medium or smaller creatures, bite for 2d8+8/round or claw for 2d6+4/round. Yeridajniosjuth Old White Dragon Yeridajniosjuth spent many years nursing envy and hatred of those more powerful than she and now this cold and cruel white dragon is in a position for some payback. Rather than settle into a lair and dominate a particular territory, Yeridajniosjuth entertains herself by hunting other dragons and destroying or dominating them. Her favored opponents are young or juvenile metallic dragons (particularly brass or gold), but she is not above attacking red or even other white dragons when she thinks she can win. Skills and Feats: Bluff +7, Concentration +19, Diplomacy +3, Hide +16, Intimidate +15, Knowledge (nature) +17, Listen +25, Move Silently +24, Search +25, Spellcraft +7, Spot +25, Swim +33; Cleave, Flyby Attack, Hover, Improved Initiative, Power Attack, Quicken Breath, Recover Breath, Rend, Snatch, Wingover. Snatch (Ex): Against Small or smaller creatures, bite for 2d8+9/round or claw for 2d6+4/round. Sepsecolskegyth Very Old White Dragon Unusually clever for a white dragon, Sepsecolskegyth has a personality like an icy, rusted blade. While his strength assures him of few challengers, Sepsecolskegyth prefers intimidation to overt action. When threatened or challenged, Sepsecolskegyth makes good use of his enslaved minions, his breath weapon, and his magic, preferring to avoid direct physical confrontation whenever possible. Skills and Feats: Bluff +8, Concentration +23, Diplomacy +4, Hide +19, Intimidate +20, Knowledge (arcana) +17, Knowledge (nature) +17, Listen +29, Move Silently +27, Search +29, Spellcraft +16, Spot +29, Swim +34, Survival +8; Cleave, Dire Charge, Great Cleave, Hover, Improved Maneuverability, Legendary Reflexes, Power Attack, Recover Breath, Rend, Snatch. Snatch (Ex): Against Small or smaller creatures, bite for 2d8+10/round or claw for 2d6+5/round. Csarivchizzik Ancient White Dragon Once an aggressive, active predator, Csarivchizzik has slowed down somewhat with age. It is not a lack of courage or power that changed her ways, but a growing knowledge of the threats in the world around her. Abandoning her lair in the northern mountains, she carried her treasure to a floating glacier far from the nearest coast. Csarivchizzik hunts whales and other sea creatures for food, and harries shipping for sport and treasure. Wisely, she usually attacks from below the surface of the water, erupting upward to spray her icy breath at surprised opponents. Csarivchizzik has a fondness for extraordinarily powerful magic items, however, and she can be lured out of her remote lair by rumors of artifacts in the hands of those unable to defend them from her predations. Skills and Feats: Bluff +11, Concentration +26, Diplomacy +13, Hide +10, Intimidate +24, Knowledge (arcana) +18, Knowledge (nature) +18, Listen +32, Move Silently +30, Search +32, Spellcraft +18, Spot +32, Swim +35; Cleave, Dire Charge, Great Cleave, Hover, Improved Maneuverability, Improved Multiattack, Multiattack, Power Attack, Recover Breath, Rend, Snatch. Cheynchaytion Wyrm White Dragon One of the most powerful dragons in the world Cheynchaytion revels in his strength.

Hence when we find that hybrids produced by a cross between two distinct species are few in number treatment of lyme disease order 60 caps brahmi otc, owing to their perishing soon after conception or at a very early age medicine on time buy brahmi 60 caps with visa, or if surviving that they are rendered more or less sterile medicine bg purchase brahmi 60caps free shipping, it seems highly probable that this result is due to their having been in fact subjected to a great change in their conditions of life treatment of schizophrenia buy discount brahmi 60 caps online, from being compounded of two distinct organisations treatment example buy brahmi 60 caps low cost. He who will explain in a definite manner why medications related to the female reproductive system brahmi 60 caps without prescription, for instance, air elephant or a fox will not breed under confinement in its native country, whilst the domestic pig or dog will breed freely under the most diversified conditions, will at the same time be able to give a definite answer to the question why two distinct species, when crossed, as well as their hybrid offspring, are generally rendered more or less sterile, whilst two domesticated varieties when crossed and their mongrel offspring are perfectly fertile. Turning to geographical distribution, the difficulties encountered on the theory of descent with modification are serious enough. All the individuals of the same species, and all the species of the same genus, or even higher group, are descended from common parents; and therefore, in however distant and isolated parts of the world they may now be found, they must in the course of successive generations have travelled from some one point to all the others. Yet, as we have reason to believe that some species have retained the same specific form for very long periods of time, immensely long as measured by years, too much stress ought not to be laid on the occasional wide diffusion of the same species; for during very long periods there will always have been a good chance for wide migration by many means. A broken or interrupted range may often be accounted for by the extinction of the species in the intermediate regions. It cannot be denied that we are as yet very ignorant 436 as to the full extent of the various climatal and geographical changes which have affected the earth during modern periods; and such changes will often have facilitated migration. As an example, I have attempted to show how potent has been the influence of the Glacial period on the distribution of the same and of allied species throughout the world. With respect to distinct species of the same genus inhabiting distant and isolated regions, as the process of modification has necessarily been slow, all the means of migration will have been possible during a very long period; and consequently the difficulty of the wide diffusion of the species of the same genus is in some degree lessened. As according to the theory of natural selection an interminable number of intermediate forms must have existed, linking together all the species in each group by gradations as fine as are our existing varieties, it may be asked: Why do we not see these linking forms all around us With respect to existing forms, we should remember that we have no right to expect (excepting in rare cases) to discover directly connecting links between them, but only between each and some extinct and supplanted form. Even on a wide area, which has during a long period remained continuous, and of which the climatic and other conditions of life change insensibly in proceeding from a district occupied by one species into another district occupied by a closely allied species, we have no just right to expect often to find intermediate varieties in the intermediate zones. For we have reason to believe that only a few species of a genus ever undergo change; the other species becoming utterly extinct and leaving no modified progeny. Of the species which do change, only a few within the same country change at the same time; and all modifications are slowly effected. I have also shown that the intermediate varieties which probably at first existed in the intermediate zones, would be liable to be supplanted by the allied forms on either hand; for the latter, from existing in greater numbers, would generally be modified and improved at a quicker rate than the intermediate varieties, which existed in lesser numbers; so that the intermediate varieties would, in the long run, be supplanted and exterminated. On this doctrine of the extermination of an infinitude of connecting links, between the living and extinct inhabitants of the world, and at each 437 successive period between the extinct and still older species, why is not every geological formation charged with such links Why does not every collection of fossil remains afford plain evidence of the gradation and mutation of the forms of life Although geological research has undoubtedly revealed the former existence of many links, bringing numerous forms of life much closer together, it does not yield the infinitely many fine gradations between past and present species required on the theory; and this is the most obvious of the many objections which may be urged against it. Why, again, do whole groups of allied species appear, though this appearance is often false, to have come in suddenly on the successive geological stages Although we now know that organic beings appeared on this globe, at a period incalculably remote, long before the lowest bed of the Cambrian system was deposited, why do we not find beneath this system great piles of strata stored with the remains of the progenitors of the Cambrian fossils I can answer these questions and objections only on the supposition that the geological record is far more imperfect than most geologists believe. The number of specimens in all our museums is absolutely as nothing compared with the countless generations of countless species which have certainly existed. The parent-form of any two or more species would not be in all its characters directly intermediate between its modified offspring, any more than the rock-pigeon is directly intermediate in crop and tail between its descendants, the pouter and fantail pigeons. We should not be able to recognise a species as the parent of another and modified species, if we were to examine the two ever so closely, unless we possessed most of the intermediate links; and owing to the imperfection of the geological record, we have no just right to expect to find so many links. If two or three, or even more linking forms were discovered, they would simply be ranked by many naturalists as so many new species, more especially if found in different geological sub-stages, let their differences be ever so slight. Numerous existing doubtful forms could be named which are probably varieties; but who will pretend that in future ages so many fossil links will be discovered, that naturalists will be able to decide whether or not these doubtful forms ought to be called varieties Only organic beings of certain classes can be preserved in a fossil condition, at least in any great number. Many species when once formed never undergo any further change but become extinct without leaving modified descendants; and the periods, during which species have undergone modification, though long as measured by years, have probably been short in comparison with the periods during which they retain the same form. It is the dominant and widely ranging species which vary most frequently and vary most, and varieties are often at first local- both causes rendering the discovery of intermediate links in any one formation less likely. Local varieties will not spread into other and distant regions until they are considerably modified and improved; and when they have spread, and are discovered in a geological formation, they appear as if suddenly created there, and will be simply classed as new species. Most formations have been intermittent in their accumulation; and their duration has probably been shorter than the average duration of specific forms. Successive formations are in most cases separated from each other by blank intervals of time of great length; for fossiliferous formations thick enough to resist future degradations can as a general rule be accumulated only where much sediment is deposited on the subsiding bed of the sea. During the alternate periods of elevation and of stationary level the record will generally be blank. During these latter periods there will probably be more variability in the forms of life; during periods of subsidence, more extinction. With respect to the absence of strata rich in fossils beneath the Cambrian formation, I can recur only to the hypothesis given in the tenth chapter; namely, that though our continents and oceans have endured for an enormous period in nearly their present relative positions, we have no reason to assume that this has always been the case; consequently formations much older than any now known may lie buried beneath the great oceans. With respect to the lapse of time not having been sufficient since our planet was consolidated for the assumed amount of organic change, and this objection, as urged by Sir William Thompson, is probably one of the gravest as yet advanced, I can only say, firstly, that we do not know at what rate species change as measured by years, and secondly, that many philosophers are not as yet willing to admit that we 439 know enough of the constitution of the universe and of the interior of our globe to speculate with safety on its past duration. That the geological record is imperfect all will admit; but that it is imperfect to the degree required by our theory, few will be inclined to admit. If we look to long enough intervals of time, geology plainly declares that species have all changed; and they have changed in the manner required by the theory, for they have changed slowly and in a graduated manner. We clearly see this in the fossil remains from consecutive formations invariably being much more closely related to each other, than are the fossils from widely separated formations. Such is the sum of the several chief objections and difficulties which may be justly urged against the theory; and I have now briefly recapitulated the answers and explanations which, as far as I can see, may be given. I have felt these difficulties far too heavily during many years to doubt their weight. But it deserves especial notice that the more important objections relate to questions on which we are confessedly ignorant; nor do we know how ignorant we are. We do not know all the possible transitional gradations between the simplest and the most perfect organs; it cannot be pretended that we know all the varied means of Distribution during the long lapse of years, or that we know how imperfect is the Geological Record. Serious as these several objections are, in my judgment they are by no means sufficient to overthrow the theory of descent with subsequent modification. Under domestication we see much variability, caused, or at least excited, by changed conditions of life; but often in so obscure a manner, that we are tempted to consider the variations as spontaneous. Variability is governed by many complex laws,- by correlated growth, compensation, the increased use and disuse of parts, and the definite action of the surrounding conditions. There is much difficulty in ascertaining how largely our domestic productions have been modified; but we may safely infer that the amount has been large, and that modifications can be inherited for long periods. As long as the conditions of life remain the same, we have reason to believe that a modification, which has already been inherited for many generations, may continue to be inherited for an almost infinite number of generations. On the other hand, we have evidence that 440 variability when it has once come into play, does not cease under domestication for a very long period; nor do we know that it ever ceases, for new varieties are still occasionally produced by our oldest domesticated productions. Variability is not actually caused by man; he only unintentionally exposes organic beings to new conditions of life, and then nature acts on the organisation and causes it to vary. But man can and does select the variations given to him by nature, and thus accumulates them in any desired manner. He may do this methodically, or he may do it unconsciously by preserving the individuals most useful or pleasing to him without any intention of altering the breed. It is certain that he can largely influence the character of a breed by selecting, in each successive generation, individual differences so slight as to be inappreciable except by an educated eye. This unconscious process of selection has been the great agency in the formation of the most distinct and useful domestic breeds. That many breeds produced by man have to a large extent the character of natural species, is shown by the inextricable doubts whether many of them are varieties or aboriginally distinct species. There is no reason why the principles which have acted so efficiently under domestication should not have acted under nature. In the survival of favoured individuals and races, during the constantly-recurrent Struggle for Existence, we see a powerful and ever-acting form of Selection. The struggle for existence inevitably follows from the high geometrical ratio of increase which is common, to all organic beings. This high rate of increase is proved by calculation,- by the rapid increase of many animals and plants during succession of peculiar seasons, and when naturalised in new countries. A grain in the balance may determine which individuals shall live and which shall die,- which variety or species shall increase in number, and which shall decrease, or finally become extinct. As the individuals of the same species come in all respects into the closest competition with each other, the struggle will generally be most severe between them; it will be almost equally severe between the varieties of the same species, and next in severity between the species of the same genus. On the other hand the struggle will often be severe between beings remote in the scale of nature. The slightest advantage in certain 441 individuals, at any age or during any season, over those with which they come into competition, or better adaptation in however slight a degree to the surrounding physical conditions, will, in the long run, turn the balance. With animals having separated sexes, there will be in most cases a struggle between the males for the possession of the females. The most vigorous males, or those which have most successfully struggled with their conditions of life, will generally leave most progeny. But success will often depend on the males having special weapons, or means of defence, or charms; add a slight advantage will lead to victory. As geology plainly proclaims that each land has undergone great physical changes, we might have expected to find that organic beings have varied under nature, in the same way as they have varied under domestication. And if there has been any variability under nature, it would be an unaccountable fact if natural selection had not come into play. It has often been asserted, but the assertion is incapable of proof, that the amount of variation under nature is a strictly limited quantity. Man, though acting on external characters alone and often capriciously, can produce within a short period a great result by adding up mere individual differences in his domestic productions; and every one admits that species present individual differences. But, besides such differences, all naturalists admit that natural varieties exist, which are considered sufficiently distinct to be worthy of record in systematic works. No one has drawn any clear distinction between individual differences and slight varieties; or between more plainly marked varieties and sub-species, and species. On separate continents, and on different parts of the same continent when divided by barriers of any kind, and on outlying islands, what a multitude of forms exist, which some experienced naturalists rank as varieties, others as geographical races or sub-species, and others as distinct, though closely allied species! If, then, animals and plants do vary, let it be ever so slightly or slowly, why should not variations or individual differences, which are in any way beneficial, be preserved and accumulated through natural selection, or the survival of the fittest What limit can be put to this power, acting during long ages and rigidly scrutinising the whole constitution, structure, and habits of each creature,- favouring the good and rejecting the bad I can see no limit to this power, in slowly and beautifully adapting each form to the most complex relations of life. The theory of natural selection, even if we look no farther than this, seems to be in the highest degree probable. I have already recapitulated, as fairly as I could, the opposed difficulties and objections; now let us turn to the special facts and arguments in favour of the theory. On the view that species are only strongly marked and permanent varieties, and that each species first existed as a variety, we can see why it is that no line of demarcation can be drawn between species, commonly supposed to have been produced by special acts of creation, and varieties which are acknowledged to have been produced by secondary laws. On this same view we can understand how it is that in a region where many species of a genus have been produced, and where they now flourish, these same species should present many varieties; for where the manufactory of species has been active, we might expect, as a general rule, to find it still in action; and this is the case if varieties be incipient species. Moreover, the species of the larger genera, which afford the greater number of varieties or incipient species, retain to a certain degree the character of varieties; for they differ from each other by a less amount of difference than do the species of smaller genera. The closely allied species also of the larger genera apparently have restricted ranges, and in their affinities they are clustered in little groups round other species- in both respects resembling varieties. These are strange relations on the view that each species was independently created, but are intelligible if each existed first as a variety. As each species tends by its geometrical rate of reproduction to increase inordinately in number; and as the modified descendants of each species will be enabled to increase by as much as they become more diversified in habits and structure, so as to be able to seize on many and widely different places in the economy of nature, there will be a constant tendency in natural selection to preserve the most divergent offspring of any one species. Hence, during a long-continued course of modification, the slight differences, characteristic of varieties of the same species, tend to be augmented into the greater differences characteristic of the species 443 of the same genus. New and improved varieties will inevitably supplant and exterminate the older, less improved, and intermediate varieties; and thus species are rendered to a large extent defined and distinct objects. Dominant species belonging to the larger groups within each class tend to give birth to new and dominant forms; so that each large group tends to become still larger, and at the same time more divergent in character. But as all groups cannot thus go on increasing in size, for the world would not hold them, the more dominant groups beat the less dominant. This tendency in the large groups to go on increasing in size and diverging in character, together with the inevitable contingency of much extinction, explains the arrangement of all the forms of life in groups subordinate to groups, all within a few great classes, which has prevailed throughout all time. This grand fact of the grouping of all organic beings under what is called the Natural System, is utterly inexplicable on the theory of creation. As natural selection acts solely by accumulating slight, successive, favourable variations, it can produce no great or sudden modifications; it can act only by short and slow steps. Hence, the canon of "Natura non facit saltum," which every fresh addition to our knowledge tends to confirm, is on this theory intelligible. We can see why throughout nature the same general end is gained by an almost infinite diversity of means, for every peculiarity when once acquired is long inherited, and structures already modified in many different ways have to be adapted for the same general purpose. We can, in short, see why nature is prodigal in variety, though niggard in innovation. But why this should be a law of nature if each species has been independently created no man can explain. How strange it is that a bird, under the form of a woodpecker, should prey on insects on the ground; that upland geese which rarely or never swim, should possess webbed feet; that a thrush-like bird should dive and feed on sub-aquatic insects; and that a petrel should have the habits and structure fitting it for the life of an awk! But on the view of each species constantly trying to increase in number, with natural selection always ready to adapt the slowly varying descendants of each to any unoccupied or ill-occupied place in nature, these facts cease to be strange, or might even have been anticipated. That beauty, according to our sense of it, is not universal, must be admitted by every one who will look at some venomous snakes, at some fishes, and at certain hideous bats with a distorted resemblance to the human face. Sexual selection has given the most brilliant colours, elegant patterns, and other ornaments to the males, and sometimes to both sexes of many birds, butterflies, and other animals.

Hill symptoms 4 weeks pregnant discount brahmi 60 caps on line, it is now sixty-five years since I first heard you preach; but I remember your text medications names generic brahmi 60 caps with mastercard, and a part of your sermon medications you cannot crush buy discount brahmi 60 caps line. An American gentleman related the following anecdote symptoms just before giving birth discount brahmi 60caps on line, which just answersthe purpose I have in view treatment 4 ringworm buy brahmi 60caps without prescription, so I will pass it on to you medications used to treat ptsd generic 60caps brahmi overnight delivery. Hislife,asallliveswill,drewtoaclose;butbeforehepassed away,feelingsomedesiretobenefitthemembersofhiscraft,hegaveout wordthat,onacertainday,hewouldbehappytocommunicatetoallthe tailors of the neighbourhood the secret by which they might become wealthy. Agreatnumberofknightsofthethimblecame,andwhilethey waitedinanxioussilencetoheartheimportantrevelation,hewasraised up in his bed, and with his expiring breath uttered this short sentence, "Always put a knot in your thread. Yet,hasitnotbeenthe case with very many of the sermons to which we have listened, or the discourseswehaveourselvesdelivered There is an authenticated case of a man being converted by a sermon eighty-fiveyearsafterhehadhearditpreached. Sixthly, anecdotes and illustrations are useful because they frequently arousethefeelings. They will not do this, however, if you tell the same stories over and over again ever so many times. I recollect, when Ifirst heardthatwonderfulstoryabout"Thereisanotherman,"Icriedagood deal over it. Poor soul, just rescued, half-dead, with only a few rags on him,and,yethesaid,"Thereisanotherman,"needingtobesaved. Thebrotherdrawshimselfup,and looks wonderfully solemn, and in a sepulchral tone says, "There is anotherman,"andIthinktomyself,"Yes,andIwishtherehadnotbeen," for I have heard that story till I am sick and tired of it. Still, a live illustration is better for appealing to the feelings of an audience than any amount of description could possibly be. Beecher brought a beautiful slave girl, with her manacles on, into his pulpit,hedidmorefortheanti-slaverycausethanhemighthavedoneby themosteloquentharangue. Whatwewantinthesetimesisnottolisten to long prelections upon some dry subject, but to hear something practical, something matter-of-fact, that comes home to our every-day reasoning;andwhenwegetthis,thenourheartsaresoonstirred. I have no doubt that the sight of a death-bed would move men much more than that admirable work called Drelincourt on Death, a book which,Ishouldthink,nobodyhaseverbeenabletoreadthrough. There mayhavebeeninstancesofpersonswhohaveattemptedit;butIbelieve that, long before they have reached the latter end, they have been in a stateofasphyxiaorcoma,andhavebeenobligedtoberubbedwithhot flannels; and the book has had to be removed to a distance before they could recover. If you have not read Drelincourt on Death, I believe I knowwhatyouhaveread,thatis,theghoststorythatisstitchedinatthe endofthebook. Theworkwouldnotsell,thewholeimpressionwasupon the shelves of the bookseller, when Defoe wrote the fiction entitled, "A True Relation of the Apparition of Mrs. Bargrave," in which Drelincourt on Death is recommended by the apparitionasthebestbookonthesubject. Thisstoryhadnotavestigeor shadowoftruthinit,itwasallapieceofimagination;butitwasputinat theendofthebook,andthenthewholeeditionwasspeedilyclearedout, and more were wanted. It may be something like that very often with your sermons; only you must tell the people of what has actually occurred,andsoyouwillretaintheirattention,andreachtheirhearts. Manyhavebeenmovedtoself-sacrificebythestoryoftheMoravians,in South Africa, who saw a large enclosed space of ground, in which there were persons rotting away with leprosy, some without arms and some without legs; and these Moravians could not preach to the poor lepers withoutgoingintherethemselvesforlifetorotwiththem,andtheydid so. Two more of the same noble band of brethren sold themselves into slaveryintheWestIndies,inorderthattheymightbeallowedtopreach to the slaves. When you can give such instances as these of missionary disinterestednessand devotedness, it will do more to arouse a spirit of enthusiasm for foreign missions than all your closely-reasoned argumentscouldpossiblydo. Afterhehadbeen drownedanhour,amansaid,"Icouldhavesavedhim,"andwhenthey askedhimhowhecouldhavesavedhim,hedescribedaplanthatseemed tobemostexcellentandfeasible,bywhichthemanmight,nodoubt,have been saved; but then, unfortunately, by that time he was drowned! So, therearesomewhoarealwayswisejusttoolate,somewhomayhaveto saytothemselves,whensuchandsuchaoneisgonethewayofallliving, "What might I not have done for him if I had but taken him in time! Seventhly, and lastly, anecdotes and illustrations are exceedingly useful becausetheycatchtheearoftheutterlycareless. Wereallydesiretheir salvation, and we would bait our trap in any way possible by which we mightcatchthemforChrist. Wecannotexpectouryoungpeopletocome and listen to learned doctrinal disquisitions that are not at all embellished with anything that interests their immature minds. Nay, evengrown-uppeople,afterthetoilsoftheweek,someofthembusytill early on the Sunday morning, cannot be expected to attend to long prosaicdiscourseswhicharenotbrokenbyasingleanecdote. HowIdopitythoseunpracticalbrethrenwhodonot seem to know to whom they are preaching! A minister should not preach before the people, but he should preach right at them; let him look straightatthem;ifhecan,lethimsearchthemthroughandthrough,and takestockofthem,asitwere,andseewhattheyarelike,andthensuithis messagetothem. Hecannotmakeoutwhatsortofserviceitis;hebeginsto counthowmanypeoplesitinthefrontrowinthegallery,andallkindsof ideas pass through his mind. If I quote a text of Scripture, he may not know what it means,andmaynotbeinterestedinit. Somethingissaid thatsoexactlysuitshiscasethathebeginstoaskhimselfwhohasbeen telling the minister about him, and he thinks, "Why, I know; my wife comestohearthismansometimes,soshehasbeentellinghimallabout me! They say I do not stick to my subject; but, thank God, I always stick to my object,whichis,thewinningofyoursouls,andbringingyoutothecross ofJesusChrist! Bertram aptly illustrates the way in which men are engrossed in worldlycaresbytellingthestoryofthecaptainofawhalingship,whom hetriedtointerestinthethingsofGod,andwhosaid,"Itisnouse,sir; your conversation will not have any effect upon me. Ihavebeenploughing the deep in search of whales; when I go to bed, I dream of whales; and whenIgetupinthemorning,Iwonderiftherewillbeanywhalescaught thatday;thereisawhaleinmyheart,sir,awhaleinmybrain,anditisof no use for you to talk to me about anything else but whales. Idonotthink,whenI ampreaching,thatIgetonverywell;butsometimes,whenIgointothe country,andtakethemorningandeveningservices,andthenhearsome one else in the afternoon, I think, "Well, really, when I was up there, I thoughtIwasastick:butnow! PaxtonHoodoncesaid,inalecturethatIheardhimdeliver,"Some preachersexpecttoomuchoftheirhearers;theytakeanumberoftruths into the pulpit as a man might carry up a box of nails; and then, supposingthecongregationtobeposts,theytakeoutanail,andexpectit togetintothepostbyitself. No, we have often to break open the doors with great effort, and to thrust the truth into places where itwill not at first be a welcome guest, but where, afterwards, the better it is known,themoreitwillbeloved. Illustrationsandanecdoteswillgreatlyhelptomakeawayforthetruth to enter; and they will do it by catching the ear of the careless andthe inattentive. Whitefield,ofwhomashipbuilder said,"WhenIhavebeentohearanybodyelsepreach,Ihavealwaysbeen able to lay down a ship from stem to stern; but when I listen to Mr. Now, gentlemen, these seven reasons-that they interest the mind and secure the attention of our hearers, that they render the teaching vivid and life-like, that they explain some difficult passages to dull understandings,that they help the reasoning faculties of certain minds, that they aid the memory, that they arouse the feelings, and that they catch the ear of the careless-have reconciled me for many a day to the use of anecdotes and illustrations, and I think it is very likely that they willreconcileyoutotheuseofthem,too. Atthesametime,ImustrepeatwhatIbeforesaid,wemusttakecarethat we do not let our anecdotes and illustrations be like empty casks that carrynothing. Wemustnothaveittruthfullysaidofoursermons,aswas said by a certain lady, who, after having heard a clergyman preach, was askedwhatshethoughtofthesermon,andwhethertherewasnotmuch spiritinit. If this be so with your sermons, my dear brethren,Ishallnothavespokentoyouthisafternooninvainuponthe usesofanecdotesandillustrations. Dearbrethrenaftermylastlecturetoyou,upontheusesofanecdotesand illustrations, you are probably quite ready to employ them in your discourses; but some of you may ask, "Where can we get them I have heard of one, who calledtoseeaministeronaFriday,andhewastoldbytheservantthat her master could not be seen, for he was up in his study "making anecdotes. Iwould also bid you beware of the many common anecdotes, which are often repeated, but which I half suspect could not be proved to be matters of fact. WheneverIhavetheslightestsuspicionaboutthetruthofastory,I drop it at once; and I think that everyone else should do the same. So long as the anecdotes are current, and are generally believed, and providedtheycanbeusedforaprofitablepurpose,Ibelievetheymaybe told, without any affirmation as to their truthfulness being made in a courtofjustice;butthemomentanydoubtcomesacrossthemindofthe preacherastowhetherthetaleisatleastfoundedonfact,Ithinkhehad betterlook for something else, for he has the whole world to go to as a storehouseofillustration. If you want to interest your congregation, and keep up their attention, you can find anecdotes and illustrations in many channels, like golden grains glistening amongst the mountain streams. In my little shilling book, the Bible and the Newspaper,Ihavegivenspecimensofhowthismaybedone;andwhenI waspreparingthepresentlecture,ItookupanewspapertoseeifIcould findanillustrationinit,andIsoonfoundone. Themanthen said that he had found the hare lying near some mushrooms, but his intention was to get the mushrooms only! Assoon as ever you lay hold of a man, and begin to accuse himofsin,hesays,"Sin,sir! I also read, in the same newspaper, of a calamitous shipwreck, caused throughthelackoflights. Youcouldeasilyturnthatincidenttoaccount by using it to illustrate the destruction of souls through the want of a knowledgeofChrist. Newman Hall, in addressing us once, said that every Christian minister ought to read regularly his Bible and the Times newspaper. Whether you read that particular paper, or any other, youshouldsomehowkeepyourselveswellstoredwithillustrationstaken from the ordinary transactions going on round about you. I pity even a Sunday-school teacher, much more a minister of the gospel, who could not make use of such incidents as the terrible burning of the church at Santiago,thegreatfireatLondonBridge,theentranceintoLondonofthe PrincessAlexandra,thetakingofthecensus;and,indeed,anythingthat attracts public attention. There is in all these events an illustration, a simile,anallegory,whichmaypointamoral,andadornatale. Whenaministerispreachinginanyparticulardistrict,hewilloftenfind it best to catch the ears of the people, and engross their attention, by relating some anecdote that relates to the place where they live. Theybegin,perhaps,withthenameofJohnSmith,labourer,the man who keeps the parish register, and winds up the parish clock, and makesmouse-traps,andcatchesrats,anddoesfiftyotherusefulthings; but if you have the patience to read on, you will find much information thatyoucouldgetnowhereelse,andyouwillprobablymeetwithmany incidentsandanecdotesthatyoucanuseasillustrationsofthetruthyou areseekingtosetforth. Besidethis,brethren,youhavethemarvellousstorehouseofancientand modernhistory-Roman,Greek,andEnglish-withwhich,ofcourse,you are seeking to become well acquainted. As you rise from their perusal,youwillnotmerelybefamiliarwiththeeventswhichhappened in"thebravedaysofold,"butyouwillhavelearntmanylessonsthatmay beofserviceinyourpreachingto-day. Forinstance,thereisthestoryof Phidias and the statue of the god which he had carved. So,someofusareveryaptto want to put our little names down at the bottom of any work which we havedoneforGod,thatwemayberemembered,whereasweoughtrather to upbraid ourselves for wishing to have any of the credit of that which GodtheHolyGhostenablesustodo. Then there is that other story of an ancient sculptor, who was about to put the image of a god into a heathen temple, although he had not finishedthatportionofthestatuewhichwastobeimbeddedinthewall. In likemanner,themostprivatepartsofourlife,thosesecretmattersthat can never reach the human eye, are still under the ken of theAlmighty, andoughttobeattendedtowiththegreatestcare. Itisnotsufficientfor ustomaintainourpublicreputationamongourfellow-creatures,forour God can see in the wall. He notices our coldness in the closest of communion,andHeperceivesourfaultsandfailuresinthefamily. TryingoncetosetforthhowtheLordJesusChristdelightsinHispeople because they are His own handiwork, I found a classic story of Cyrus extremelyuseful. Whenshowingaforeignambassadorroundhisgarden, Cyrus said to him, "You cannot possibly take such an interest in these flowersandtreesasIdo,forIlaidoutthewholegardenmyself,andevery planthereIplantedwithmyownhand. Ihavewateredthem,andIhave seenthemgrow,Ihavebeenahusbandmantothem,andthereforeIlove them far better than you can. The days of the Crusaders are a peculiarly rich period for noble stories thatwillmakegoodillustrations. WereadthatthesoldiersofGodfreyde Bouillon, when they came within sight of the city of Jerusalem, were so charmedwiththeviewthattheyfellontheirfaces,andthenrosetotheir feet, and clapped their hands, and made the mountains ring with their shoutsofjoy. Thus,whenwegetwithinsightoftheNewJerusalem,our happy home on high, whose name is ever dear to us, we will make our dyingchamber ring with hallelujahs, and even the angels shall hear our songs of praise and thanksgiving. It is also recorded, concerning this same Godfrey, that, when he had entered Jerusalem at the head of his victorious army, he refused to wear the crown with which his soldiers wantedtodeckhisbrow, "For," said he, "why should I wear a crown of goldinthecitywheremyLordworeacrownofthorns In the world where Christ was despised and rejected of men, it would be unseemly for a Christian to be seeking to win earthly honours, or ambitiously hunting after fame. Would not any one of you, my brethren,gladlyputhislipstotheunvenomedwoundsoftheChurchtoday,andsufferevenuntodeath,soonerthanletthedoctrinesofChristbe impugned,andthecauseofGodbedishonoured A Jew was seeking an opportunity of stabbing the Reformer; but Luther received a portrait of the would-be murderer, so that,whereverhewent,hewasonhisguardagainsttheassassin. He says, "I was once in examination before five or six bishops, where I had much trouble; thrice every week I came to examinations,andmanytrapsandsnareswerelaidtogetsomething. Then, amongst all other questions, he put forth a very subtle and craftyone,andsuchaone,indeed,asIcouldnotthinksogreatdangerin. Noonewasallowedtooccupythatchair,andduring theevening,ashotcameinthroughthewindow,andstruckacandlestick that stood immediately opposite where John Knox would have been sittingifhehadtakenhisaccustomedplace. Thereisalsothecaseofthe godlyminister, who, in escaping from his persecutors, went into a hayloft,andhidhimselfinthehay. Thesoldierswentintotheplace,pricking andthrustingwiththeirswordsandbayonets,andthegoodmanevenfelt thecoldsteeltouchthesoleofhisfoot,andthescratchwhichwasmade remained for years: yet his enemies did not discover him. Afterwards, a hen came and laid an egg every day hard by the place where he was hidden,andsohewassustainedaswellaspreserveduntilitwassafefor himtoleavehishiding-place. Itwaseitherthesameminister,oroneof his persecuted brethren, who was providentially protected by such a humbleagent as a spider. This is the story as I have read it: "Receiving friendly warning of an intended attempt to apprehend him, and finding menwereonhistrack,hetookrefugeinamalt-house,andcreptintothe emptykiln,wherebelaydown. Immediatelyafter,hesawaspiderlower itselfacrossthenarrowentrancebywhichhehadgotin,thusfixingthe firstline of what was soon wrought into a large and beautiful web. He was so much struck with the skill and diligence of the spider, and so much absorbed in watching her work, that he forgot his own danger. By the time the network was completed, crossing and recrossing the mouth of the kiln in every direction, his pursuers came intothemalt-housetosearchforhim. I remember making two or three of my congregation speak out pretty loudly by telling them this story, which I read in an American tract. A Christian minister, residing near the backwoods, took a walk one evening for silent meditation. He went much farther than he intended,and,missingthetrack,wanderedawayintothewoods. Hewas afraidthathewouldhavetospendthenightinsometree;butsuddenly, ashewasgoingforward,hesawtheglimmeroflightsinthedistance,and therefore pressed on, hoping to find shelter in a friendly cottage. Our frienddidnotwishtobeacraven,ortoholdbackinthedayofbattle,and therefore he was almost inclined to rise and speak, when a hale, burly man,whohadpassedthemeridianoflife,butwhowasstillexceedingly vigorous,andseemedastrong,muscularclearerofthebackwoods,rose and said, "I should like to speak if you will give me a hearing. I am not going to say anything about the topic which has been discussed by the oratorwhohasjustsatdown;Iamonlygoingtotellyouafact:willyou hearme Well, while I was at my employment, at some little distance from them, I heard cries and shrieks, mingled with prayerstoGodforhelp.

Bronchiolar walls are often replaced by fibrin and abundant granulomatous inflammation symptoms 6 days post iui cheap brahmi 60caps line. We observed fibrinoid change in widely scattered vessel in several slides medicine wheel colors brahmi 60 caps otc, but it was not constant over the distributed sections medications for ptsd cheap 60caps brahmi overnight delivery, so we have elected not include it in our diagnosis medicine hat lodge discount brahmi 60caps free shipping. The term acariasis equates with a mite infection and is derived from the Order Acari in which all mites are classified medicine quotes doctor generic brahmi 60caps without prescription. While most mite infections are localized to the skin medicine wheel colors generic 60caps brahmi with mastercard, there are at least ten species of lung mites which infect the lungs of Old World monkeys, all of the genus Pneumonyssus. Additional Gram, fungal and acid-fast stains did not elucidate any additional infectious organisms. Without definitive causal evidence, we elected to separate out the diagnoses of serositis and the prominent smooth muscle hyperplasia of subpleural vessels. As nicely described by the contributor, mite pigment is present in abundance in many sections. A survey of parasitic lesions in wild-caught, laboratory-maintained primates: (rhesus, cynomolgus, and baboon). Histopathologic findings of pulmonary acariasis in a rhesus monkeys breeding unit. Lung mites; pulmonary acariasis as an enzootic disease caused by Pneumonyssus simicola in imported monkeys. A colonic mass was identified when the patient was placed under general anesthesia and colonoscopy was attempted. Histopathologic Description: the section of the colonic mass is extensively ulcerated with accompanying marked collections of neutrophils, small lymphocytes, plasma cells and hemosiderophages that are also occur as a diffuse infiltrate in the lamina propria. Singleton and small groupings of neuronal ganglion cells are present throughout the lamina propria. The neuronal ganglion cells are polygonal with distinct cell borders and a moderate nuclear to cytoplasmic ratio. The nucleus is eccentric, round to oval with a finely stippled chromatin pattern and a single, prominent, round nucleus. The cytoplasm is moderate and there is a finely stippled to fibrillar pale pink material (Nissl substance) placed eccentrically in the cytoplasm. There are accompanying haphazard to parallel arrays of spindled cells and thin collagen fibers within the lamina propria that extend through the muscularis mucosa, interpreted to be a schwannian stroma. The nucleus is centric, oval to oblong with a finely stippled chromatin pattern and one to three, small nucleoli. Mitoses and cellular features of malignancy are not present in the neuronal ganglion cells and schwannian stroma. In two of the reports the affected dogs were euthanized due to the development of a postoperative septic peritonitis. Conference Comment: Without evidence of multiple sites of origin and given the welldemarcated lesion in sections with adjacent normal tissue, we prefer the diagnosis of ganglioneuroma in this case. Although we believe the inflammation and abnormal glandular orientation is secondary to the neoplasm, we elected to separate out these changes in a second diagnosis. Ganglioneuromas are characterized by exuberant proliferation of all elements of the intestinal ganglia, to include nerve fibers, ganglion cells and supporting cells. Neuroblastomas are composed of more primitive-appearing sheets of poorly defined cells with dark nuclei often forming pseudorosettes and lack the more mature ganglion cells of ganglioneuromas. They are the sites of synapsis between preganglionic and postganglionic parasympathetic nerves necessary for autonomic control of the intestinal tract. Diffuse ganglioneuromatosis in small intestine associated with neurofibromatosis type 1. Gross Pathology: the pancreas was described as markedly enlarged and firm, with mottled areas of hemorrhage and an accentuated lobular pattern. Laboratory Results: None Histopathologic Description: H&E sections of grossly abnormal pancreas are examined. There is massive, near diffuse necrosis of most lobules, with many demonstrating extensive hemorrhage, severe infiltrates of degenerative neutrophils and prominent acinar cell necrosis, with pyknosis, karyorrhexis and karyolysis. Some sections contain small adjacent and adhered portions of splenic parenchyma, in which there is moderate eosinophilic hyaline amyloid type material centrally within white pulp areas. In many necrotic lobules, remaining identifiable acinar cells contain extremely large basophilic or amphophilic intranuclear inclusion bodies, generally filling and expanding the entire nucleus and sometimes appearing to fuse with cytoplasmic contents, creating nucleocytoplasmic blurring (smudge cells). On highest light microscopy magnification, some of these inclusion structures have a fine interlaced or lattice type pattern visible. Inclusions are noted less frequently in remaining pancreatic ductal epithelium as well. In addition, some lobules not completely necrotic demonstrate prominent regenerative hyperplasia with some atypia. Islet cell structures were infrequently observed and when visible, did not have evidence of primary viral cytopathic effect. Although the organ was extensively effaced by this necrotizing process, there were small, patchy remaining areas of relatively normal appearing parenchyma (not generally seen in sections distributed). In some sections, overlying pancreatic capsule was markedly thickened and fibrotic, with infrequent fibrous adhesive tags. Most cases are diagnosed based on visualization of characteristic inclusion bodies and the presence of typical adenoviral ultrastructural morphology. In two cases where viral culture has been performed, Adenovirus types 23 and 31 have been isolated. As in previously reported cases of this distinct clinical entity, viral inclusion bodies were not noted outside of the pancreas. Concurrent hepatic histological findings included prominent canalicular and ductal bile stasis, biliary ductal hyperplasia and mild cholecystitis. Inclusion bodies or other viral cytopathic effects were not noted in hepatocytes or biliary epithelium in this case. Adenovirus has been isolated from a wide variety of tissues from healthy monkeys6 and consensus suggests that these viruses usually exist in a latent state, only rarely causing disease,3 although fatal adenoviral pneumonia has been encountered in a wide range of simian primates. Foals have been reported to have naturally occurring adenoviral pancreatitis, although this appears as part of a widespread infection with primary lung and other tissue involvement. Adenoviruses occur worldwide and are generally species specific, although transmission between closely-related species can occur, including zoonotic transmission between monkeys and people. Ultrastructurally, the inclusions are composed of prominent paracrystalline arrays of virions and unassembled capsid proteins. Respiratory and gastrointestinal epithelial cells are the most common targets of viral replication; however, the epithelial cells of the conjunctiva, cornea, urinary bladder, and kidney, in addition to hepatocytes and pancreatic acinar cells, can also be infected. Lesions of the Islets of Langerhans in Encephalomyocarditis virus infected mice with diabetes mellitus-like disease. History: A total of 9 bushy-tailed jirds (8 adult and 1 immature; 6 females and 3 males) were found dead within 2 days and without premonitory signs. Gross Pathology: Affecting over 80% of the liver parenchyma are coalescing, well demarcated, circular, flat, tan to pale red areas (necrosis). The jird is in fair body condition with small to moderate amounts of subcutaneous and abdominal adipose tissue. Lung or liver from 3 other jirds were sent for aerobic culture and revealed many Listeria spp. The areas of necrosis are characterized by loss of tissue architecture with accumulation of eosinophilic amorphous material, few degenerated neutrophils and cellular and karyorrhectic debris. Necrotic hepatocytes are characterized by shrunken and/or fragmented hypereosinophilic cytoplasm and pyknosis, karyorrhexis or karyolysis. In blood vessels adjacent or within affected areas there are increased numbers of neutrophils and eosinophilic strand-like material (fibrin) admixed with red blood cells. Multifocally in some of the sections are small areas of sinusoidal and central vein congestion. Other significant histologic findings (not present in the slide provided) include: Spleen: Splenitis, necrotizing, acute, multifocal severe with intralesional short bacilli Lymph nodes, mesenteric and mandibular: Lymphadenitis, necrotizing, acute, diffuse, severe Intestine: Enterocolitis, necrotizing, acute, multifocal to transmural, severe Bone marrow: Myelitis, necrotizing, acute, multifocal, moderate Gram stain: Bacteria are Gram positive. Septicemic listeriosis is characterized by multisystemic bacterial colonization with multifocal areas of necrosis or microabscess formation. Gerbils are used as models for Listeria monocytogenes infection and naturally succumb to the disease. This disease has been previously reported in bushy tailed jirds and the source of infection was similarly not elucidated in that mortality event. Conference Comment: the contributor presents a classic disease entity in its septicemic form and discusses its ubiquitous and hardy nature in addition to describing its molecular interactions with host target cells as highlighted in recent literature. Once the bacterial population reaches a sufficient size within a single cell, it propels into adjacent cells via actin polymerization of this protein and forms membrane protrusions known as pseudopods. The pseudopods penetrate into adjacent cells forming double-membrane endocytotic phagocytic vesicles which are subsequently lysed by the virulence factor listerolysin-O among others. Therefore, a likely target of effective antimicrobial therapy may be phosphatidylserine or its binding receptor for this and other similar bacterial pathogens. Listeria monocytogenes septicaemia in an inland bearded dragon (Pogona vitticeps). Horizontally transferred genetic elements and their role in pathogenesis of bacterial disease. Listeric meningoencephalomyelitis in a cougar (Felis concolor): Characterization by histopathologic, immunohistochemical and molecular methods. Listeria monocytogenes infection in a sugar glider (Petaurus breviceps)- New Mexico, 2011. Gross Pathology: the renal cortex was extensively disrupted by coalescing, dark red, blood-filled nodules ranging from 0. Histopathologic Description: Kidney: the renal interstitium is markedly expanded by many, severely dilated, blood-filled vascular spaces lined by mature endothelial cells surrounded by abundant fibrous tissue. Some vascular spaces contain thrombi with fibrin arranged as lines of Zahn separated by red and white blood cells that are occasionally attached to the vascular wall by fibrous tissue. The intervening and adjacent renal parenchyma is markedly atrophic with replacement of many nephrons by fibrosis, many lymphocytes and plasma cells, and variable hemorrhage. Kidney, Welsh corgi: the cortex is expanded by large, ectatic, thin-walled vessels which efface renal parenchyma. Kidney, Welsh corgi: Vessels are thin-walled and separated by a moderate fibrous stroma. Kidney, Welsh corgi: Larger vessels are partially occluded with fibrinous thrombi which contain lines of Zahn. Renal telangiectasia is differentiated histologically from hemangiosarcoma by the fact that the vascular spaces are lined by a bland, mature endothelium without mitotic activity or cellular atypia. Conference Comment: Conference participants discussed three optional diagnoses for this case: telangiectasia, hemangioma or vascular hamartoma. The familial lesion of renal telangiectasia in Pembroke Welsh corgis as described in the literature characteristically arises bilaterally with frequent occurrences in other organs. The clinical history in this case suggests the lesion is isolated to one kidney; however, the lesion lacks the well-circumscribed appearance of a hemangioma. The signalment and clinical signs do not correlate well with a hamartoma, which implies a congenital proliferation. Also known as Osler-Weber-Rendu disease, this autosomal dominant disorder occurs at a rate of 1 in 5,000 people and manifests as telangiectasia of the oral mucosa and arteriovenous malformations in the lungs, liver and less often brain. The understanding of disease pathogenesis has also shed new light on the specific molecular interactions of angiogenesis, one of the hallmarks of cancer. The authors speculated on the value of Pembroke Welsh corgis serving as an animal model for vascular malformations over 30 years ago. The patient had a 1-month history of ataxia and progressively more frequent vomiting. During diagnostic workup, there was mild C5-C6 disc protrusion noted on cervical myelogram. On cerebellomedullary cistern cerebrospinal fluid aspirate cytology there was a severe mixed pleocytosis. Therapeutic interventions included clindamycin, fluconazole, cytoarabine, and prednisolone at an immunosuppressive dose. During the following 2 weeks, the patient re-presented for weight loss, muscle wasting, and progressive ataxia leading to tetraparesis. The patient arrested shortly after presentation to urgent care in lateral recumbency and respiratory distress. Her mucous membranes and non-haired pinnae were markedly pale and eyes were recessed. In the kidneys, there were numerous miliary, pale tan, 1 to 2 mm diameter foci on the capsular surface that often extended in multifocal rays into the medullas. In the brain and spinal cord, there was moderate purulent subdural exudate (meningoencephalitis). The small and large intestines were segmentally reddened and thickened with multifocal irregular mucosal ulcerations. The adrenal cortices were mildly bilaterally thin (atrophy, consistent with steroid administration). Kidney, dog: the interstitium is infiltrated and tubules are replaced by large numbers of macrophages, lymphocytes and plasma cells. Hepatic lesions are variable and clusters of organisms are not captured in all sections. In tissues not included for conference material, multifocal to coalescing perivascular and random granulomatous inflammation with organisms is present throughout the gastrointestinal tract, pancreas, mesentery, lymph nodes, lung, myocardium, and meninges.

Involvement of one of the leptomeningeal branches (M3 or M4) can produce highly circumscribed infarcts accompanied by specific neurological deficits and is most of the time related to embolism medicine you can order online best brahmi 60 caps. The lenticulostriate arteries vascularize the basal ganglia and parts of the internal capsule 9 treatment issues specific to prisons cheap 60 caps brahmi amex. Ischemia in their territory can therefore produce severe deficits with a very small-volume lesion medications and mothers milk 2016 cheap brahmi 60 caps overnight delivery. Cortical signs are absent or minor medicine emblem brahmi 60caps without a prescription, except in the case of deafferentation of the cortex by interruption of subcortical cortical pathways medicine 319 generic brahmi 60 caps without a prescription. Clinical signs include proportional hemiparesis medications 500 mg discount brahmi 60 caps amex, hemihypesthesia, dysarthria, hypophonia, and occasionally abnormal movements in the case of involvement of basal ganglia. The centrum ovale receives its blood supply from medullary perforating arteries coming principally from leptomeningeal arteries. Both small and larger lesions may occur in the border-zone area between the deep (leptomeningeal) and superficial (meningeal) arteries from hemodynamic mechanisms (see below). Malignant stroke with brain edema may develop, leading to high intracranial pressure and subsequent herniation. Infarctions of the lower arterial segments show similar symptoms, but not the complete picture. The A1 segment has deep perforating arteries, named the medial lenticulostriate arteries, and gives rise to the recurrent artery of Heubner (raH), which supplies the caudate head, the genu and anterior arm of the internal capsule and the supero-anterior putamen. Sphincter dysfunction, mutism, anterograde amnesia, grasping, and behavioral disturbances are particularly frequent in ischemia of the deep perforating arteries and the raH. Involvement of the corpus callosum can produce the callosal disconnection syndrome, secondary to interruption of the connection of physical information from the right hemisphere to cognitive center in the left hemisphere. Therefore, it is restricted to the left hand, which presents ideomotor apraxia, agraphia, tactile anomia (inability to name objects placed into the left palm) and the alien-hand syndrome. The artery vascularizes to a variable degree the inferior posterior and retrolenticular part of the internal capsule, the tail of the caudate nucleus, part of the lenticular nucleus, the posterior corona radiata, the lateral geniculate body and the beginning of the optic radiations. Clinically less important are 123 Section 3: Diagnostics and syndromes variable contributions to the vascular supply of the uncus, amygdala, hippocampus, optic tract, parts of midbrain (substantia nigra, cerebral peduncle), subthalamic region, and choroid plexus. In the majority of patients, the presentation is a lacunar syndrome: pure motor or sensorimotor hemiparesis and less frequently a pure sensory deficit or an ataxic hemiparesis syndrome. A rare but specific visual field defect is a homonymous defect in the upper and lower quadrants with sparing of a horizontal sector [8]. It typically occurs when an orthostatic stress leads to a hypoperfusion of the brain [9] secondary to carotid severe stenosis. A progressive atherosclerotic occlusion is usually less severe, with a classic subacute two-phase presentation or even asymptomatic. Retinal ischemia from carotid emboli may be transient (amaurosis fugax) or persistent. Posterior circulation syndromes the posterior circulation is also called the vertebrobasilar circulation. In contrast, a progressive atherosclerotic occlusion is usually less severe, with a classic subacute twophase presentation. Clinical clues to differentiate posterior from anterior circulation strokes Important clinical symptoms and signs point to a posterior circulation stroke and should be recognized. Similarly, headache is more frequent in the posterior circulation, is typically ipsilateral to the infarct, and may have features of primary headaches such as migraine [10]. Past diplopia, tilt of the vision, true rotatory or linear vertigo, drunken-type gait, hiccup, bilateral or crossed motor or sensory symptoms, initial decreased level of consciousness and amnesia should be actively searched for in the history of stroke patients. It may occur as a fixed misalignment of the ocular axis, such as in vertical skew deviation of the eyes as part of the ocular tilt reaction. A lateral medullary lesion (Wallenberg syndrome) leads to an ipsilateral deviation of the eyes, however, and is usually accompanied by a marked horizontal or horizonto-rotatory nystagmus. A vertical gaze paresis (upwards, downwards, or both) points to a dorsal mesencephalic lesion and may be associated with a caudal paramedian thalamic infarct, especially if downgaze palsy is also present. A nystagmus of central origin may be recognized by its direction (vertical, multidirectional gaze-evoked or pendular), the absence of nausea despite clear-cut nystagmus with primary gaze, and its lack of improvement with fixation. An ocular tilt reaction is characterized by the triad of skew deviation (downward displacement of the axis of the globe ipsilateral to the lesion), conjugate ocular torsion towards the side of the lesion and head tilt to the side of the lesion. Visual tilt of the environment towards the side of the lesion is frequently associated and may result in "upside-down vision". It occurs with an ipsilateral dorsolateral brainstem, upper cervical, or thalamic lesion, but may also occur due to a carotid dissection, the peripheral sympathetic fibers surrounding the carotid artery. Motor, cerebellar and sensitive signs are less specific in brainstem lesions, but the presence of bilateral or crossed signs is suggestive. The latter is caused by ischemia of cranial nerves and fascicles that produce ipsilateral signs and simultaneous damage to the long sensory and motor tracts that cross in the caudal parts of the brainstem. If somnolence, early anisocoria or vertical gaze palsy are present, posterior circulation stroke is more probable than carotid territory stroke. The latter structure may also 125 Section 3: Diagnostics and syndromes 126 receive direct (long circumferential) branches from the vertebral artery. The medial medullary stroke is a rare stroke syndrome and classically includes contralateral hemiparesis sparing the face (corticospinal tract), contralateral lemniscal sensory loss (medial lemniscus) and ipsilateral tongue paresis (nucleus of hypoglossal nerve and tract). Wallenberg syndrome and an infarct in the inferior cerebellum stroke can be seen in isolation or together, the latter being usually the case if the vertebral artery is occluded. One clue which can help to make the correct diagnosis is the presence of an unusual nystagmus, which will be purely horizontal or direction-changing, and preservation of the vestibulo-ocular reflex with the head thrust (Halmagyi) maneuver. This maneuver should not be applied in patients with suspected vertebral artery dissection. With transtentorial herniation, lethargy and coma are accompanied by central hyperventilation, upward gaze paralysis, unreactive, midposition pupils and decerebration. Dorsolateral medullary stroke (or Wallenberg syndrome) is the most common brainstem syndrome of vertebral artery involvement. It is frequently misdiagnosed as Wallenberg syndrome, but the main clinical distinctions are the hearing loss and the peripheral-type facial palsy. Other signs have been described, such as ipsilateral choreiform abnormal movements or palatal myoclonus (superior cerebellar peduncle interrupting the dentatorubral pathway), sleep abnormalities, and partial contralateral deafness (lateral lemniscus). The anteromedial territory receives its blood supply from the paramedian arteries, the anterolateral territory from the short circumferential arteries (or anterolateral arteries) and the dorsolateral territory from the long circumferential arteries (or posterolateral arteries) as well as from the cerebellar arteries. Dorsolateral lesions often involve the spinothalamic tract and lateral part of the medial lemniscus, while paramedian infarcts involve the medial part of the medial lemniscus. Involvement of the tegmentum implies more sensory, cranial nerves and oculomotor deficits. Different eponym syndromes have been described in the literature, corresponding to circumscribed lesions and precise deficits (see Table 8. About half of individuals present premonitory signs and symptoms, especially if atherosclerosis of the vertebral or basilar artery is the cause. Some symptoms are nonspecific, such as paresthesias, dysarthria, ("herald") hemiparesis or dizziness. More specific prodromes are mentioned above, and also include pathological laughter ("fou rire prodromique") [13] as well as pseudoseizures with tonic spasm of the side which will become paretic [14]. Rapid identification of basilar artery ischemia can help to provide aggressive therapy by i. Severe pontine strokes are characterized by a locked-in syndrome that involves quadriplegia, bilateral face palsy, and horizontal gaze palsy. Consciousness and vertical gaze are usually spared unless the midbrain is involved. Therefore, careful examination of voluntary up- and downgaze in a seemingly comatose patient may establish preserved consciousness and communication. Distal basilar territory stroke usually leads to midbrain ischemia and is therefore characterized by ocular manifestations, such as disorders of reflex and voluntary vertical gaze, skew deviation, disorder of convergence with pseudosixth palsy in the presence of hyperconvergence, Collier sign (upper eyelid retraction), and small pupils with diminished reaction to light because of interruption of the afferent limb of the pupillary reflex. Hypersomnolence or coma usually requires extension of the ischemia into the thalamic territory as part of the "top of the basilar syndrome" [16]. Atherosclerosis and embolism are the two major mechanisms of basilar artery stroke and occlusion. Embolic clots may arise from vertebral or basilar atherosclerosis or from aortic or cardiac sources. They have been documented in up to 10% and are related to the presence of vascular risk factors and an increased risk for lacunar stroke [18]. Rapid identification of basilar artery ischemia can help to provide timely aggressive therapy by i. Motor symptoms are infrequent and minor [19] and are mostly related to laterothalamic edema affecting the posterior internal capsule or to ischemia of the cerebral peduncles. The "top of the basilar syndrome" causes headaches, central visual loss and decreased level of consciousness. Carotid artery (1); basilar artery (2); posterior cerebral segment P1 (3); segment P2 (4); posterior communicating artery (5); tuberothalamic artery (6); paramedian arteries (7); thalamogeniculate artery (8); posterior choroidal artery (9). Therefore it can mimic cortical and subcortical strokes in the anterior or posterior circulation and is also called "the great imitator". Its vascularization is subdivided into four territories correlated with the organization of the thalamic nuclei [20] (Figure 8. There are inter-individual variations in thalamic supply, leading to variable clinical presentations and prognosis. For example, Percheron reported that the paramedian arteries may arise from a unique P1 segment or from a vascular arcade connecting both P1 segments. It is absent in about a third of the population, in which case the paramedian arteries vascularize its territory. Infarction results in anterograde amnesia (mostly reversible if unilateral), automatic-voluntary dissociation with facial paresis for emotional movement, personality changes, mild contralateral hemiparesis or clumsiness. Cognitive and behavioral disturbances include temporospatial disorientation, euphoria, misjudgment, lack of spontaneity, apathy, emotional unconcern, and a unique behavioral pattern, named palipsychism [21]. Individuals present a disorganized speech with grammatically correct phrases, but with intrusions of unrelated themes, which have usually been discussed previously. With a left lesion, buccofacial or limb apraxia and thalamic aphasia can occur with reduced fluency, anomia, phonological and semantic paraphasia, perseveration, impaired comprehension, acalculia with preservation of reading and repetition. The principal branches supply the ventrolateral nucleus and the ventroposterior nuclei, while the medial branches supply the medial geniculate body and the inferior branches the rostral and lateral pulvinar, as well as the laterodorsal nucleus. The clinical presentation can include contralateral hemihypesthesia, involving one or several sensory modalities. It may be associated with choreoathetoid movements, hemiataxia, slight transient hemiparesis and thalamic astasia. Thalamic astasia is characterized by disequilibrium backwards or toward the side contralateral to the lesion in the absence of significant motor deficit and is thought to result from interruption of the dentatorubrothalamic pathway. Individuals describe paresthesias without objective deficit, particularly in the cheiro-oral region, or a "mid-line split", defined by a subjective sensation of an abrupt stopping of the deficit on the midline of the trunk. The "thalamic hand", described by Foix and Hillemand, is flexed, pronated and the thumb is buried beneath the other fingers [20]. Behavioral disturbances are infrequent in inferolateral stroke and include soft executive dysfunction and affective changes, resembling those found after cerebellar stroke [21]. The inferior and middle rami irrigate parts of the midbrain and the pons, while the superior ramus irrigates a variable extent of thalamus but mostly the dorsomedial nucleus, the intralaminar nuclei and internal medullary lamina. The classic features consist of a triad with an initial decreased level of consciousness with or without fluctuations, vertical gaze abnormalities and cognitive impairment, which become more obvious after the resolution of the somnolence. Cognitive disturbances consist mostly of personality changes with disinhibited behavior, impulsivity, apathy and even loss of psychic selfactivation associated with amnesia similar to Korsakoff syndrome. This picture of amnesia and behavioral disturbances is recognized as a "thalamic dementia". However, severe persistent amnestic syndrome is observed only with concomitant lesion of the anterior nucleus. The aphasia, named adynamic aphasia [20], is characterized by a reduced verbal fluency, with perseveration and paraphasic errors but with a relatively preserved syntax, comprehension and repetition. They supply the pulvinar, part of the lateral and medial geniculate body, the posterior parts of the intralaminar nuclei, and lateral dorsal and lateral posterior nuclei. They also irrigate posterior portions of medial temporal structures, parts of midbrain and probably the subthalamic nucleus. The clinical syndrome is characterized by visual field defects, decreased optokinetic nystagmus contralaterally to the lesion, contralateral hemisensory loss with mild Chapter 8: Common stroke syndromes hemiparesis, and transcortical aphasia. Some individuals, in the event of pulvinar involvement, develop delayed contralateral hyperkinetic movements, including ataxia, rubral tremor, dystonia, myoclonus and chorea, a syndrome named the "jerky dystonic unsteady hand". No specific behavioral disturbance is described, but some spatial neglect was associated with right pulvinar lesions. Ischemia in the thalamus can mimic cortical and subcortical strokes in the anterior or posterior circulation. Lacunar stroke syndromes Lacunes are defined as small subcortical infarcts less than 1.

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